Bipolar Disorder

We all have periods of ups and downs, but in people with bipolar disorder, also known and manic-depressive illness, these mood swings are extreme and intense. The disorder is marked by high periods of mania and low periods of depression. Bipolar disorder isn’t a rare diagnosis, it is thought that about 2.5% of the population suffers from this illness. People with bipolar disorder may have trouble managing everyday life tasks, at school or work, or maintaining relationships. Although it is a lifelong condition, bipolar disorder can be managed effectively with a good treatment plan.

Causes

The exact causes of bipolar disorder are not known, however scientists think that the interaction of genetic, neurochemical and environmental factors play a role in the start and progression of bipolar disorder. From a neurochemical standpoint, it is thought to be a dysfunction of certain neurotransmitters or brain chemicals, the major ones being serotonin, dopamine and noradrenaline. For example, there's evidence that episodes of mania may occur when levels of noradrenaline are too high, and episodes of depression may be the result of noradrenaline levels becoming too low.

Bipolar disordermay lie dormant and be triggered by a stressor such as a stressful life event, alcohol or drug abuse or hormonal problems. Medications such as antidepressants or appetite suppressants, excessive caffeine or drugs can also trigger a manic episode in people who are vulnerable to bipolar disorder.

Bipolar disorder also appears to be linked to genetics. The risk of bipolar disorder goes up if close family members have the disorder, however,no single gene is responsible for bipolar disorder and more research needs to be done on the genetics.

Brain structure and functioning

Some brain-imaging tools such as MRI and positron emission tomography (PET), have been used to study the brains of people with bipolar disorder to see if they differ from healthy people.

One MRI study found that the brain’s prefrontal cortex, which controls functions such as problem solving and decision making, in people with bipolar disorder is usually smaller and does not function as well as healthy adults. This suggests that there may be abnormal development of the brain structure in adolescent years and may help doctors pinpoint who is at risk of bipolar disorder.

However, scientists still don’t fully understand how the different regions of the brain connect and influence each other, so they are still working on learning more about this before they can understand which treatment will work most effectively.

Signs & Symptoms

Bipolar disorder can look different in different people, but is usually characterised by extreme mood swings that can vary in their severity and frequency. The intense emotional states occur in periods called “mood episodes”. They can range from extreme highs (mania) to extreme lows (depression).The symptoms vary widely in their pattern, severity, and frequency. Episodes of depression and mania often last for weeks or even months. Sometimes the episode has symptoms of both mania and depression, this is known as a mixed state, for example, feeling both agitated and hopeless at the same time. Generally, there is a time of feeling normal between depressive and manic episodes, but some people experience “rapid cycling” which is where they repeatedly go from a high to low phase quickly without having a "normal" period in between. This needs to be treated urgently.

Mania and hypomania:

These are two different types of mania, mania and hypomania. They have the same symptoms, but hypomania is not as severe as mania and may not affect relationships and job performance. However, the person affected will notice that there is a change in their mood. In the manic phase, it is common to experience three or more of the following symptoms:

Abnormally upbeat, jumpy or wired
Heightened energy, creativity and activity or restlessness and irritability
Unrealistic, grandiose beliefs about one’s abilities or powers
Euphoria, feeling overjoyed or elated
Sleeping very little, but still having lots of energy
Unusual talkativeness and rapid speech
Racing thoughts
Distractibility and inability to concentrate
Not eating
Impaired judgement, impulsiveness and acting recklessly, for example,going on spending sprees, taking sexual risks or making foolishinvestments
In severe cases, delusions and hallucinations, for example, believing that you are famous or have super powers.
Depression

During a major depressive episode symptoms are severe enough to affect normal functioning. An episode typically includes a number of these symptoms:

Feeling deep sadness, hopelessnessor emptiness
Feeling irritable
Loss of energy or fatigue
Restlessness or slowed behaviour
Lack ofpleasure and interest in activities one once enjoyed
Appetite or weight changes
Sleep problems: insomnia or sleeping too much
Difficulty concentrating or remembering things
Feelings of worthlessness or inappropriate guilt
Feeling pessimistic about everything
Suicidal thoughts

Who Is At Risk?

