When acquiring knowledge it is best to define terms either before or as they are being used. Let us begin by defining:
Bipolar (Affective) Disorder (manic-depression): a “mental disorder” exhibiting oscillating periods of elation and “clinical depression.” It is essentially a psychiatric diagnosis of elevated and depressive cognition, moods, behaviors and energy levels. The clinical term for the elated moods is “mania”. A gentler form is “hypomania.” Afterwards, bipolar individuals usually manifest either depressive symptoms or a “mixed state” in which features of both highs and lows are simultaneously present. These up-and-down events quickly slide through “average” mood zones enjoyed by the general population. For some folks,”rapid-cycling” between up-and-down mood levels occurs. Fierce manic episodes can exhibit delusions, psychosis and hallucinations. The bipolar mood range, in increasing levels of manic severity, are termed cyclothymia, hypomania (bipolar-II) and mania (bipolar-I). Descending levels of clinical depression are cyclothymia, depression (bipolar-II) and clinical depression (bipolar-I). Clinical depression alone is termed “unipolar.” [abridged-paraphrased Wikipedia “Bipolar Disorder” entry]
The bipolar continuum (spectrum) is best illustrated verbally as follows:
MANIA (BIPOLAR-I)
HYPOMANIA (BIPOLAR-II)
CYCLOTHYMIA (HIGH)
AVERAGE MOOD HIGH
AVERAGE MOOD
AVERAGE MOOD LOW
CYCLOTHYMIA (LOW)
DYSTHYMIA (BIPOLAR II)
CLINICAL DEPRESSION (BIPOLAR I)
Patient moods are continuously variable as they ascend and descend this bi-directional spectrum, prompting Johns Hopkins leading Professor of Psychiatry, Dr. Kay Redfield Jamison and Bipolar I patient, to call bipolar disorder “this quicksilver illness.”
“Average Mood” is just another day at the office and at home with no cause for either sadness or celebration.
“Average Mood High” might be a time when you marry, birth a baby, earn a raise or win the lottery.
“Average Mood Low” could range from the loss of a favorite pet to the passing of a family member.
“Cyclothymia High” might be a time of extra energy and focus and general exuberance without drug use.
“Cyclothymia Low” can be a habit of extra sleepfulness or sleeplessness and a gloomy outlook.
“Hypomania” is a period of excess energy, high productivity, many achievements and goal-orientation.
“Dysthymia” is sluggishness, loss of normal interests, negativity and general malaise.
“Mania” is a time of grandiosity, rapid and pressured speech and frightening, erratic behaviors.
“Clinical or Major Bipolar Depression” is a total loss of interests and hope, often featuring suicidality
Here are a few American statistics:
- Women suffer major depression twice as much as men
- 90% of all suicides result from clinical depression
- Men and women suffer manic-depression equally
- 1 of 3 bipolar individuals will either attempt or complete the act of suicide
You have likely seen more than enough lists of manic and depressive visible behaviors, but it is important to adhere to those listed in the “Psychiatrist’s Bible,” DSM-IV (Diagnostic and Statistical Manual of Mental Disorders). The DSM-5 will be published in May 2013. It is from these basic definitions that we can build a discussion and understand what is to follow. Here are the essential “Diagnostic Criteria for Manic Episode:”
- Abnormally, persistently elevated, expansive, or irritable mood
- Inflated self-esteem or grandiosity [w/uninhibited, skewed volition]
- Decreased need for sleep, e.g., feeling rested after only 3 hours of sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility, i.e., attention too easily drawn to unimportant or irrelevant external stimuli
- Increase in goal-directed activity (either socially, at work, at school or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences, e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments
- Mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others
- [Giving away money or cherished or valuable possessions]
I have included this last, bracketed symptom, as that has been my own personal experience during my bipolar I episodes and also that of many of my co-patients and manic-depressive friends. Although this frightening list is not intended for use by “armchair psychiatrists,” it is useful for spotting and obtaining professional help for a mood-challenged friend or family member. Mania reminds me of the metamorphosis that produces the “Incredible Hulk.” My bipolar-I episodes always involve an obsession-either “seeking true love” or “starting my own high-tech energy company.” Oh, the wonders of manic grandiosity!
