Bipolar Disorder
What is Bipolar Disorder
Bipolar Disorder is a chronic lifelong mood disorder characterized by extreme recurring mood swings or mood fluctuations.
Previously known as manic depression or manic depressive illness, the terms generally refer to extremes of mood from depression to what is known as being on a "high" or "hypomanic" or "manic" state. These mood symptoms are often associated with impaired ability to work and make decisions, sleep problems, alcohol and drug abuse, sexual promiscuity and bad decision making.
Bipolar disorder affects between 2 and 7 percent of the population directly and many more indirectly - the family, carers, colleagues and friends. Support groups for relatives and carers form an essential part of management of patients with this challenging illness.
The cause of bipolar disorder is unknown but there is strong genetic and familial association between schizophrenia, depression and bipolar disorder.
Symptoms of Bipolar Disorder
The symptoms usually consist of mood extremes which fluctuate with varying frequency and varying severity - sometimes as often as several times a week and sometimes there may only be one episode in a lifetime, and everything in between. Age of first onset of symptoms is typically late teens to early 30s.
There is significant debate in the academic psychiatric community about classification and diagnostic criteria for bipolar disorder and its many subtypes, a task made all the harder by lack of any diagnostic tests.
Manic phase:
The "manic" symptoms are usually characterized by sleep disturbance, decreased need for sleep, waking up early and not feeling tired, not feeling as if you need the sleep.
The mood is elevated, one feels a sense of grandiosity, like "I can do anything". There may be increase in speed and amount of speech, it is difficult to interrupt and in extreme cases the speech may become incomprehensible. One easily becomes irritated and even angry. Friends are made easily and business dealings are entered into easily. There is often excessive spending and incessant need to talk - increased number of phone calls, constantly talking on the phone, and generally doing everything "over the top".
If drinking alcohol, people can often consume large amounts of alcohol without feeling the intoxicating effects of it, "not feel drunk". It is not unusual for people to engage in sexually promiscuous behaviour, bring strangers home, enter into business dealings that appear unrealistic and spend large amounts of money. There is often associated drug use and it may be difficult to distinguish whether the manic state is caused by the drugs (especially amphetamines, ice, cocaine) or preceded the drug taking behaviour.
In extreme cases, manic psychosis ensues. Patients are said to be in a psychotic state if they lose touch with reality. There are many different types of psychosis, and in manic psychosis patients often feel that they are endowed with some grandiose task to save the world, or have magic powers to influence world events or the environment.
They may hear voices or feel that they are influenced by a higher power. They may feel that they are getting instructions or special messages from the TV, radio or the internet. They may feel the need to travel in order to achieve their goals.
If confronted about their unusual symptoms, patients usually deny that anything is wrong and often become angry and even aggressive. Talking logically and sensibly at this extreme level of illness usually does not work and admission may often be required.
Depressive phase:
At the other end of the spectrum, is severe depressive illness, which often follows after a manic phase. This consists of low mood, decreased speech, decreased desire to talk or socialize with others, lack of pleasure in daily activities.
Patients often become withdrawn. Appetite is decreased and there is also sleep disorder, but unlike in manic patients, depressed patients feel tired, lethargic and generally ill. They often lose will to live and become suicidal. The risk of suicide is extremely high in patients in depressive phase of bipolar disorder.
Patients are often confronted with the relationship, financial and professional chaos that may have been created during the manic phase of illness (if this was not managed properly at the time) and may be faced with the destruction that was created at that time, which exacerbates their depression and suicidality.
Diagnosis of Bipolar Disorder
Diagnosis relies on assessment which consists of accurate detailed history taking, including involving the family members and carers, possible investigations for medical conditions which may cause similar symptoms such as thyroid disease, adrenal problems, psychological assessment and possible radiological investigations.
There are no diagnostic tests for bipolar illness and there is considerable debate about just what can be diagnosed as bipolar disorder. For example, some people may wake up feeling "on a high" but this may wane within several hours and by afternoon they may feel "low".
There may or may not be associated triggers.