Bipolar disorder can occur at any age, but it is typically develops in the late teens or early adult years. Having a first a first degree relative such as a parent or a sibling with bipolar disorder increases a person’s risk of developing the illness, but it doesn’t necessarily mean that other family members will develop the disorder. If one parent has bipolar disorder, there's a 10% chance that their child will develop the illness.If both parents have bipolar disorder, the likelihood of their child developing bipolar disorder rises to 40%.

Diagnosis

There are four basic types of bipolar disorders. Doctors diagnose bipolar disorder using guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM).Each type of bipolar disorder is defined by the length and frequency and the patterns of the episodes.  The basic types of bipolar disorder are:

  • Bipolar I disorder. This involves periods of extreme mood episodes from mania to depression. At least one manic episode must have occurred. In some cases, mania may even trigger psychosis, which is a break from reality.
  • Bipolar II disorder.  This disorder involves minor forms of mood elevation that alternate with severe depression. The highs in Bipolar II, which are called hypomanias, are not as high as those in Bipolar I. Bipolar II is not a milder form of Bipolar I, but a separate disorder.
  • Cyclothymic disorder. This is a milder form of bipolar, with a number of hypomanic episodes and less severe depression than major depression. These episodes must have been taking place for at least two years.
  • Rapid Cycling: Bipolar disorder with rapid cycling is when a person has four or more episodes of major depression, mania, hypomania or mixed states in a year. It can happen in any type of bipolar disorder and can be a temporary condition for some people. Rapid cycling seems to happen more in people who have their first bipolar episode at a younger age.

Currently, bipolar disorder can’t be identified through lab tests or scans. An experienced doctor or mental health professional, such as a psychiatrist, must discuss signs and symptoms and do a mental health evaluation of the person experiencing bipolar symptoms, in order to make a diagnosis.

In order to help a doctor make an accurate diagnosis, it is useful to write down your symptoms, particularly those which reflect depression or mania. Also note sleep patterns, energy patterns, thinking and behaviour. A family history is also very helpful. 

If you suspect that you may have bipolar disorder, it is important to see help as soon as possible as bipolar disorder can worsen if left undiagnosed and untreated. It often has an adverse effect on relationships and work which can lead to problems in these areas if undiagnosed. Substance abuse is also common in people with bipolar disorder, which could become an issue and needs to be addressed.

Treatments

A combination of medication and counselling is generally used to treat bipolar disorder. For people who have very severe symptoms, don’t respond to, or can’t take the medication, other treatments such electroconvulsive therapy (ECT) may be used.

Medications

Some medications address both mania and depression, but at times it is necessary to treat the mania and depression symptoms separately with different medications. Some medications are used to keep moods steady. Generally, antidepressants are not used alone, as they can cause mania. Often with the correct medications, mood symptoms disappear, but even if they do not, they should become more manageable.

For those suffering from mania, the first step is usually treatment with an anti-manic mood stabilizer and sometimes an antipsychotic drug or benzodiazepine to quickly control the symptoms.

Mood stabilizers treat manias or depressions without causing symptoms to cause the opposite effect. These often have to be taken for many years. Examples include lithium and certain anticonvulsant drugs such as carbamazepine (Tegretol), lamotrigine (Lamictal) or valproate (Depakote).  Atypical antipsychotics used to treat mania include aripiprazole (Abilify), asenapine (Saphris), cariprazine (Vryalar), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) .

For those who are in a manic state, hospitalisation may be necessary to help control reckless or risky behaviour and to make sure that medication is taken. 

Not everyone responds to medications in the same way, so you may need to work closely with your doctor to find the ones that work best for you. You may need to try several different medications and monitor the side effects and symptoms closely.

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls. This can lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20. It may also lead to suicidal thoughts. Young girls and women taking valproic acid should be monitored carefully by a doctor.

What are the side effects of mood stabilisers?

Lithium can cause side effects such as:

Restlessness
Dry mouth
Bloating or indigestion
Acne
Unusual discomfort to cold temperatures
Joint or muscle pain
Brittle nails or hair.

When taking lithium, your doctor should check the levels of lithium in your blood regularly, and will monitor your kidney and thyroid function as well. Lithium treatment may cause low thyroid levels in some people. Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important that your doctor check your thyroid levels carefully. You may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Common side effects of other mood stabilising medications include:

Drowsiness
Dizziness
Headache
Diarrhea
Constipation
Heartburn
Mood swings
Stuffed or runny nose, or other cold-like symptoms.

