Bipolar Disorder in Adults
Ever since his mid 20's, a normally shy man gets high energy periods lasting up to several days where he doesn't need to sleep, and where he impulsively goes on spending sprees that put him into severe debt. These high periods are often followed by periods of severe low mood and depression, even to the point where he has thoughts of suicide. What's going on here? Is it normal mood swings, or could it be something else?
Everyone gets mood swings whereby sometimes our mood and energy is up, and where sometimes our mood and energy is down. But if you have mood swings so severe that it causes problems in your life, then it may be bipolar disorder.
In classic bipolar disorder, people have periods of (‘episodes') of:
- Extremely low moods such as depression
- Extremely high energy periods, with either high, manic or euphoric moods, or irritable moods
Hence the term, "bipolar", which refers to the two different poles of mood that a person can have.
High energy periods, or manic episodes / mania consists of periods with symptoms such as:
- Persistent period of high energy, lasting days to weeks, during which time a person has a decreased need for sleep (e.g. only needs a few hours of sleep, or even none at all, yet still has lots of energy the next day).
- Extremes of mood, which may be excessively "high" (overly good, euphoric mood) and at times extreme irritability.[this would be mixed not manic]
- Racing thoughts, i.e. thought flow increased speed
- Pressured speech, i.e. talking very fast
- Distractibility, can't concentrate well
- Increased self-esteem, which can be the point where one has grandiose, unrealistic ideas about oneself
- Increased activity
- Poor judgment, decision-making and impulsive behaviours such as making large purchases, gambling or other risky behaviours such as doing drugs or increased sex drive.
- Lack of insight that anything is wrong, such that the person may deny that there is a problem. But in a classic manic episode, it is obvious to friends and family that something is wrong as the patient's thoughts and behaviours represent a change for this person.
While some individuals with bipolar disorder experience full-blown manic episodes, others also experience a mild to moderate level of mania, known as "hypomania". Hypomania is milder than mania, but it is a major change in functioning for the individual and it may lead into full-blown mania, or major depression.
What goes up must come down, which is why periods of high energy (manic episodes) are typically followed by low energy periods.
Low energy episodes or depressive episodes may occur to the extreme such that the person may have:
- Extremely low energy for days or weeks, with increased need for sleep
- Extremely low, depressed mood that is stuck and not reactive to what is happening around the person
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities
- Due to low mood, the person may have thoughts that life isn't worth living, even to the point of thinking about making attempts to end one's life.
Mood episodes may also get so extreme that the person loses touch with reality, and may have symptoms of psychosis such as:
- Hallucinations, which includes hearing or seeing things which aren't actually there. For example, hearing voices or seeing people.
- Delusions, which are false beliefs with no basis in reality. For example, in a manic phase, one might believe that they can fly, or that they are a famous celebrity. On the other hand in a depressive phase, one might feel extreme irrational guilt.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a manual used by mental health professionals to diagnose mental health conditions, the main types of bipolar disorder recognized in adults are:
- Bipolar I, classically consisting of manic (major high) and depressive episodes (major low). In fact, many individuals present first with major depressive episodes when younger and do not go onto develop manic episodes until older.
- Bipolar II, consisting of hypomanic (mild highs) episodes and major depressive episodes (major low).
- Cyclothymia, consisting of hypomanic episodes (mild high) with minor depressive episodes (minor low).
- Bipolar Not Otherwise Specified (NOS), which is used to describe individuals with mood swings that cause problems, but which do not fit into any of the other above categories.
In addition, other terms used include:
- Rapid-cycling: when a person has at least 4 episodes per year. This type is seen about 5-15% of patients.
- Mixed state: when a person has both manic and depressive symptoms occurring at the same time
It is generally believed that bipolar I or II occurs in up to 4% of adults (Kessler, 2005), and it is usually believed to start in late teens or adulthood (Kessler, 2005).
The following are simply screening questions for bipolar. If you find yourself answering YES to more than a few of these questions, consider seeing a doctor.
- Do you often get high energy periods?
- During these high energy periods, do you find that you have less need for sleep (e.g. sleeping very little or not at all)?
- During these times, do you find yourself being much more talkative or speaking much faster than usual?
- During these times, are much more active and do more things than usual?
- Do you often get times when you have felt both high (elated) and low (depressed) at the same time?
- During these periods, do you find your self-confidence being greatly improved?
If you suspect that you have bipolar disorder, then see your doctor.
Psychologists and psychiatrists are the main professionals qualified to make a diagnosis of bipolar disorder. During an assessment, the doctor asks the patient (and family members) about symptoms, the developmental and school history and the family history in order to make a determination about diagnosis and recommendations. At this time, there is not yet any blood test, brain scan or other diagnostic test that can help with the diagnosis of bipolar disorder.
