by the pines

Introduction

From high to low. From mania to depression. From recklessness to listlessness. These are the extremes associated with bipolar disorder, a mental illness characterized by mood instability that can be serious and disabling. Bipolar disorder is also known as manic-depression or manic-depressive illness — manic behavior is one extreme of this disorder, and depression is the other.

The deep mood swings of bipolar disorder may last for weeks or months, causing great disturbances in the lives of those affected, and those of family and friends, too. Today, a growing volume of research suggests that bipolar disorder occurs across a spectrum of symptoms, and that many people aren’t correctly diagnosed. Left untreated, bipolar disorder generally worsens, and the suicide rate is high among those with bipolar disorder. But with effective treatment, you can live an enjoyable and productive life despite bipolar disorder.

Signs and symptoms

Bipolar disorder symptoms are characterized by an alternating pattern of emotional highs (mania) and lows (depression). The intensity of signs and symptoms can vary from mild to severe. There may even be periods when your life doesn’t seem affected at all.

Manic phase of bipolar disorder
Signs and symptoms of the manic phase of bipolar disorder may include:

• Euphoria
• Extreme optimism
• Inflated self-esteem
• Poor judgment
• Rapid speech
• Racing thoughts
• Aggressive behavior
• Agitation
• Increased physical activity
• Risky behavior
• Spending sprees
• Increased drive to perform or achieve goals
• Increased sexual drive
• Decreased need for sleep
• Tendency to be easily distracted
• Inability to concentrate
• Drug abuse

Depressive phase of bipolar disorder
Signs and symptoms of the depressive phase of bipolar disorder may include:

• Sadness
• Hopelessness
• Suicidal thoughts or behavior
• Anxiety
• Guilt
• Sleep problems
• Appetite problems
• Fatigue
• Loss of interest in daily activities
• Problems concentrating
• Irritability
• Chronic pain without a known cause

Types of bipolar disorder
Bipolar disorder is divided into two main subtypes:

• Bipolar I disorder. You’ve had at least one manic episode, with or without previous episodes of depression.
• Bipolar II disorder. You’ve had at least one episode of depression and at least one hypomanic episode. A hypomanic episode is similar to a manic episode but much briefer, lasting only a few days, and not as severe. With hypomania, you may have an elevated mood, irritability and some changes in your functioning, but generally you can carry on with your normal daily routine and functioning, and you don’t require hospitalization. In bipolar II disorder, the periods of depression are typically much longer than the periods of hypomania.
• Cyclothymia. Cyclothymia is a mild form of bipolar disorder. Cyclothymia includes mood swings but the highs and lows are not as severe as those of full-blown bipolar disorder.

Other bipolar disorder symptoms
In addition, some people with bipolar disorder have rapid cycling bipolar disorder. This is the occurrence of four or more mood swings within 12 months. These moods shifts can occur rapidly, sometimes within just hours. In mixed state bipolar disorder, symptoms of both mania and depression occur at the same time.

Severe episodes of either mania or depression may result in psychosis, or a detachment from reality. Symptoms of psychosis may include hearing or seeing things that aren’t there (hallucinations) and false but strongly held beliefs (delusions).

Causes

It’s not known what causes bipolar disorder. But a variety of biochemical, genetic and environmental factors seem to be involved in causing and triggering bipolar episodes:

• Biochemical. Some evidence from high-tech imaging studies indicates that people with bipolar disorder have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes. The naturally occurring brain chemicals called neurotransmitters, which are tied to mood, also may play a role. Hormonal imbalances also are thought to be a culprit.
• Genes. Some studies show that bipolar disorder is more common in people whose biological family members also have the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder. Some studies also show links between bipolar disorder and schizophrenia, pointing to a shared genetic cause.
• Environment. Environment also is thought to play a causal role in some way. Some studies of identical twins show that one twin has the condition while the other doesn’t — which means genes alone aren’t responsible for bipolar disorder. Environmental causes may include problems with self-esteem, significant loss or high stress.

Risk factors

It’s estimated that about 1 percent of the population has bipolar disorder. However, some researchers suggest that bipolar disorder occurs on a continuum, and that many more people may have other forms of the disorder, pushing its prevalence as high as 6 percent of the population. In addition, some people may go undiagnosed because they don’t seek treatment, because their condition is mistaken for depression or because their symptoms don’t meet current diagnostic criteria.

Bipolar I disorder affects about the same number of men and women, but bipolar II, the rapid cycling form, is more common in women. In either case, bipolar disorder usually starts between ages 15 and 30.

Factors that may increase the risk of developing bipolar disorder include:

• Having other biological family members with bipolar disorder
• Periods of high stress
• Drug abuse
• Major life changes, such as the death of a loved one

When to seek medical advice

If you have any symptoms of bipolar disorder, seek medical help as soon as possible. Bipolar disorder doesn’t get better on its own. Yet many people with the disorder don’t get treatment or are reluctant to get treatment. Despite the mood extremes, people with bipolar disorder often don’t recognize how greatly it affects their lives — and the lives of their loved ones. And if you’re like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive — but they’re bound to be followed by emotional crashes that can leave you depressed, worn out, and perhaps in financial or legal trouble.

