Bipolar Disorder

I felt prompted to write about bipolar disorder after recent public revelations from two American congressmen who suffer from this illness.   Bipolar illness falls into the mood disorder category of our DSM IV, but is called bipolar because both “poles” of mood, high and low are part of the symptomatology.  An earlier label , manic-depressive illness is still often used today.

There are three designations of the illness; bipolar I, bipolar II and cyclothymia.    All three have a cyclic nature.  There are recurring highs alternating with depressed periods. The three diagnosis depend  and differ on the severity and duration of the mood swings and whether or not there is mania or a psychotic component.

One can only be diagnosed bipolar l if their high mood constitutes the definition of mania.  There may also be a mixed episode of depression and or psychosis.   Bipolar I patients are hospitalised more for mania and psychosis.

Mania can best be described as an extremely intense feeling of elation and euphoria.  At this time the patient is very talkative, laughing with a continuous flight of lofty ideas and projects in mind.

Thoughts literally race with great speed to the degree that they go from one subject to another without pause. It is not unusual to see intense religiosity too.

There is an increased libido, and tremendous energy and feelings of overconfidence and invincibility that can lead to impairment in judgment leading to unfortunate sexual liaisons, or spending sprees, risky business investments or putting themselves in a dangerous situation.

Mania can come up spontaneously and I remember one who left  home in the middle of night walking around naked and very delusional, until picked up by the police.  I have had other patients whose spending sprees got them into very hot water, such as spending $2,000 for videos at one time.  Another who bought two Cadillacs he could not afford.  As prevention, credit cards are taken away to avoid these serious mishaps.

They usually have little need for sleep and will resent you leaving them to go to bed.  During this time they can be overly creative with writing and creating multiple projects.  The euphoria can quickly turn to hostility and even aggression.  Psychotic symptoms can occur such as  auditory hallucinations, paranoia and even delusions .

Patients in true mania  and or psychosis need to be hospitalised for their own protection.  At this time antipsychotic medications are prescribed along with mood stabilizers.  Most are very resentful of being sequestered since they feel so wonderful, energetic and creative, and can be very difficult to deal with to say the least.  They remain hospitalised  until their judgment returns and their mood becomes normal.

Some fragile bipolar I patients are rapid cyclers, which means that they can cycle very quickly from highs to extreme lows and are very difficult to manage.  I have seen this happen multiple times and it is a strange phenomena to observe.   The rapid cyclers are also the most difficult to manage medication wise.

Bipolar ll has very severe depressive phases, but the highs  are hypomanic and not true mania, nor is there any psychotic component.  That is the major difference between the two.   Most bipolar ll patients do not have highs as often as bipolar l, and it seems that depressive episodes are more prominent and recurring.  Risks of suicide is of major concern due to the dept of melancholy and hopelessness during these major depressive phases.

Cyclothymia from the Greek meaning cyclic and thymia, meaning mood, is the mildest form of a cycling mood disorder.  The depressive periods are not as severe, nor are the highs well-defined or sustained as in bipolar ll.   I refer to it as baby bipolar.  Antidepressant medication is used for the depression, but mood stabilizers are rarely needed.

It has been found that approximately 3 to 5% of the population suffer from  bipolar illnesses. I suspect there are more bipolar ll’s not diagnosed, as many who receive antidepressant medication, never see a psychiatric clinician.  Any time I see someone who has a history of depressive episodes , it is imperative to screen for highs or hypomania. Often high periods are overlooked as being problematic because they feel good and are productive , in addition to the patient and family members seeing that as normal.

The age of onset  in the majority of cases is late teens to early twenties.    It runs in families and studies demonstrate a definite genetic link.   From a simplified neurophysiological point of view, it is caused by the instability of the neurotransmitter system.   For example the euphoria after cocaine use, can mimic that of bipolar I.  The neurons are flooded with extremely high levels of neurotransmitters, and inevitably is followed by a very low depressed and irritable mood.   Women constitute more rapid cyclers, probably due to hormonal fluctuations.

For some as of yet unknown reason, the majority of episodic exacerbations occur during the spring and fall.  Bipolar l patients must be careful to get adequate sleep as lack of sleep as well as intense social stimulation, and loud music can trigger a high.  Stressful life events can also cause onsets and decompensations(getting worse).   Antidepressant medication can trigger hypomania in genetically predisposed patients and is considered a biological marker that can facilitate a diagnosis.

Mood stabilizers such as Depakote and or lithium. are started initially for mania in Bipolar l patients,  usually along with some antipsychotics, either orally or injected, especially  during manic psychosis.  For those who present a depressive episode, an antidepressant is started along with one of the mood stabilizers.    Other newer mood stabilizers such as lamotrigine and new generation antipsychotics such as Seroquel, Zyprexa, Risperidone, and Abilify  may also be employed.

Prior to starting any mood stabilizers, lab work is needed to establish base renal, hepatic and thyroid levels, in addition to a EKG.   Lithium,  requires periodic blood levels to ensure therapeutic levels, and to avoid toxicity, along with renal functioning tests, since lithium is excreted by the kidneys.    Lithium works great, but can in some cases with very long-term use cause renal dysfunction  and hypothyroidism.  Depakote is easier to manage but can cause weight gain.

Acceptance of the chronicity of the illness is as difficult to accept as in any chronic disease such as diabetes for example.  Young bipolars are often unwilling to stay on medication and end up with multiple relapses.  It can be frustrating for both clinician and patients to find the perfect combination of medications, as trial and error is often needed.

I have found that the majority of bipolar patients have a higher level of IQ and creativity.  Their productivity during a high is  notorious prodigious.

Not surprising many famous writers, artists, and composers, such as Van Gogh, Beethoven and Hemingway to name just a few suffered from the illness.   Although obviously talented, one wonders if these greats sustained creativity was fueled by their neuronal highs. Unfortunately the associated deep depression can lead many to suicide as in the case of Van Gogh.

Suicidal ideation can be intense during the depressive episodes in either Bipolar I or II, and may necessitate hospitalization. Most Bipolar II patients with proper medications, including continuous follow up, can lead  normal and productive lives personally and professionally.

Bipolar I patients have a more difficult time and have to be vigilant about any highs turning into true mania, or psychosis, which hospitalization is necessary for their protection.  It is not unusual that they end up having several hospitalizations a year in severe cases.

Every case is different and some Bipolar I patients can function in certain job situations, that are not overly stressful and demanding. Families need to be aware of the onset of symptoms, as they are often a better judge than the patient, especially concerning highs that are accelerating.

Either onset of highs or depression may necessitate changing medications several times, so teaching patients to be self monitoring is important, as well as family members.

I find the neurophysiology fascinating as well as the patients themselves.  I once had an outpatient group of bipolar patients and they are some of the most interesting, delightful, and at times entertaining patients to work with!