Bipolar disorder is usually treated with a combination of several components, which includes:
- Physical treatments including medications
- Counselling / psychotherapy (talk therapy)
- Education about the condition and coping strategies
Because bipolar disorder is due to changes in brain chemistry, medications are generally necessary in the treatment.
Common medications used in the treatment of bipolar disorder include:
- Divalproex (trade name Epival)
- Lamotrigine (trade name Lamictal)
- Olanzapine (trade name Zyprexa)
- Seroquel (trade name Quetiapine)
- Risperidone (trade name Risperdal)
Talk to a medical doctor (such as a family physician, or psychiatrist) for more information about medication treatment.
Life Style Strategies
Keep regular, daily routines, which will help you set your body's internal clock and thus help with bipolar disorder (Frank, 2007). As much as possible, set the same times every day (weekends and weekdays) for a) bedtime and b) wakeup time, and mealtimes (like breakfast, lunch and dinner).
If you are having trouble sleeping in the evenings, then try a dim or dark environment, which approximates the natural environment that humans evolved under. The ‘light pollution' in our modern society, as well as the high amount of artificial lighting in our homes probably in the evenings may very well interfere with our body's internal, biological clock. One study in fact, showed that "dark therapy" (exposing patients to darkness from 6 PM to 8 AM for a few days) helped improve manic symptoms in hospitalized patients with bipolar disorder (Barbini, 2005).
- Regular exercise: In addition to the fact this will be good for your health in general, studies show that exercise acts to treat depression, and it can also help set your body's clock.
- Healthy diet with regular meals. In addition to the fact that this will give your body the necessary nutrients it needs, this too will help set your body's clock.
- Avoid stimulants because they may trigger manic episodes. This includes: street drugs such as amphetamines, ‘uppers' or ‘speed'. Even milder stimulants such as coffee or prescription medications for ADHD (such as methylphenidate) need to be monitored closely by a physician.
If you are a friend or family member of someone with bipolar disorder:
- Learn as much as you can about bipolar disorder.
- Tell your friend or relative that you are concerned, and be there to give support. You might say: "I'm concerned about you and want to be there for you. How can I support you?", or "How can I help?"
- Advice. Note that advice is better accepted when the other person gives you permission to receive it. Simply lecturing or telling the other person what to do may not work as well, particularly with independence-seeking teens, because this may lead him/her to withdraw. You might say: "I'm worried about you. Would you be open if I gave you my advice?"
- Help get your family member get connected to professional help. Offer to help set up an appointment, drive or even accompany him/her to the appointment.
- Talk with your family member's doctor, if possible.
- Support your friend so that s/he stays with treatment, such as taking medications, seeing the doctor, and avoiding alcohol and drugs.
- Learn to watch for warning signs that may signal that person is getting unwell, such as
- Early signs of depression, such as thoughts of suicide.
- Early signs of mania
It is much easier to get help and treatment before they progress to full-blown depression or mania.
- Learn to watch for warning signs of suicide. These include:
- Making final arrangements for one's affairs
- Giving away one's possessions
- Feeling hopeless about the future.
- If you are concerned about suicide, then get help as soon as possible, which may even include calling 911 in a crisis. People who consider suicide often consider it as a way to stop being a burden to others - tell your loved one that suicide would be a tremendous burden and not a good way to find relief.
- If your friend is prone to manic episodes, have an ‘advance directive' in case your friend becomes manic. People who are manic may engage in impulsive activities such as spending sprees, long trips, or other behaviours. You should talk to your family member about holding onto credit cards, banking privileges and car keys. Talk openly to your family member about when hospitalization may be necessary.
- Don't take rejection personally. If your family member becomes unwell with a mood episode, and stops accepting your help, remember this is not a rejection of you - it is the illness.
- As a caregiver, don't neglect your own health! Remember that you are not alone, and consider joining a support group for networking and mutual support.
If your loved one is having either a manic episode or a severe depression, then see a doctor as soon as possible. In emergency situations, simply call emergency services (usually by calling 911).
- Expert Consensus Treatment Guidelines for Bipolar Disorder: A Guide for Patients and Families from http://www.psychguides.com/sites/psychguides.com/files/docs/Bipolar%20Handout.pdf
- Bipolar Disorder, National Institutes of Mental Health, retrieved Feb 22, 2008 from http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-publication.shtml.
- The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, David Miklowitz
- Bipolar Disorder for Dummies, Candida Fink
- Bipolar Disorder: The Ultimate Guide, Sarah Owen
- Barbini et al.: Dark therapy for mania: a pilot study, Bipolar Disorder, Feb 2005: 98-101.
- Frank E. Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy, 2007.
- Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627
- Stoll AL, Locke CA, Marangell LB, Severus WE. Omega-3 fatty acids and bipolar disorder: A review. Prostaglandins, Leukotrienes and Essential Fatty Acids. Volume 60, issues 5-6, May-June 1999, pages 329-337.
Written by the eMentalHealth Team and Partners.
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Date of Last Revision: Oct 8, 2016