- Does this constitute bipolar illness?
- Or mood instability associated with some personality disorders?
- Or "the moodiness" of adolescents?
The jury is out and there is no consensus of opinion.
Types of Bipolar Disorder
There is broad agreement about three main types of bipolar disorder, and these are:
- Bipolar I disorder - this is characterized by at least one clearly manic episode and at least one depressive episode, but predominantly recurring manic episodes.
- Bipolar II disorder - characterized by at least one "hypomanic" episode (not as severe as full mania) lasting at least four days but predominantly recurring depressive episodes.
- Bipolar disorder with mixed symptoms - this is characterized by someone who presents with a mixture of manic and depressive symptoms at the same time.
There are psychiatrists and schools of thought that also include:
- rapid cycling bipolar disorder indicating that the cycles of mania-depression occur every within several weeks of each other;
- ultra rapid cycling bipolar disorder indicating that cycles occur even more frequently or within days of each other;
- ultra ultra rapid cycling bipolar disorder indicating that cycles occur within a day;
Bipolar Disorder in Children
Bipolar disorder in children is highly controversial. There are certainly children who may appear to be moody or grumpy, and this may affect their relationships and school performance. This may have many causes which would be discerned by an assessment by a skilled child psychologist or psychiatrist.
As a matter of principle, medication should be used highly cautiously in children and adolescents as a last resort and only if there are good indications for doing so.
Treatment of Bipolar Disorder
The treatment of bipolar disorder relies on four broad principles:
- psychoeducation,
- cognitive behavioural therapy,
- medication,
- involving family in treatment
There is no curative treatment, and all treatment is aimed at preventing recurring episodes of mania or depression and limiting or controlling their severity if such episodes occur.
A combination of individual and group therapy is usually recommended, as well as attendance at day treatment programmes and support groups for families and carers.
In some cases, admission to psychiatric hospital may be necessary.
Psychoeducation:
Bipolar disorder is a chronic illness with the highest risk of successful suicide among all psychiatric disorders. Because it is a chronic illness and has specific predisposing and precipitating factors - events/triggers that may cause an episode - psychoeducation of both sufferers and their families/carers forms an essential component of treatment.
It involves educating the patient and their families about the chronic nature of the illness; possible causative factors such as drugs, lack of sleep, stressful events; what to watch out for as "early signs".
Part of successful education is involving patient in treatment, establishing a trusting relationship with the psychiatrist, and establishing compliance with medication. Psychoeducation usually forms part of regular reviews with psychiatrist, along with regular review of mental state.
Cognitive behavioural therapy:
There are many forms of cognitive behaviour therapy (CBT) that may be used in patients with bipolar illness, but only one was demonstrated to be effective in scientific trials.
This is so called "rhythms" therapy which focuses on maintaining regular daily routines and circadian rhythms.
Medication:
As much as people don"t like to hear it, medication is still mainstay of treatment in bipolar illness. The choice of therapy is complex and is best done in consultation and with agreement between doctor and patient.
Some of the medications that are used include:
- Lithium,
- Valproate,
- Tegretol,
- Lamotrigine,
- Seroquel,
- Zyprexa,
- Zeldox
- as well as a whole range of antidepressants.
It is essential that you discuss medication, its side effects and all relevant issues of concern to you with your doctor. There are also a range of complementary medicines which may be useful such as N-acetyl cysteine, omega-3 fatty acids and inositol.
Involving family in treatment:
The family and the patient are equally involved in someone suffering from bipolar disorder. The family is also our patient.
We offer a range of support services to families of patients with bipolar disorder.
How We Can Help With Treating Bipolar Disorder
Research Update
Neuroprotection in Bipolar Disorder a viable therapeutic option: The biological processes involved in causation of bipolar disorder may include inflammatory processes and oxidative stress. A recent paper published in the Medical Journal of Australia by Prof.Michael Berk of Melbourne University discusses potential novel treatments such as antioxidants, in particular n-acetyl-cysteine, as having impact on clinical course of the illness.
