What is Bipolar Disorder?

The distinguishing characteristic of Bipolar Disorder, as compared to other mood disorders, is the presence of at least one manic episode. Additionally, it is presumed to be a chronic condition because the vast majority of individuals who have one manic episode have additional episodes in the future. The statistics suggest that four episodes in ten years is an average, without preventative treatment. Every individual with bipolar disorder has a unique pattern of mood cycles, combining depression and manic episodes, that is specific to that individual, but predictable once the pattern is identified. Research studies suggest a strong genetic influence in bipolar disorder. 

Bipolar disorder typically begins in adolescence or early adulthood and continues throughout life. It is often not recognized as a psychological problem, because it is episodic.  Consequently, those who have it may suffer needlessly for years without treatment.

Effective treatment is available for bipolar disorder. Without treatment, marital breakups, job loss, alcohol and drug abuse, and suicide may result from the chronic, episodic mood swings. The most significant treatment issue is noncompliance with treatment. Most individuals with bipolar disorder do not perceive their manic episodes as needing treatment, and they resist entering treatment. In fact, most people report feeling very good during the beginning of a manic episode, and don't want it to stop. This is a serious judgment problem. As the manic episode progresses, concentration becomes difficult, thinking becomes more grandiose, and problems develop. Unfortunately, the risk taking behavior usually results in significant painful consequences such as loss of a job or a relationship, running up excessive debts, or getting into legal difficulties. Many individuals with bipolar disorder abuse drugs or alcohol during manic episodes, and some of these develop secondary substance abuse problems. 

Facts About Bipolar Illness

• More than 2 million Americans have manic-depressive illness. It is extremely distressing and disruptive to their lives.

• Like any serious illness, bipolar disorder also creates problems for spouses, family members, friends, and employers.

• Family members of people with bipolar disorder often have to cope with serious behavioral problems (such as wild spending sprees) and the lasting consequences of these behaviors.

• Bipolar disorder tends to run in families, and there is strong evidence that it is inherited. However, despite ongoing research efforts, a specific genetic defect associated with the disease has not yet been identified.

• Bipolar illness has been diagnosed in children under age 12, although it is not common in this age bracket. The symptoms can be confused with attention-deficit/hyperactivity disorder, so careful diagnosis is necessary.

What is a manic episode?

A manic episode is an abnormally elevated, expansive or irritable mood, not related to substance abuse or a medical condition, that lasts for at least a week, and includes a number of disturbances in behavior and thinking that results in significant life adjustment problems. Chronic behavior that appears somewhat similar to manic behavior is more likely ADHD or evidence of personality problem.

It may be helpful to think of the various mood states in manic-depressive illness as a spectrum or continuous range. At one end is severe depression, which shades into moderate depression; then come mild and brief mood disturbances that many people call "the blues," then normal mood, then hypomania (a mild form of mania), and then mania. 

Some people with untreated bipolar disorder have repeated depressions and only an occasional episode of hypomania (bipolar II). In the other extreme, mania may be the main problem and depression may occur only infrequently. In fact, symptoms of mania and depression may be mixed together in a single "mixed" bipolar state. 

Descriptions of Mood States

Here are some first-person accounts of the various mood states associated with bipolar disorder: 

Depression:

I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless. I am haunted with the desperate hopelessness of it all. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?

Hypomania:

At first when I'm high, it's tremendous...ideas are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do anything...but, somewhere this changes.

Mania:

The fast ideas become too fast and there are far too many...overwhelming confusion replaces clarity...you stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped.

Recognition of the various mood states is essential so that the person who has manic-depressive illness can obtain effective treatment and avoid the harmful consequences of the disease, which include destruction of personal relationships, loss of employment, and suicide.