These medications may also be linked with rare, but serious side effects. Talk with your doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you're taking. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

Atypical antipsychotics are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications, such as antidepressants. Atypical antipsychotics include:

Olanzapine (Zyprexa), which when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis. Olanzapine can be taken as a pill or a shot. The shot is often used for urgent treatment of agitation associated with a manic or mixed episode. Olanzapine can be used as maintenance treatment as well, even when psychotic symptoms are not currently present. Aripiprazole (Abilify), which is used to treat manic or mixed episodes. Aripiprazole is also used for maintenance treatment. Like olanzapine, aripiprazole can be taken as a pill or a shot. The shot is often used for urgent treatment of severe symptoms. Quetiapine (Seroquel), risperidone (Risperdal) and ziprasidone (Geodon) also are prescribed to relieve the symptoms of manic episodes.What are the side effects of atypical antipsychotics?

If you are taking antipsychotics, you should not drive until you have adjusted to your medication. Side effects of many antipsychotics include:

Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in your metabolism. This may increase your risk of getting diabetes and high cholesterol. Your doctor should monitor your weight, glucose levels and lipid levels regularly while you are taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes uncontrollable muscle movements, frequently around the mouth. TD can range from mild to severe. Some people with TD recover partially or fully after they stop taking the drug, but others do not. Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

However, taking only an antidepressant can increase your risk of switching to mania or hypomania, or of developing rapid-cycling symptoms. To prevent this switch, doctors usually require you to take a mood-stabilizing medication at the same time as an antidepressant.

What are the side effects of antidepressants?

Antidepressants can cause:

Headache
Nausea (feeling sick to your stomach)
Agitation (feeling jittery)
Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.

Report any concerns about side effects to your doctor right away. You may need a change in the dose or a different medication. You should not stop taking a medication without talking to your doctor first. Suddenly stopping a medication may lead to "rebound" or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

Should women who are pregnant or may become pregnant take medication for bipolar disorder? Women with bipolar disorder who are pregnant or may become pregnant face special challenges. Mood-stabilising medications can harm a developing fetus or nursing infant. But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy. Lithium is generally the preferred mood-stabilising medication for pregnant women with bipolar disorder. However, lithium can lead to heart problems in the fetus. In addition, women need to know that most bipolar medications are passed on through breast milk. The FDA has also issued warnings about the potential risks associated with the use of antipsychotic medications during pregnancy. If you are pregnant or nursing, talk to your doctor about the benefits and risks of all available treatments.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behaviour, or any unusual changes in behaviour such as trouble sleeping, agitation, or withdrawal from normal social situations. For the latest information, see the FDA website .

Psychotherapy

Psychotherapy can help people find ways to deal with bipolar disorder and the effect it has on their lives. It can help the person to cope with difficult feelings, manage stress, rebuild relationships and provide support and guidance.

Some psychotherapy treatments used at Papillon to treat bipolar disorder include:

Cognitive therapy: this therapy involves learning to identify and change harmful or negative patterns of thinking.

Interpersonal and Social Rhythm therapy: this helps people with bipolar disorder manage their daily routines and relationships.

Family-focused therapy: helps family members learn coping strategies to help themselves and their loved ones. It also assists in improving communication in families.

Psychoeducation: teaches people how to recognise warning signs so they can get help and treatment before they have a serious episode. Research has shown that psychoeducation leads to fewer relapses and hospitalisation rates and a faster recovery rate.

Other treatments

Electroconvulsive therapy (ECT) is primarily used to treat the depressive phase of bipolar disorder, but it can also be used for the manic phase.

It uses a short electric current which is passed through the scalp while the patient is under anaesthetic. This causes a small seizure which in turn causes changes in the brain chemistry and “reboots” the brain. Although there are some negative associations with ECT and misuse in the past, it has greatly improved and is considered very effective for treating bipolar episodes. It is generally only used when other methods have been ineffective. It has also been shown to be effective in preventing future episodes. A side effect can be memory loss, but it is typically only loss of memory around the time of the therapy session. Other side effects such as confusion and nausea are only temporary. It is considered safe enough to use on pregnant women and elderly people, but it may pose risks for people with certain medical issues. It needs to be done by a trained doctor.

