Bipolar Disorder: The Other Mood Disorder

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As with many mental health disorders, bipolar disorder is often misunderstood. Many of us, myself included, have used the word “manic” to describe a friend who is racing around, with a lot of energy, talking fast about a bright idea. Or we have used the word “bipolar” to describe someone who gets angry and irritated easily and quickly.

The concept of different extremes of human mood states dates back many centuries. The Greek physician Hippocrates (460 B.C.-370 B.C.) coined the term “melancholia,” which he attributed to an excess of “black bile” (from the ancient Greek terms melas (black) and chole (bile)). In contrast, he hypothesized that manic states we were caused by a buildup of “yellow bile.” The term “manic” derives from the Greek mainesthai (to go mad, to rage) or menos (passion, spirit).

In the mid-1800’s, two French psychiatrists described illnesses with extreme mood states, high and low, appearing in the same patient, but at different times, in a cyclical pattern. Jean-Pierre Falret wrote about “la folie circulaire,” literally translated as “circular madness.” And Jules Baillarger named it “folie à double forme,” or “double form madness.”

In the early 1900s, Emil Kraeplin, a German psychiatrist, described “manic-depressive psychosis” and differentiated it from a schizophrenia-type illness by noting symptom-free periods of normal functioning in between mood episodes. Manic-depressive illness was renamed Bipolar Disorder in 1980, in the third revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III).

Bipolar disorder is a mood disorder characterized by episodes of clinical depression and episodes of mania or hypomania. Mania is a state of abnormally elevated or irritable mood along with symptoms such as very high energy, not needing much sleep, racing thoughts, impulsive or risky behaviors (which are out of character for the person), much higher levels of activity, agitation, rapid speech, inflated self-esteem, unrealistic plans, and sometimes psychotic symptoms (such as hallucinations or false beliefs-delusions). The delusions may be grandiose in nature, such as believing that one is a celebrity or that one has special powers. Hypomania (“below mania”) is a milder version, without psychotic symptoms, need for hospitalization, or significant impairment of functioning.

There are many different forms of bipolar disorder, and, as we learn more about the underlying biology, we may come to find that it is not really even a single disorder, but may in fact be different illnesses that all manifest as mood swings. Bipolar I disorder involves depressive episodes and full manic episodes, while people with bipolar II disorder have hypomanic, but not full manic, episodes.  We also now tend to think of bipolar “spectrum” disorder, as it often doesn’t present with the classic discrete manic and depressive episodes, but instead manifests as variations, such very rapid cycling between mood states, or “mixed” mood episodes. Mixed episodes are especially distressing, for example depressed mood along with agitation, racing thoughts and inability to sleep.

The etiology of bipolar disorder is multifactorial, complex, and poorly understood, but there is strong genetic heritability. The age of onset is often late adolescence and early adulthood. Estimates of prevalence vary, from 1% of the population for bipolar I disorder, to 2.5-5% for “bipolar spectrum” illnesses. The risk of suicide is significant with bipolar disorder, with estimates in the range of 25-50% for suicide attempts, and up to 20% (many with untreated illness) of those with bipolar disorder die by suicide. Therefore, accurate and timely diagnosis and access to treatment is crucial.

Bipolar disorder often co-occurs with other illnesses, including anxiety, OCD, substance use disorders, PTSD and ADHD.

Correctly diagnosing bipolar disorder is important, especially differentiating it from “regular” “unipolar” depression (“one pole” depression, without the mood cycling or abnormally elevated mood episodes.)  The treatments are different, and the antidepressant medications used to treat unipolar depression can lead to a worsening course of bipolar disorder (by precipitating a manic episode or mood cycling). Getting the initial diagnosis right is easier said than done; the onset of bipolar disorder is more likely to present with and one or more depressive episodes before the first hypomanic or manic episode. Therefore, we take other clues into account, such as a family history of bipolar disorder, early age of first depression, careful questioning to elicit any forgotten or overlooked episodes of subtle hypomanic symptoms, or “mixed” symptoms such as prominent agitation, impulsivity and restlessness.

Treatment is individualized and varies depending on specific circumstances, clinical presentation, and personal preference. Modalities include psychotherapy (individual, group, and/or family therapy), mood stabilizing medications (some complimentary), and alternative medicine strategies (such as omega 3 fatty acids and meditation), minimizing substance use, and other self-care practices. There are many examples of mood stabilizing medications; all have their pros and cons and none are perfect. Lithium carbonate, despite its potential side-effects, is still considered the gold standard and also has been shown to independently reduce suicidal thoughts in some people.

Maintaining regular daily schedules and routines helps tremendously with stabilizing mood. Interpersonal and Social Rhythm Therapy is one form of this, emphasizing regular schedules for eating, sleeping, exercise and other activities. Avoiding sleep deprivation is key; the importance cannot be overstated. Sleep deprivation in and of itself is a driver of mania and mood cycling. 

Bipolar disorder is a biologically based and treatable illness. Accurate and early diagnosis, along with access to care, can help reduce the impact of the disorder over the longer term.

If you or someone you know may be struggling with suicidal thoughts, you can call the National Suicide Prevention Lifeline at 800-273-TALK (8255) any time of day or night or chat online. You can also text HOME to 741741 to reach the Crisis Text Line. 

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