Bipolar disorder, also known as manic depression, is a mood disorder characterised by extreme shifts in mood, energy and functioning.
Bipolar disorder used to be called manic depression. This is much less common than Major Depressive Disorder and Dysthymia, and only 2% of the population is affected over a lifetime. Males and females are affected equally.
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This type of depressive disorder involves episodes of depression and episodes of mania/euphoria. The switches between these two states may be fairly sudden and dramatic, but are more commonly gradual in onset. Both mood states may co-exist – mixed bipolar disorder.
During episodes of mania judgement is often impaired and this can result in
socially embarrassing behaviour
sexual indiscretions
excessive spending
unwise business decisions
Bipolar disorder tends to be a chronic, recurring condition and is generally considered to have a poorer long-term outcome than Major Depressive Disorder.
During a manic, “high” episode a person displays behaviour that is out of character. He/she may be “overly” happy and/or highly irritable, have boundless energy, go for days without sleeping and lose his/her inhibitions in social settings. People with mania may develop unrealistic beliefs in their capabilities that may impair their judgement, the result of which is engagement in foolish activities or projects which often lead them into financial or other difficulties. As a manic episode develops, there may be an increase in the use of alcohol or stimulants which may aggravate or prolong the episode.
Typically a manic person denies that there is anything wrong or unusual with him/her. The changes in mood and behaviour are observable by others who know the person well.
During the “low” phase the person is depressed, lacks energy and struggles to enjoy activities which were previously enjoyable.
Some people can experience symptoms of depression and mania at the same time. This is called mixed bipolar disorder.
The disorder can disrupt the person’s work, school, family and social life. As such it can be very disabling, but if treated appropriately responds well. Treatment can help prevent future episodes.
What are the symptoms?
Signs and symptoms of mania include:
Abnormally “high”, euphoric mood
Extreme irritability/agitation
Anger and/or aggression
Increased energy, activity and restlessness
Inflated self esteem and self confidence, feeling superior to others
Decreased need for sleep
More talkative than usual and talking rapidly and loudly
Racing thoughts or jumping from one idea to another making it difficult for others to follow
Distractibility and difficulty concentrating
Increase in goal-directed activity
Poor judgement
Excessive involvement in pleasurable activities that can have painful consequences (such as spending sprees or sexual indiscretions)
Abuse of drugs and alcohol
Denial that anything is wrong
Signs and symptoms of depression include:
Intense sadness
Loss of interest or pleasure in activities previously enjoyed
Feelings of guilt, despair and worthlessness
Sleeping too much or struggling to sleep (hypersomnia or insomnia)
Loss of energy
Change in appetite leading to weight loss or weight gain
Difficulty concentrating and remembering
Restlessness or irritability
Thoughts of death or suicide
Some people may have psychotic symptoms during severe episodes of mania and depression. Common symptoms are delusions (false, strongly held beliefs that are not influenced by logical reasoning) and hallucinations (hearing, seeing or otherwise sensing things that are not there). These symptoms tend to reflect the mood state at the time. For example, during a manic phase a person may believe that he is the president or has special powers. Delusions of guilt or worthlessness may appear during depression.
A mild to moderate level of mania is called hypomania. The symptoms are similar to mania but less severe and psychotic symptoms are not present. There is also less overall impairment of functioning and hospitalisation is usually not needed. It may even be associated with good functioning and enhanced productivity. If left untreated, hypomania may become severe mania or can switch into depression.
Types of bipolar disorder
There are two main types of bipolar disorder.
Bipolar 1:
The person has manic or mixed episodes as well as depression.
Bipolar 2:
The person only has one or more depressive episodes with at least one hypomanic episode. For some, hypomanic episodes are not severe enough to cause severe impairment in functioning.
When four or more episodes of illness occur within a year, the person is said to have bipolar disorder with rapid cycling.
Cyclothymic disorder
This is characterised by chronic fluctuating moods involving periods of hypomania and depression.
Who suffers from bipolar disorder?
Bipolar disorder is common. Approximately two percent of the population suffers from the disorder. Men and women are equally affected. Men tend to have more manic episodes while women experience more depressive episodes.
The onset is usually in the twenties but children and adolescents can also be affected. If the onset is after the age of fifty, it is usually due to another medical condition such as multiple sclerosis or the effect of drugs, alcohol or steroids.
What causes bipolar disorder?
There is no single cause. The disorder tends to run in families which suggests that there is a genetic link. In people predisposed to the disorder, the onset can be triggered by stressful life events and the use of drugs of abuse. In rare cases individuals who for reasons such as a family history may be vulnerable to develop bipolar disorder, episodes may be triggered by the use of some older antidepressants and other medications including steroids.
An imbalance in various neurotransmitters (chemicals by which the brain cells communicate) may also be involved. There may also be disturbances in the production or release of certain hormones within the brain that contribute to causing bipolar disorder.
