Bipolar Disorder (Manic-Depression)
Stuck at the extremes
Bipolar affective disorder, also called manic depression, is a devastating illness marked by alternating periods of euphoria and depression. Instead of feeling in charge of their moods, people with bipolar disorder feel victimized by them.
This widely misunderstood condition's stereotype focuses on major mood swings, ranging from deep depression to extremely energetic and unrealistic, "crazy" behavior. Wild mood swings that a person cannot control may happen (and could lead to hospitalization), but bipolar disorder is often much more subtle. Everyone has mood swings, so it's often difficult to distinguish between people who are simply "moody" and those who are truly bipolar.
Bipolar disorder usually begins with a period of depression, typically lasting three to six months. The manic phase that follows is usually shorter -- several days to months. In the first few days of a manic episode, the person not only feels wonderful but often attracts others because of his or her enthusiastic mood and expansive behavior. If the mood escalates, however, its inappropriateness becomes apparent and the person's actions become more erratic and destructive, possibly alienating even close friends and family.
- Manic depression
- Bipolar affective disorder, type I
- Bipolar affective disorder, type II
- Mood disorder
- Cyclothymic disorder
A manic episode of bipolar affective disorder is marked by hyperactivity paired with extreme euphoria, out of proportion to any event worth celebrating. While the person exhibits extreme, even self-destructive behavior, he or she feels better than ever and may have no sense that his or her behavior is inappropriate. Those in the throes of a manic episode will typically talk excessively, stay up all night, and have bursts of energy, though they accomplish little because they cannot focus on any task for long. They have racing thoughts and grandiose delusions, frequently using poor judgment. In the throes of mania, patients may spend a great deal of money, become sexually reckless, and break laws.
As mania progresses, patients become increasingly irritable, hostile, angry, and even delusional. The last stage of a manic episode is also the most destructive. Patients are filled with panic and terror. Sleep is impossible. Physical activities dissolve to a state of frenzy, and hallucinations may occur. Not all manic-depressives reach this final stage.
The "down" phase of bipolar affective disorder can have all the features of major depression, such as "blue" mood, disturbed sleep, lack of pleasure and interest in activities, disturbed appetite, weight change, and trouble concentrating.
There are four types of bipolar affective disorder:
- Bipolar affective disorder, type I consists of alternating episodes of major depression and full-blown psychotic mania in which the person is incapacitated by physical frenzy and hallucinations
- Bipolar affective disorder, type II is marked by alternating episodes of depression and hypomania (a milder form of mania in which the person has an inappropriately elevated mood, but whose behavior doesn't impair his or her ability to work or have relationships)
- Bipolar affective disorder, not otherwise specified consists of major depressions and episodes that almost but don't quite reach criteria for hypomania
- Cyclothymic disorder is characterized by hypomania and mild depression alternating together over the course of a few days
How Common Is Bipolar Affective Disorder?
Nearly 2% of the U.S. population has the disorder -- more than 5.4 million people. It usually emerges during the teens, 20s, and 30s; however, it can arise at any age. Men and women are equally affected, on average at age 30.
What You Can Expect
Untreated, a manic episode may last several months. Like depressive episodes, mania may pass without treatment. However, the toll on the person and his or her family may be intolerable. Fortunately, bipolar affective disorder is treatable with drug therapy, as well as psychotherapy. With proper care, doctors may bring a manic episode under control within a few weeks.
No one knows what causes bipolar affective disorder.
Researchers believe that interference with the molecules that act as messengers to the brain and nerves (neurotransmitters) may cause bipolar affective disorder. The disorder appears to have a hereditary component, though the exact gene or genetic defect is still unknown. Life experiences, such as traumas, may trigger the condition in those who are vulnerable to it.
Factors that can put you at risk for bipolar affective disorder include:
- Personal history of depressive disorder with no manic episodes (unipolar)
- Family history of manic-depressive disorder (bipolar)
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
The name of this condition describes it well. People with bipolar affective disorder swing back and forth between the poles of mania -- a state of extreme elation or hyperactivity -- and depression. One in three people with manic depression experiences both manic and depressive symptoms at the same time.