Getting treatment from a mental health provider with experience in bipolar disorder can help you learn ways to manage your symptoms. If you’re reluctant to seek treatment, try to work up the courage to confide in someone, whether it’s a friend or loved one, a health care professional, a faith leader or someone else you trust. They can help you take the first steps to successful treatment.

When you have suicidal thoughts
Suicidal thoughts and behavior are common among people with bipolar disorder. Tragically, the suicide rate is higher in bipolar disorder than most other mental illnesses. If you’re considering suicide right now and have the means available, talk to someone now. The best choice is to call 911 or your local emergency services number. If you simply don’t want to do that, for whatever reason, you have other choices for reaching out to someone:

• Contact a family member or friend
• Contact a doctor, mental health provider or other health care professional
• Contact a minister, spiritual leader or someone in your faith community
• Go to your local hospital emergency room
• Call a crisis center or hot line

Helping a loved one with bipolar disorder symptoms
If you have a loved one you think may have symptoms of bipolar disorder, have an open and honest discussion about your concerns. You may not be able to force someone to seek professional help, but you can offer encouragement and support and help your loved one find a qualified doctor or mental health provider. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, take them to the hospital or call for emergency help.

Screening and diagnosis

When doctors suspect someone has bipolar disorder, they typically run a battery of medical and psychological tests and exams. These can help rule out other problems, pinpoint a diagnosis and also check for any related complications.

These exams and tests generally include:

• Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; listening to the heart and lungs; and examining the abdomen.
• Laboratory tests. These may include a complete blood count (CBC) as well as thyroid tests and other blood tests. You may also have a urinalysis.
• Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out psychological self-assessments and questionnaires. You may be asked about substance or alcohol abuse. And with your permission, family members or close friends may be asked to provide information about your symptoms and possible episodes of mania or depression.

Diagnostic criteria for bipolar disorder
To be diagnosed with bipolar disorder, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Diagnostic criteria for bipolar disorder are based on the specific type of bipolar disorder as well as the history and types of episodes, such as manic, hypomanic or depressed. Talk to your doctor about which type of bipolar disorder you have so that you can learn more about your specific situation and its treatments.

Some researchers believe the current diagnostic criteria are too strict, though. Indeed, a growing volume of evidence indicates that bipolar disorder can be thought of more as a spectrum of disorders, with varying degrees of symptoms. Some researchers believe that many people go undiagnosed or misdiagnosed — and thus don’t get appropriate treatment — because the criteria don’t account for less severe but still serious symptoms.

Complications

Left untreated, bipolar disorder can result in severe emotional and even legal and financial problems that affect every area of your life.

Complications that bipolar disorder may cause or be associated with include:

• Suicide
• Substance and alcohol abuse
• Legal problems
• Financial problems
• Relationship troubles
• Isolation
• Poor work or school performance

Treatment

Bipolar disorder is a long-term condition that requires lifelong treatment, even during periods when you feel better. Bipolar disorder treatment is usually guided by a psychiatrist skilled in treating the condition. But you may have others on your treatment team as well, including psychologists, social workers and psychiatric nurses, because the condition can affect so many areas of your life.

Effective and appropriate treatment is vital for reducing the frequency and severity of manic and depressive episodes and allowing you to live a more balanced and enjoyable life. Maintenance treatment — continued treatment during periods of remission — also is important. People who skip maintenance treatment are at high risk of a relapse of their symptoms or having minor episodes turn into full-blown mania or depression. If you have problems with alcohol or substance abuse, you must get treatment for those, too, since they can worsen bipolar symptoms.

Here are the core treatments for bipolar disorder:

Medications
Medications are a vital part of bipolar treatment. Because medications for bipolar disorder can cause serious but rare side effects, you may be reluctant to take medications. But you can work with your psychiatrist and other health care professionals to find a medication regimen that works for you.