Features of a Depressive Episode

• Persistent sad, anxious, or empty mood

• Feeling helpless, guilty, or worthless

• Hopeless or pessimistic feelings

• Loss of pleasure in usual activities

• Decreased energy

• Loss of memory or concentration 

• Irritability or restlessness

• Sleep disturbances

• Loss of or increase in appetite 

• Persistent thoughts of death

Features of a Manic Episode 

• Extreme irritability & distractibility

• Excessive "high" or euphoric feelings 

• Sustained periods of unusual, even bizarre, behavior with significant risk-taking

• Increased energy, activity, rapid talking & thinking, agitation 

• Decreased sleep 

• Unrealistic belief in one's own abilities 

• Poor judgment 

• Increased sex drive 

• Substance abuse 

• Provocative or obnoxious behavior 

• Denial of problem 

Factors Preventing Early Detection of Bipolar Disorder

An early sign of manic-depressive illness may be hypomania--a state in which the person shows a high level of energy, excessive moodiness or irritability, and impulsive or reckless behavior.  Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong. In its early stages, bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work     performance. If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression.

Treatment of Bipolar Disorder

Psychological treatment often focuses on the life adjustment problems that develop because of the manic episodes, and in helping the individual recognize the onset of a manic episode and take corrective action. Supportive counseling is needed, to help the individual accept that he/she has a chronic psychological problem that will have a major impact on life management. Anyone with bipolar disorder should be under the care of a psychiatrist skilled in its diagnosis and treatment, as well as a psychologist. Psychologists provide the individual and his/her family with support, education, coping skills training, They also help monitor the symptoms and encourage the individual to continue medical treatment. The psychiatrist monitors the medication that is usually required with this disorder. 

Most people with manic depressive illness can be helped with treatment.

Almost all people with bipolar disorder--even those with the most severe forms--can obtain substantial stabilization of their mood swings.  One medication, lithium, is usually very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.  Most recently, the mood stabilizing anticonvulsants carbamazepine and valproate have also been found useful, especially in more refractory bipolar episodes. Often these medications are combined with lithium for maximum effect. 

Some scientists have theorized that the anticonvulsant medications work because they have an effect on kindling, a process in which the brain becomes increasingly sensitive to stress and eventually begins to show episodes of abnormal activity even in the absence of a stressor. It is thought that lithium acts to block the early stages of this kindling process and that carbamazepine and valproate act later.  Children and adolescents with bipolar disorder are generally treated with lithium, but carbamazepine and valproate are also used. Valproate has recently been approved by the Food and Drug Administration for treatment of acute mania.  The high potency benzodiazepines clonazepam and lorazepam may be helpful adjuncts for insomnia. Thyroid augmentation may also be of value. For depression, several types of antidepressants can be useful when combined with lithium, carbamazepine, or valproate.  Constructing a life chart of mood symptoms, medications, and life events may help the health care professional to treat the illness optimally.  Because manic-depressive illness is recurrent, long-term preventive (prophylactic) treatment is highly recommended and almost always indicated.

Treatment Issues

Symptoms of bipolar disorder may prevent those affected from recognizing that they have an illness.  Family, friends, and primary care physicians should provide encouragement and referrals for treatment. Psychological treatment can help the person and his/her family cope with the life management problems created by bipolar disorder. Medical treatment is usually needed to control mood swings with medication. To ensure proper treatment and personal safety, commitment to a hospital may be necessary for a person in a severe episode. Hospital commitment, which is placing a person in the hospital against their will, is sometimes necessary with bipolar disorder because of the effects of manic episodes. While the person is "high" he/she is not rational, and may engage in activities that are a threat to themselves or others. The person cannot understand the need for hospitalization because of the disturbance that occurs to his/her judgment. Suicidal thoughts, remarks, or behaviors should always be given immediate attention by a qualified professional. It is not true that if a person talks about suicide, they will not kill themselves. Self-destructive thoughts are sometimes acted out indirectly. For example, a person may drive excessively fast, or take drugs, or start confrontations with others, as a way to harm himself/herself. With appropriate treatment, the suicidal thoughts and behavior can be controlled and eliminated. 

Bipolar disorder is a lifetime illness. To keep his/her mood stable, ongoing treatment is needed, even when the person is feeling better.  It may take time to discover the best treatment regimen for an individual. It is very important for both the person with bipolar disorder, and his/her family, to work with a psychologist and physician to develop the most appropriate treatment plan.  In addition to treatment, mutual support self-help groups can benefit patients and their families. National Depressive and Manic Depressive Association (NDMDA) and National Alliance for the Mentally Ill (NAMI) sponsor such groups.