Mania is marked by having three or more of the following symptoms for at least one week:
- Hyperactivity, marked increase in energy
- Increased sexual drive
- Difficulty sleeping, and/or beginning to wake earlier and earlier
- Diminished need for sleep
- Disproportional anger, considering what triggered it
- Disjointed, racing thoughts
- Easily distracted
- Starts many projects, but doesn't finish them
- Rapid and/or excessive speech
- Momentary tearfulness
- Inflated self-esteem
- Pursuit of risky activities (gambling, sexual recklessness, illogical business deals)
- Buying sprees
- Inappropriate social behavior
Depression is marked by having five or more of the following symptoms for two weeks:
- Feeling sad, hopeless, pessimistic, unnecessarily guilty, and/or helpless
- Anxiety, restlessness, unremitting worries
- Rumination about death or suicide
- Poor self-image
- Loss of interest in previously pleasurable activities, including sex
- Diminished energy or fatigue
- Sleep disorder: sleeping too much or insomnia
- Difficulty remembering things, making decisions, or concentrating
- Change in appetite (either up or down) nearly every day
- Weight loss (without dieting) or weight gain
- Chronic physical symptoms like headaches, digestive problems, and/or pain
- Delusions or hallucinations
Conditions That May Be Mistaken for Bipolar Affective Disorder
Your physician will rule out these conditions to correctly diagnose bipolar affective disorder:
- Schizo-affective disorder
- St. Louis encephalitis
- Huntington's chorea
- Syphilitic infection of the brain
- Systemic lupus erythematosus
- Multiple sclerosis
- Organic brain disease
- Diseases of the hormone-secreting endocrine glands, such as the thyroid or adrenal glands
- Partial seizures
- Liver failure
- Vitamin deficiency
- Side effects of medications
- Medication overdose
- Substance abuse
- Withdrawal from medication
How Bipolar Affective Disorder Is Diagnosed
Your physician will examine you and look at your personal and medical history to determine whether you are having a manic or depressive episode.
Your medical history
Your family history is suggestive. If other relatives have a diagnosis of bipolar affective disorder, you may want to watch out for it too. Indirect indications may be when relatives have had episodes of "nervous breakdowns" with times in between of normal function.
Doctors use laboratory tests primarily to rule out other diseases.
The following tests help diagnose bipolar affective disorder:
- Electroencephalography (EEG): measures brain waves to diagnose brain abnormalities
- Electrocardiography (ECG): measures electrical activity of the heart to diagnose heart diseases
Your physician may want to use the following imaging methods to scan the brain for possible organic disorders:
- CT (computed topography)
- MRI (magnetic resonance imaging)
Goals of Treatment
Currently there is no cure for bipolar affective disorder, although research about its treatments and causes continues. Doctors seek to recognize and treat the condition early; to carefully manage antidepressant drugs so patients don't switch from a depressive state to a manic state; and to keep patients free of manic and depressive episodes.
Current drug therapies are effective in about 70% of people with bipolar affective disorder, and electroconvulsive therapy may also successfully treat the illness. Psychotherapy can augment drug treatment, but is not effective alone. Your treatment probably won't require a hospital stay; you'll be treated in your doctor's office and go home the same day. However, an initial episode may require hospitalization and powerful antipsychotic and mood-stabilizing drugs until the episode is under control. A long-term maintenance program includes regular assessment of mood, blood lithium levels, and well-being.
The most common drug treatment is lithium, a mineral proven to be extremely effective for maintaining a manic-free, depression-free state for about 70% of people with bipolar affective disorder. Lithium has potential side effects that include decreased thyroid function, nausea, diarrhea, tremors, thirst, increased urinary frequency, and other neurological or psychological symptoms. Depakote is now very widely used as well, and is often a better choice.
Drugs most commonly prescribed
- Depakene (valproic acid)
- Depakote (divalproex)
- Eskalith (lithium carbonate)
- Tegretol (carbamazepine)
In the depressive phase of bipolar disorder, antidepressant drug therapy may be needed. However, these drugs could potentially shift a person with bipolar disorder into mania. In these cases, it is important to ensure that the person is already using a mood stabilizer.