Medication options include:

• Mood stabilizers. Mood stabilizers are most the commonly prescribed medications for bipolar disorder. These medications help regulate and stabilize mood so that you don’t swing between depression and mania. Lithium (Eskalith, Lithobid) has been widely used as a mood stabilizer and is generally the first line of treatment for manic episodes. Your doctor may recommend that you take mood stabilizers for the rest of your life to prevent and treat manic episodes.
• Anti-seizure medications. The medications are used to prevent mood swings, especially in people with rapid cycling bipolar disorder. These medications, such as valproic acid (Depakene), divalproex (Depakote) and lamotrigine (Lamictal), also are widely used as mood regulators. These medications are also known as anticonvulsants.
• Antidepressants. Use of antidepressants in bipolar disorder, although once common, is now controversial. Antidepressants may not be advised at all, depending on your situation. There’s limited data indicating that antidepressants are effective for bipolar disorder, and in some cases they can trigger manic episodes. Before taking antidepressants, carefully weigh the pros and cons with your doctor.
• Other medications. Certain atypical antipsychotic medications, such as olanzapine (Zyprexa) and risperidone (Risperdal), may help people who don’t gain benefits from anti-seizure medications. And anti-anxiety medications, such as benzodiazepines, may help improve sleep. In addition, one medication, quetiapine (Seroquel), has been approved by the Food and Drug Administration to treat both the manic and depressive episodes of bipolar disorder.Numerous medications are available to treat bipolar disorder. If one doesn’t work well for you, there are many others to explore. Your doctor may advise combining certain medications for maximum effect. It can take several weeks after first starting a medication to notice an improvement in your symptoms.Be aware that all medications have side effects and possible health risks. Certain antipsychotic medications, for instance, may increase the risk of diabetes, obesity and high blood pressure. If you take these medications, talk to your doctor about being monitored for health problems. Also, mood-stabilizing medications may harm a developing fetus or nursing infant. So women with bipolar disorder who want to become pregnant or do become pregnant must fully explore with their health care providers their options and the benefits and risks of medications.

Psychotherapy
Psychotherapy is another vital part of bipolar disorder treatment. Several types of therapy may be helpful.

• Cognitive behavioral therapy. This is a common form of individual therapy for bipolar disorder. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. In addition, you can learn about bipolar disorder and its treatment and what may trigger your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
• Family therapy. Family therapy involves you and your family members. Family therapy can help identify and reduce stressors within your family. It can help your family improve its communication style and problem-solving skills and resolve conflicts.
• Group therapy. Group therapy provides a forum to communicate with and learn from others in a similar situation. It may also help build better relationship skills.

Electroconvulsive therapy(ECT)
Electroconvulsive therapy is geared mainly for people who have episodes of severe depression with suicidal tendencies or for people who haven’t seen improvements in their symptoms despite other treatment. Electroconvulsive therapy is a procedure in which electrical currents are passed through your brain to trigger a seizure. Researchers don’t fully understand just how ECT works. But it’s thought that the seizure causes changes in brain chemistry that may lead to improvements in your mood.

Hospitalization
In some cases, people with bipolar disorder may benefit from inpatient hospitalization. Hospitalization for psychiatric treatment can help stabilize your mood, whether you’re in a full-blown manic episode or a deep depression. Partial hospitalization or day treatment programs also are options to consider.

Prevention

There’s no sure way to prevent bipolar disorder. However, treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder from worsening. Long-term preventive treatment also can help prevent minor episodes from becoming full-blown episodes of mania or depression.

Self-care

Bipolar disorder isn’t an illness that you can treat on your own. But you can do some things for yourself that will build on your treatment plan:

• Take your medications as directed. Even if you’re feeling well, resist any temptation to skip your medications. If you stop, bipolar signs and symptoms are likely to come back.
• Pay attention to warning signs. You and your caregivers may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you’re facing an episode. Involve family members or friends in watching for warning signs. Addressing symptoms early on can prevent episodes from becoming full blown.
• Avoid drugs and alcohol. Illicit drugs and alcohol may be part of what triggers episodes of bipolar disorder.
• Check first before taking other medications. Call the doctor who’s treating you for bipolar disorder before you take medications prescribed by another doctor. Sometimes other medications trigger episodes of bipolar disorder or may interfere with medications you’re taking to treat bipolar disorder.

Coping skills

Coping with bipolar disorder can be difficult. Medications can have unwanted side effects, and you may feel angry or resentful about having a serious condition that requires lifelong treatment. During periods when you feel better, you may be tempted to stop treatment. Here are some ways to cope with bipolar disorder:

• Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan.
• Join a support group. Support groups for people with bipolar disorder can help you reach out to others facing similar challenges.
• Stay focused on your goals. Recovery from bipolar disorder can take time. Stay motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and financial and legal problems.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn relaxation and stress management. Try such stress reduction techniques as meditation, yoga or tai chi.

Complementary and alternative medicine

Some people with bipolar disorder turn to complementary and alternative medicine treatments to help manage symptoms, improve mood and reduce stress. These treatments may include prayer or spiritual healing, meditation, and vitamin and herbal supplements.

Although some complementary treatments can be a good addition to your regular treatment, take some precautions first:

• Don’t stop taking your prescribed bipolar medications or skip therapy sessions. Complementary medicine is not a substitute for regular medical care.
• Be honest with your doctors and mental health providers. Tell them exactly which complementary treatments you practice or would like to explore.
• Be aware that some complementary treatments can interfere with your regular treatment. Even over-the-counter or so-called natural supplements can interfere with your prescribed medications.

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