What is a Bipolar Disorder?

‘Manic depressive psychosis’ which was first defined at the end of the 1800’s, and can be described as a psychological disorder in which episodes of mania and episodes of depression occur at different times in the same patient. Except for these periods the person is entirely healthy.

From manic depressive psychosis to bipolar disorder

A return in cycles and a repetition are amongst the main characteristics of the bipolar disorder. In some patients where the cyclic return is marked, the illness has a tendency to recur at a particular time of the year (for example, depressive episode during the winter months, manic episode during the months of spring). For the past 30 years medical circles have been referring to manic depressive psychosis as a bipolar disorder. The name was changed because in psychosis the patient loses touch with reality whereas bipolar disorder patients who do not experience severely marked episodes, and patients who have a mild form of the disorder, do not lose insight into their own illness.

The expression bipolar disorder emphasizes two main characteristics of the disorder: The same person experiences episodes of depression during certain times, and the exact opposite, namely episodes of mania during other times. Research during the past years has revealed that bipolar disorder does not consist of a single condition. Together with its sub-types in which the illness takes a milder course and cannot easily be identified, it includes more than one type of disorder (for instance cyclothymia, bipolar disorder triggered by use of drugs, seasonal depression disorder). Therefore it would be more correct to talk about bipolar disorders rather than a single bipolar disorder.

Bipolar disorders are also called ‘mood disorders’. What is meant by this is that during the periods characteristic of the disorder, serious mood changes occur in the person. For example, a person who normally is introverted, quiet and shy, can during the agitation phase feel a high level of self-confidence and turn into a talkative, energetic and enterprising person. Or a person who normally is of a lively, talkative and energetic nature, can during the depressive phase of the disorder be dispirited, display an introvert, sluggish personality and avoid contact with other people.

Types of bipolar disorder

We can differentiate between different sub-types of bipolar disorders, each of which displays different symptoms, has a different prognosis and requires a different method of treatment.

In bipolar disorder type 1 the mood changes are severe enough to disrupt the person’s professional life, academic success and social relations. In bipolar disorder type 1 we encounter both episodes of severe agitation during which the person’s level of excitement is raised, and episodes of severe depression during which the person’s mood drops and depression sets in.

In bipolar disorder type 2 the illness takes a milder course than in type 1. During periods when the person’s mood is raised, he loses his temper more quickly and is more irritable. This may lead to a partial deterioration in the person’s ability to carry out daily tasks, but the deterioration is not as severe as that seen in mania. During these periods of mild agitation called hypomania the person is still able to carry out most of his or her daily activities. The more serious problem in bipolar disorder type 2 is caused by the state called the depressive state, a period of feeling low which lasts much longer than the period of hypomania.

In cyclothymic disorder the symptoms are much milder than those in the two types mentioned above. In the disorder called cyclothymia the hypomania episodes are accompanied by attacks of mild depression (episodes of mild depression). As the symptoms are fairly mild, it is particularly difficult for the mood swings to be detected. In some cases it might not be possible to determine which period reflects the person’s normal disposition and which is a reflection of the cyclothymic disorder.

It should not be forgotten that the symptoms of bipolar disorder vary greatly from person to person. In some patients treatment of the depressive episode can be particularly difficult, in others the treatment of the agitated phase forms the bigger problem. In some patients, symptoms of the agitated phase (called mania and hypomania) can be accompanied by symptoms of depression. These periods are called the mixed state.

What are the Symptoms of the Manic Episode?

The following symptoms can be seen during the manic (agitated) episode of bipolar disorder:

– Increased self-confidence

– Deterioration in the ability to reason

– Fast speech, increased amount of speech

– Increased physical activity

– Reduced need for sleep

– More enterprising, more contact with people

– More goal-orientated activities

– Quickly irritated, experiences anger

– Increased risky behaviour

– Easily distracted

– Spends a lot of money

– Has wrong believes (called delusions) and/or unreal perceptions (called hallucinations)

– Increased libido

In order to diagnose a patient with mania it is not essential that all the symptoms are present in that person. What is meant by a deterioration in the ability to reason is the condition in which the patient is unable to assess the outcome of his actions in advance. For example, although not true, the person may mistakenly believe that he or she is very rich and may spent large amounts of money or borrow amounts he cannot possibly pay back. He may believe that he has some kind of immunity and may enter arguments with security personnel. All this behaviour leads not only to serious legal problems but also causes major deterioration in the person’s professional life, family life and relationship with other people.