Well, DSM-IV has been kind enough to help us understand what bipolar mania is. Here it does likewise for clinical depression in the form of “Diagnostic Criteria for Major Depressive Episode”:
- Depressed mood (can be irritable mood in children and adolescents) most of the day, nearly every day, as indicated either by subjective account or observation by others
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observations by others of apathy most of the time
- Significant weight loss or weight gain when not dieting (e.g., more than 5% of body weight in a month), or decrease or increase in appetite nearly every day (in children, consider failure to make expected weight gains)
- Insomnia or hypersomnia almost every day
- Psychomotor agitation or retardation nearly every day (observable by by others, not merely subjective feelings of restlessness or being slowed down
- Fatigue or loss of energy almost every day
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide
- [Vegetative, catatonic; retarded or loss of motor skills; unable to commit the act of suicide]
Once again, this last, bracketed listing is based on my personal experience and that of many of my co-patients and manic-depressive friends. When taken together, all of these up-and-down states are can be peppered with psychosis, hallucinations and delusions, making a psychiatrist’s diagnosis that much more difficult to make. Bipolar diagnoses are primarily made by psychiatrists (64%), psychologists (18%), and general practitioners (13%). In suspected cases of mental issues it only makes sense to cut to the chase and make an appointment with a psychiatrist. This specially trained professional is best able to treat a mood disorder patient. There are also “mixed episodes” during which an individual will suffer both manic and depressive characteristics simultaneously-pure hell. Once correctly diagnosed, the patient and doctor will need three years, on average, to sculpt a useful combination of psychotropic (psychiatric) drugs to achieve acceptable patient mood stability, the goal of which is to reduce the frequency, duration and intensity of episodes. These potent drugs have wicked side-effects and must be a carefully selected combination chosen from the five major classes of psych medicines:
- Mood Stabilizers
- Antidepressants
- Antipsychotics
- Anxiolytics
- Anticonvulsants
When the bipolar patient is manic, he or she is feeling good and is unlikely to visit a doctor unless coerced by another individual. That is why psychiatrists often diagnose manic-depressive patients with unipolar (depressive) disorder because the only time he gets to see the patient is when he or she is feeling bad. It is fascinating that nearly 70% of bipolar-disorder sufferers are misdiagnosed an average of 3.5 times before that correct diagnosis is dialed-in. The manic individual is on a “high” and feels wonderful-there is “no need” for a doctor.
Because bipolar or depressive disorders involve relative amounts of neurotransmitters (serotonin, dopamine, norepinephrine) in the brain’s limbic system (that portion of the brain responsible for emotion, behavior, motivation and long-term memory), a paucity of them results in depression and a surplus of them results in mania. Neurotransmitters are what transmit electrical signals between nerve endings, and, in this case, those of the neurons found in the brain. Unfortunately, there are no physical tests, no “dipsticks,” blood tests, imaging, invasive or non-invasive medical techniques for determining the relative levels of these biochemicals. Bipolar disorder is every bit a physical disease as are diabetes, cancer and heart disease. Here are the ways psychiatrists must achieve their diagnoses for their mood patients:
- Questioning the patient
- Questioning family, significant others
- Establishing a patient history
- Behavioral observation
- Reading body language
- Evaluating speech characteristics
- Combining the results of these presentations with knowledge and experience
Although bipolar disease can strike anyone at anytime, it usually can be traced to either a genetic component or a crippling physical, mental, or emotional stressor like child abuse or PTSD (Post Traumatic Stress Disorder) that produces tremendous amounts of anxiety and stress. On the genetic side, children having a sibling or parent with manic-depression have up to six times the likelihood of inheriting the disorder. Other predispositions and correlations for having bipolar disorder are having a Germanic heritage, a high IQ, or being an artist or scientist. Musicians, composers, poets, painters, philosophers, photographers, comedians, TV personalities, sculptors, etc., have an elevated risk of being bipolar when compared with the general population. My casual study of 277 famous persons revealed 84% were in those fields and suffer(ed) mood disorders. I can identify at least five triggers that launch bipolar episodes:
- Stressors (including major life events); physical, mental and emotional
- Substance abuse
- Sleep deprivation and severe circadian rhythm disruption
- Seasonal change
- Medicinal side-effects
When it comes to religion, much of Christendom judges those having mental disorders as being sinful, shameful, lacking faith, weak, self-centered, selfish, storytellers, guilty or demon-possessed. Or “That is just an excuse, you are trying to get attention.” These judgments result in private upbraiding, public ridicule, shunning or excommunication. The affected person’s beliefs fail when his mind fails. Other significant world religions either quarantine or eradicate mentally persons (defectives) by using any means possible, including homicide. It is interesting to note the statistical incidence of people’s mood disorders is unaffected by any particular religious belief or affiliation.