What is the course of bipolar disorder
Bipolar disorder is a lifelong condition and is generally considered to have a poorer long-term outcome than Major Depressive Disorder.
The course varies from person to person. Bipolar disorder can start with major depression or a manic episode. Manic episodes usually begin suddenly with a rapid escalation of symptoms over a few days. They tend to be shorter and end more abruptly than depressive episodes.
For some there may be long symptom-free periods between episodes. Episodes can last for days, weeks or months. The average person with bipolar disorder has four episodes (manic or depressed) during the first ten years of the illness. A minority of people may have several episodes of mania and depression with only brief periods of normal mood in between.
If properly controlled by medication, a person can lead a full, productive life. If left untreated, moods will continue to swing from one extreme to another and cause severe impairment in functioning. The time period between episodes usually narrows and episodes become more severe. In such cases, suicide is a real danger especially if the person abuses substances and/or suffers from anxiety.
How is it diagnosed?
There is no diagnostic test. In order to make a diagnosis, an evaluation by a physician/psychiatrist, who will take a detailed history and thoroughly assess symptoms, is essential.
It is very useful to get feedback from close family and friends as a person with this disorder often lacks insight into his/her condition. They will often deny that anything is wrong and resist efforts to be treated. This resistance can often delay diagnosis and effective treatment.
Many other medical conditions such as substance abuse or thyroid problems can mimic bipolar disorder and these need to be ruled out and effectively treated.
How is bipolar disorder treated?
There is no cure for bipolar disorder but it responds well to treatment. It is a recurrent, lifelong illness. People suffering from bipolar disorder may need long-term psychiatric care to monitor medication, enhance treatment compliance and prevent future episodes. A combination of medication and psychotherapy is optimal.
Treatment aims are to:
1. Effectively treat whatever the current (acute) episode is (mania or depression).
2. Effectively reduce the risk and severity of further episodes with maintenance treatment and support.
Vigilance is the key to preventing relapse. If early symptoms are reported to the doctor when first noticed, adjustments can be made to the treatment plan in order to prevent a “full-blown” episode.
In the maintenance phase support is needed to continue the use of medication to prevent future episodes. This is often difficult as people feel so much better in these periods.
Medication - Manic episode
In the first instance a good assessment and clear diagnosis (to exclude medical causes) is essential. Commonly an acute episode of mania will require a period of hospitalisation.
The mainstay of medical treatment is the mood stabiliser lithium which is used in acute episodes or relapses. Drugs used to treat epilepsy, such as valproate (Epilim) and lamotrigine (Lamictin) are effective and can be prescribed if lithium is not tolerated well. Certain antipsychotic drugs such as olanzapine (Zyprexa) have also been used successfully to treat manic episodes. In episodes where psychotic symptoms are present, antipsychotics are invariably prescribed with the mood stabiliser until symptoms have subsided.
Benzodiazepines (tranquillisers) may be prescribed to manage agitation, psychosis or dangerous behaviour while waiting for a mood stabiliser to take effect.
Depression
The Selective Serotonin Reuptake Inhibitors (SSRI’s) are used most commonly.
These antidepressants act on the neurotransmitter serotonin. Examples of SSRI’s are sertraline (Zoloft) and fluoxetine (Lilly-Fluoxetine).
Antidepressants should never be used without a mood stabilising drug as they can trigger a manic episode.
Electroconvulsive therapy (ECT)
ECT is a safe and effective treatment for both mania and depression. This is generally reserved for people in hospital and as such for more severe episodes.
Maintenance therapy
Acute episodes represent only brief periods in the life of most people with bipolar disorder. To lengthen time between episodes and minimise the effects of further episodes the continued use of moodstablising medication (maintenance therapy) is essential. This may be difficult as maintenance therapy is needed in periods when people feel well. In this phase, people with bipolar disorder need ongoing psychotherapy to assist with understanding the risks of the illness and minimise early discontinuation.
Patients on lithium need regular blood tests to make sure that there is enough lithium in the body for it to work but not too much which can be harmful and lead to serious side-effects. This monitoring is done in routine follow-up with a physician.
Psychosocial support
As bipolar disorder disrupts a person’s life and relationships, psychotherapy can help people regain control and re-establish relationships with others. Support should extend to the family and support structures to help all involved come to terms with the illness. This aims to help people come to terms with their illness and motivate for better treatment compliance.
Support groups
Support groups offer a valuable opportunity to people to meet other people with bipolar disorder and to learn more about the disorder and how to live with it. The Western Cape Bipolar Association can be contacted for a list of support groups in the country. Tel: 082 8553180.
Reviewed by Dr Paul Carey, MRC Research Fellow, MRC Research Unit for Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch.
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