What are the Symptoms of the Hypomania Episode?

The symptoms of hypomania, or mild agitation episode, are not as severe as those seen in the manic episode, they are milder symptoms and the patient’s functionality is affected to a lesser degree.

What are the Symptoms of the Depression Episode?

– Sadness

– A feeling of helplessness

– Thoughts of suicide, suicide plans and attempts

– Worries

– Feelings of guilt

– Sleep problems

– Decreased or increased appetite

– Fatigue

– Unable to enjoy activities which he normally enjoys

– Difficulty in concentrating

– Irritability

– Pains in the body for extended periods of time

– Decreased academic or professional success

What is the Aim of Treatment?

In bipolar disorder, treatment consists of two parts:

1. Treatment of an Acute Episode

If the patient is still suffering from a manic, hypomanic or depressive episode, treatment should be commenced without delay. If the patient has thoughts of suicide or if he displays anger and aggression, as can be the case in some severe manic attacks, or if he has no insight or insufficient insight into his own illness, treatment on an outpatient basis may be considered too dangerous. In such a case the patient is admitted to hospital for a short inpatient stay. With the correct treatment, the length of which can vary from a few weeks to a few months, the patient will be able to return to his daily life and fulfil has professional and family related functions.

2. Maintenance Treatment

In view of the repetitive nature of bipolar disorder, a prophylactic maintenance therapy is commenced as the second stage of treatment. The aim in this stage is to minimize the risk of a new mood attack in the patient. Positive cooperation between the patient, his family and the doctor is particularly important during this stage. Maintenance treatment may have to continue for many years.

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Bipolar Mood Disorder

It is also known as Manic Depressive Psychosis or Bipolar Affective Disorder. It is characterised by periods of depression that occur from time to time, and at the other end periods of mood elevation. The depressive state displays the characteristics I explained in my article called Depression. Mania presents a picture of increased self-confidence, increased libido, accelerated associations, increased motor activities, excessive energy, lack of sleep without tiredness the next morning, lack of appetite, passion for shopping, excessive travelling, rejoicing without any reason.

The onset of mania is sudden. Although the person may sense something strange going on, he is not entirely aware that he is in an episode of the illness. In many cases insight into the illness is only gained after a few attacks.

Outside the episodes of mania and depression the person’s life unfolds almost normally. When the patient recognizes that the manic periods stem from his illness, he may experience great sadness or, to use a more correct word, shame, as the manic attack has probably resulted in serious damage to his social relationships and economic status. Being stigmatized is one of the greatest problems of persons with manic attacks.

The frequency of occurrence of bipolar-I is 1%. If we include bipolar-II, the frequency increases to a fairly large percentage of 5%. Bipolar I-I is defined as hypomania, the name given to the illness when the progression of the manic attacks is mild.

The illness is often seen in people with a high level of creativity. It has a hereditary aspect. An important fact that points to this is that in monozygotic twins the likelihood of occurrence in both twins is a lot higher. However, it is considered that genetic predisposition alone is not enough to establish the illness and certain stressors are required to as a genetic trigger.

Biochemical theories on mania tend to point to a possible pathology in the dopaminergic and cholinergic systems of the patient. Electrophysiological analyses on the other hand describe a state of neural hypersensitivity.

Various endocrinopathy, diseases that directly affect the central nervous system, and certain drugs like cortisone and narcotics may create a similar picture. In order to distinguish such pictures from the illness itself and to make a correct diagnosis, the diagnosis and follow-up should only be undertaken by a psychiatrist.

Like with other psychiatric occurrences, bipolar mood disorder is addressed and treated in two ways, which can be summed up as pharmacotherapy and psychotherapy. In pharmacotherapy mood regulating drugs like lithium play an important role. In order to avoid their toxic effects they have to be used long-term throughout the patient’s life. In addition, treatment agents with anti-manic qualities can be used on a periodical basis. During the depressive episode the short-term use of antidepressants is indicated but these have to be used carefully as they may trigger manic attacks.

In psychotherapy emphasize is placed on giving the patients an insight into their condition and supporting them in the process. Again there are signs that cognitive-behavioural therapy decreases the risk of a relapse.

Compliance with the doctor’s recommendations and treatment is very important. The quality of life of patients who are regularly followed up by their doctor, shows a marked improvement, with fewer and less severe attacks.