Drugs for the depressive phase may include the following:
- Selective serotonin reuptake inhibitors (SSRIs)
- Trycyclic antidepressants (TCAs)
- Desyrel (trazodone)
- Effexor (venlafaxine)
- Remeron (mirtazapine)
- Serzone (nefazodone)
- Wellbutrin (bupropion)
With severe mania, antipsychotic medications may be used. This class of medications includes:
- Clozaril (clozapine)
- Haldol (haloperidol)
- Loxitane (loxapine)
- Moban (molindone)
- Navane (thiothixene)
- Risperdal (risperidone)
- Zyprexa (olanzapine)
Psychotherapy is effective largely because it helps keep the person aware of his or her illness, the likelihood of it happening again, and the need to continue with drug therapy. People with bipolar disorder sometimes deny an emerging manic episode because its initial euphoria is seductive. A good therapist will help the patient recognize warning signs such as a change in sleep, and acknowledge mania before it can accelerate into dangerous activity.
Electroconvulsive therapy (ECT)
ECT, previously known as "shock treatment," is reserved for severe, unresponsive, life-threatening manic states. Doctors place electrodes on the patient's head and deliver a mild shock, inducing a brain seizure. Doctors give the treatment under general anesthesia, in five to seven treatments, one treatment every other day. It may cause temporary memory loss, but it can deliver almost immediate relief from a severe manic episode. Why ECT works is still a mystery.
Healthcare Professionals Who May Be Involved in Treatment
These health providers help treat bipolar disorder:
- Family physician
- General internists
- Clinical psychologists
- Physician assistants
- Nurse practitioners
- Psychiatric nurse specialists
- Medical social workers
Activity & Diet Recommendations
If you have bipolar disorder, you must learn to recognize an emerging manic episode and report it to your doctor. You can also keep a daily checklist to help objectively monitor your sleep, work, spending, and sexual habits. If a pattern of potentially destructive behavior emerges, you should contact your therapist.
If your appetite is suppressed during a depressive phase, make sure you get enough calories, protein, and vitamins.
Monitoring Manic Depression
Since this is a cyclical disease that fluctuates from one extreme to the other, a physician must carefully monitor symptoms to most effectively treat them. In addition, lithium and other drug therapies may require monitoring via blood tests. Therefore, periodic visits to a physician will be necessary.
The side effects of lithium include decreased thyroid function, nausea, diarrhea, tremor, and other neurological or psychological symptoms. Depakote causes mild elevations of liver enzymes. Carbamazepine can cause blood cell changes. If bipolar affective disorder is untreated, it could eventually lead to suicide.
Quality of Life
Although the behavior of a person with bipolar disorder in a manic state is out of his or her control, it can be intolerable nonetheless for friends, family, and co-workers. People with bipolar disorder often divorce, lose their jobs, and suffer financial and legal problems. As seductive as the euphoria of the manic phase of the disease may be, people with bipolar disorder need to accept their diagnoses and rigorously follow their prescribed course of treatment.
Considerations for Women
Research is ongoing about the potential harm lithium may cause to a fetus, but doctors don't usually prescribe it during pregnancy. However, there are also potential risks to you if you stop using lithium. There are also risks to the fetus from Depakote and Carbamazepine. You should carefully discuss all potential risks with your doctor.
In addition, right after delivery the mother is at high risk for relapse of bipolar affective disorder.
Breastfeeding is not advised for women taking lithium. Much of the lithium in the bloodstream can be passed through the breast milk, with toxic effects for the baby.
Considerations for Older People
Ten percent of all mood disorders affecting older people are diagnosed as bipolar affective disorder. The manic state of the disease is less likely to appear as euphoria or excitement; it tends to appear as agitation, irritability, and disturbed sleep instead.
- Fish oil: In a small but pioneering new study, capsules of the fatty oil found in salmon and other cold-water fish have been shown to significantly improve symptoms of bipolar disorder. Researchers at Harvard's Pharmacology Research Laboratory at McLean Hospital gave 30 bipolar patients either a placebo or fish oil capsules. They all were evaluated every two weeks for four months. The fish-oil group showed marked improvement in the highs and lows of bipolar disorder. Fish oil is rich in omega-3 fatty acids. Most experts recommend four to 12 standard fish-oil capsules a day.