Herbal supplements:

Not much research has been done on herbal or natural supplements and bipolar disorder. St John’s wort is a herb that is sometimes marketed as a natural antidepressant, but it may cause mania in people with bipolar disorder.

Ongoing research

Scientists are working to better understand bipolar disorder. The NIMH is heading up the Research Domain Criteria (RDoC) Project, which is working to widen our understanding of brain circuitry that relates to behavioural and cognitive functioning. It is hoping to open the door to new preventive interventions, improve current medications and develop new treatments for bipolar disorder.

A particular focus is to find faster-acting medications. Some progress has been made in this sphere already. Ketamine has been shown to reduce symptoms of depression in less than an hour. This is a type of anaesthetic medicine and has serious side effects, so it cannot be used, but scientists are trying to find medications that act in the same way, without the side effects.

Living With

Bipolar disorder affects about 60 million people worldwide. If you have bipolar disorder you are not alone. Beyond your medical treatment, there are many things you can do to maintain your balance and develop coping skills. Among them are educating yourself as much as possible on the disorder, surrounding yourself with a support system and leading a healthy lifestyle.

To help yourself:

Be involved in your treatment: Learn everything you can about bipolar disorder, know the symptoms so that you can recognise them in yourself. Work with your doctor or therapist on your treatment. Don’t be afraid to ask questions or give input. Make healthy choices for yourself. Take your medication.

Monitor your symptoms and moods: Keep a close track of your moods. Know your triggers, such as stress, arguments with family, financial difficulties. Keep a mood chart so you don’t forget to monitor yourself in the business of life.

If you spot warning signs, you need to have something to draw on to get your back on track. Something like a wellness toolbox, which is a list of coping skills, may help. You will know which coping skills work for you, but consider tools like, talking to someone supportive, making sure you get enough sleep, cut back on commitments or activities, go to a support group, call your doctor, exercise, do something creative, make sure your diet is healthy and cut out stimulants.

Relapses do occur, so have an emergency plan in place too; write down a list of doctor’s numbers, the medication you are on and treatment preferences.

Remember that it takes time, symptoms tend to improve gradually.

Don’t isolate yourself: Keep in regular communication with your therapist and people who support you. Have regular contact with family and friends. Join a bipolar support group, spending time with people who know what you are going through can be very therapeautic. Join new community activities too, such as a church or charity work or classes and courses on something you are interested in.

Have a daily routine: Build structure into your life, eat healthily, exercise, make sure you sleep for at least eight hours a night. Try to go to bed and wake up at the same time each day and try to reduce stress in your life, using relaxation methods and making sure you schedule leisure time.

Friends and relatives:

If you are a friend, relative or caregiver of someone with bipolar disorder, it can be stressful and disruptive and you may need support or coping skills too.

You can help your friend or relative by:

Getting help for them. If you suspect someone has bipolar disorder you need to help him or her to get the right treatment. You may need to take them to the right doctor for a diagnosis and be there to encourage them to stick with the treatment.

Educate yourself about bipolar disorder, know the symptoms and as much as you can about the disorder, so that you are equipped to help.

Be understanding and sympathetic. Let the person know that you are there for them and will support them. Listen carefully; show that you understand their triggers. Keep in contact with the person, arrange times to see them and take them out. Be encouraging about their treatment and chances of recovery.

Be patient. Getting well is a long process and may have setbacks. Don’t expect a quick recovery.

Dealing with a person with bipolar disorder can be challenging. Family members or caregivers often struggle with a range of emotions from fear to anger as well as the daily struggles to deal with the symptoms. The strain can cause damaged relationships and exhaustion.

There are ways to cope:

Accept the illness: Understand that it isn’t anyone’s fault, but also that things will never be exactly the same again. Have realistic expectations. Don’t take the things the person may say or do personally.

Accept your loved ones limits as well as your own limits. People with bipolar disorder cannot control their moods in the same way as other people, you need to understand this. At the same time you are not responsible for your loved one’s recovery, that lies in their hands.

Establish routines for both your loved one and yourself, this will ease stress. Have regular meal times and bed times.

Reduce your own stress: Do this by having a support network, or belonging to a support group. Set boundaries; be realistic about the amount of care you can give without burning out. Keep sight of your own goals and interests too. If it becomes too much for you, ask for help.

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