Bipolar Disorder

Bipolar disorder, also known as manic depression, is a mood disorder, characterised by extreme shifts in mood, energy and functioning. More recently this term is also used to include the more subtle variants of the disorder, called the soft bipolar spectrum disorders. Bipolar disorder Type I is much less common than Major Depressive disorder, with 1% of the general population affected over time. Males and females are affected equally. The incidence of the soft bipolar spectrum disorders have not been established yet but it might be as high as 6% of the general population. It is also still unclear what the sex ratio of this disorder is.

As a group, the bipolar disorders entail episodes of depression as well as episodes of mania/euphoria or hypomania. The switches between these two states may be fairly sudden and dramatic, but are more commonly gradual in onset. Both mood states may occur at the same time. This is called a mixed episode.

Bipolar disorder tends to be a chronic, recurring condition and is generally considered to have a poorer long-term outcome than Major Depressive Disorder.

During a manic (“high”) episode a person displays behaviour that is out of character. He/she may be “overly” happy and/or highly irritable, have boundless energy, go for days without sleeping and lose their inhibitions in social settings. People with mania may develop unrealistic beliefs in their capabilities that may impair their judgement, the result of which is engagement in foolish activities or projects which often lead them into financial or other difficulties. As a manic episode develops, there may be an increase in the use of alcohol or stimulants, which may aggravate or prolong the episode. Typically a manic person denies that there is anything wrong or unusual with him/her. The changes in mood and behaviour are observable by others who know the person well.

During a hypomanic episode similar symptoms are present but only in a more subtle form. This sometimes makes it difficult to recognize and therefore contributes to the diagnosis being missed.

During the “low” phase the person is depressed, lacks energy and struggles to enjoy activities, which were previously enjoyable. In contrast to the classic unipolar form of depression, a person tends to sleep more and have an increased appetite with possible weight gain.

Some people can experience symptoms of depression and mania at the same time. This is called “black mania” or a mixed episode.

Each of the different phases of the disorder can disrupt the person’s work, school, family and social life. As such it can be very disabling, but if treated appropriately, it responds well. Treatment can help prevent future episodes.

Symptoms

Signs and symptoms of mania include:

• Abnormally “high”, euphoric mood
• Extreme irritability/agitation
• Anger and/or aggression
• Increased energy, activity and restlessness
• Inflated self esteem and self confidence, feeling superior to others
• Decreased need for sleep
• More talkative than usual and talking rapidly and loudly
• Racing thoughts or jumping from one idea to another, making it difficult for others to follow
• Distractibility and difficulty concentrating
• Increase in goal-directed activity
• Poor judgement
• Excessive involvement in pleasurable activities that can have painful consequences (such as spending sprees or sexual indiscretions)
• Abuse of drugs and alcohol
• Denial that anything is wrong

Signs and symptoms of depression include:

• Intense sadness
• Loss of interest or pleasure in activities previously enjoyed
• Feelings of guilt, despair and worthlessness
• Change in sleeping pattern – more commonly sleeping to much (hypersomnia)
• Loss of energy
• Change in appetite more commonly an increase in appetite resulting in weight gain
• Difficulty concentrating and remembering
• Restlessness or irritability
• Thoughts of death or suicide

Some people may have psychotic symptoms during severe episodes of mania and depression. Common symptoms are delusions (false, strongly held beliefs that are not influenced by logical reasoning) and hallucinations (hearing, seeing or otherwise sensing things that are not there). These symptoms tend to reflect the mood state at the time. For example, during a manic phase a person may believe that he is the president or has special powers. Delusions of guilt or worthlessness may appear during depression.

As mentioned, the symptoms of hypomania are similar to that of a manic episode but less severe. Psychotic symptoms are not present and hospitalization is usually not needed. There is also less overall impairment of functioning. It may even be associated with good functioning and enhanced productivity.

Types

There are four main types of bipolar disorder.

Bipolar I
The person involved has one or more depressive episodes with at least one manic or mixed episode.

Bipolar II
The person has one or more depressive episodes with at least one hypomanic episode. When four or more episodes of illness occur within a year, the person is said to have bipolar disorder with rapid cycling.

Cyclothymic disorder
This is characterised by chronic fluctuating moods, involving periods of hypomania and depression. The depressive episode is not severe enough to meet the criteria for MDE. This is often considered a personality type.

Who suffers from bipolar disorder?

Although it is less common than Major depressive disorder, bipolar disorder is probably more common than previously thought. Approximately 1% of the population suffers from Bipolar I disorder. It is however suspected that the lifetime prevalence of the bipolar spectrum disorders (including bipolar disorder type II) can be as high as 6%.

In contrast to Major depressive disorder, bipolar disorder has an earlier onset. The onset is often before the age of 20, but may even start in early childhood, when it is often confused with ADHD. If the onset is after the age of fifty, it is usually due to another medical condition, such as multiple sclerosis or the effect of drugs, alcohol or steroids.

Causes

There is no single cause. The disorder tends to run in families, which suggests that there is a genetic link. In people predisposed to the disorder, the onset can be triggered by stressful life events, the use/abuse of drugs and/or prescription medication, including antidepressants and steroids.

An imbalance in various neurotransmitters (chemicals by which the brain cells communicate) may also be involved. There may also be disturbances in the production or release of certain hormones within the brain that contribute to causing bipolar disorder.

Course

Bipolar disorder is a lifelong condition. Bipolar I disorder is generally considered to have a poorer long-term outcome than Major Depressive Disorder. The reasons for this are unclear but may be a result of poor compliance with medical treatment. Bipolar II disorder and the soft bipolar spectrum disorders have a better outcome

The course varies from person to person. Bipolar disorder can start with major depression or a manic episode. Manic episodes usually begin suddenly with a rapid escalation of symptoms over a few days. They tend to be shorter and end more abruptly than depressive episodes. It is important to note that over a lifetime patients with bipolar mood disorder have a much higher likelihood of suffering from a depressive episode than from a hypomanic/manic episode. For some there may be long symptom-free periods between episodes. Episodes have been described to last for days, weeks or months. However, more recent research suggests that some individuals may experience several switches in mood state within one day. The average person with bipolar I disorder has four episodes (manic or depressed) during the first ten years of the illness. A minority of people may have several episodes of mania and depression with only brief periods of normal moods in between.

If properly controlled by medication, a person can lead a full, productive life. If left untreated, moods will continue to swing from one extreme to another and cause severe impairment in functioning. The time period between episodes usually narrows and episodes become more severe. In such cases, suicide is a real danger, especially if the person abuses substances and/or suffers from anxiety.

Diagnosis

There is no diagnostic test. In order to make a diagnosis, an evaluation by a psychiatrist, who will take a detailed history and thoroughly assess symptoms, is essential.

It is very useful to get feedback from close family and friends, as a person with this disorder often lacks insight into his/her condition. They will often deny that anything is wrong and resist efforts to be treated. This resistance can often delay diagnosis and effective treatment.

Substance abuse or medical conditions such as thyroid problems can mimic bipolar disorder. These need to be ruled out and effectively treated.

Look after yourself