- Vitamin B: The B vitamins play an important role in mood and mental health. In one study at the University of Arizona, researchers gave 14 depressed older people either antidepressant drugs plus a placebo, or antidepressant drugs plus vitamins B-1, B-2, and B-6 (10 mg a day of each). A month later, the supplement group showed greater relief.
- St. John's wort: a very popular herbal treatment for depression. St. John's wort works because it's a natural selective serotonin reuptake inhibitor, the class of antidepressants which includes Prozac.
Recently, American and German researchers analyzed 23 studies comparing St. John's wort and a placebo for depression. In the placebo group, 22% reported benefit. In the herb group, 55% obtained significant relief. Among those who responded to St. John's wort, the relief obtained was similar to that experienced from pharmaceutical antidepressants.
St. John's wort is less likely to cause side effects than pharmaceutical antidepressants. Possible side effects may include fatigue, restlessness, stomach distress, and allergic reactions. Don't mix St. John's wort with pharmaceutical antidepressants. And don't take this herb if you are pregnant or nursing. Also, there is a theoretical risk of initiating a mania, as with other antidepressants.
- Ginkgo: also recommended to treat depression.
- Kava kava: recommended for treating depression accompanied by anxiety.
Meditation, imagining pleasant scenes (visualizations), and similar therapies are deeply relaxing. And deep relaxation often improves mood. British researchers gave one of three treatments to 154 breast cancer patients who felt depressed: face-to-face meetings (control group), meditation instruction with visualization exercises, or progressive muscle relaxation, a technique similar to meditation. The control group remained depressed, but both relaxation therapies helped lift the women's depression.
Bright light is the treatment of choice for the type of depression that develops in winter from lack of sunlight, called seasonal affective disorder, or SAD.
Though there is no known method of preventing bipolar disorder, effective medical and self-care treatments exist to control the frequency and severity of manic episodes.
- Cognitive therapy. This is a powerful self-care approach to treating depression (not bipolar affective disorder) by changing the way you think, helping you shed unrealistic attitudes and perceptions that may be making you unhappy.
In an analysis of 28 studies, a University of Calgary psychologist determined that for mild to moderate depression, cognitive therapy is as effective as drug treatment or psychotherapy.
You can learn to use cognitive therapy by reading two books by Stanford University psychiatrist David Burns, M.D.: Feeling Good: The New Mood Therapy and The Feeling Good Handbook. You can also read more about cognitive therapy at Depression.com.
- Exercise. Exercise relieves depression, although the mechanism is not known. It does reduce blood levels of cortisol, a hormone associated with stress; increases levels of endorphin, the body's own internal antidepressant; and boosts levels of serotonin, as do the SSRIs.
In one study at the University of Illinois, researchers surveyed 401 adults about their health, mental health, and lifestyle. The more time the subjects spent in strenuous exercise, the less depression, anxiety, and insomnia they reported.
Researchers at the University of California-Berkeley have followed the mental health of 6,000 local residents since 1965. The more sedentary the participants are, the more likely they are to suffer depression.
- Self-monitoring. Take care to recognize an emerging manic episode and report it to your doctor. Some patients keep a daily checklist to help objectively monitor sleep, work, spending, and sexual habits. If a pattern of potentially destructive behavior emerges, contact your clinician.
Websites & Organizations
American Psychological Association
750 First St., N.E.
Washington, DC 20002-4242
D/ART Public Inquiries
National Institute of Mental Health
Room 15C-05, 5600 Fishers Lane
Rockville, MD 20857
Internet Mental Health
National Alliance for the Mentally Ill
2101 Wilson Blvd., Suite 302
Arlington, VA 22201
National Depressive Manic Depressive Association (DMDA)
730 Franklin St., #501
Chicago, IL 60610
Phone: 800-82MDMDA (800-826-3632)
National Foundation for Depressive Illness
20 Charles Street
New York, NY 10014
National Mental Health Association
1021 Prince Street
Alexandria, VA 22304-2971
Stanley Center for the Innovative Treatment of Bipolar Disorder
3811 O'Hara Street, Suite 279
Pittsburgh, PA 15213
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