Depression is the number three reason for doctor visits in America today and the class of psychiatric drugs prescribed is second only to analgesics (painkillers). It has historically taken an average of four doctors and ten years to correctly diagnose a case of bipolar disorder. Even today only 49% of those with manic-depression receive treatment. Most of the remainder, unaware of their disease, will unwittingly self-medicate with “feel-good” drugs, food, alcohol and wanton (hyper) sex. Denial can be a mental patient’s best friend. Bipolar disorder is very much like a “mood roller-coaster,” with rapid ascents into mania, yet slower descents into suicidal depression stemming from a loss of confidence, identity and neurotransmitter imbalances. Our thoughts race at disturbing speeds while manic. When depressed we feel envious of anyone who is not in our place. We must train others to understand us and help us no matter how impossible that seems. And we must live “in the moment” every day. Our only real duty is to avoid mood swings that steal our reason and cause the loss of hope that constitutes our desire for death.
Fortunately, these numbers are gradually trending better due to higher levels of awareness and today’s many campaigns against stigma and discrimination targeting the mentally ill. Stigma of the disorder is fueled by the popular media characterization of bipolar individuals as being crazed homicidal maniacs having murderous/suicidal intent. Stigma means “disapproval and disgrace.” It alienates its victims, creates undeserved prejudice against them, and produces a societal shame that delivers a powerful blow to those already suffering a horrific mental disease. Stigma is every bit as inappropriate for the mental patient as it would be for the heart or cancer patient!The sufferer considers herself a public “killjoy,” and hides it as best she can. She and others like her often cannot summon the self-esteem and confidence to share their emotional battles. Every societal aberrance appears to have its own equal and opposite form using the word “phobia.” Should those guilty of fear of the mentally ill be branded “psycho-phobes?” It has been my experience that, like “mean” drunks and “happy” drunks, there are both “mean” and “happy” individuals who suffer episodes of bipolar disorder. The “mean” and violent ones are only those who abuse drugs and alcohol. After all, violent persons aren’t born, they’re made.
Bipolar individuals, on average, will suffer 8 to 10 episodes over their lifetimes. It is living hell on earth without a cure. It can only be managed. The impact on society includes these facts:
- Manic-depression is nearly the 2nd-highest reason for federal disability awards
- Unemployment for mood disorder sufferers is 50% higher than the U.S. average
- Bipolar patient lifespans are 9.2 years shorter than the nominal U.S. age of 78 years
Because drug therapy often requires 2-3 weeks to begin exhibiting a therapeutic effect, hospitalization may be indicated for the patient’s safety during a mood disorder episode. Sadly, “new and improved” healthy patient outlooks, beliefs and budding improved behavioral habits, when compared with previous behaviors, can actually spook family and friends and cause a separation of ways. Co-dependencies vanish. Outpatient counseling is often required to either prevent this ordeal or deal with its aftermath. A new setting may be a big boon to the psychiatric patient. Whether manic or depressed, the individual’s feelings must be moderated-restored to a stable range. Julie A. Fast has described a “centered” bipolar’s life as being possible, wonderful, having fun and enjoying one’s talents. I have also found these aspects of stability to be true and have reached my treasured state of serenity..
For me, clinical depression, a crafty adversary, produces the worst suffering. Its simplest definition is “anger turned inward.” A depressed patient must find a non-injurious, non-damaging way to vent those demons of anger to slam the brakes on a dangerously deepening depression.
Imagine awaking after being buried 6 feet under, the utter hopelessness of your shouts going unheard, unable to roll over in your coffin, claustrophobic. Clinical depression’s hopelessness is worse! Suicide easily becomes a viable, attractive option. In the words of Marybeth Smith, “… I just want to end the pain.” The wild mood swings of bipolar disorder in a sufferer have nothing to do with volition, choices or will. With depression, one may unknowingly begin to sink into the abyss of hopelessness.
“You can always think your way into a depression but cannot always think your way out [of one].” – Dr. Lewis Britton
At that point the only option is either drug therapy or ECT. Because psychiatric treatment usually involves only 15-minute “meds checks,” a patient must request a referral for a psychologist who can provide the “talk therapy” needed for the patient to work out thinking, behaviors, lifestyle and myriad other issues. Patients must be ascertain whether or not their psychiatrists and psychologists will communicate with one another to create a holistic continuum of care. The patient must learn habits of living including eating, exercise and sleeping habits. Mood disorder behaviors are non-volitional and re-learning healthy physical, mental and emotional habits is a must for preventing further mental mayhem. Friends and family can neither sympathize nor empathize, never having “been there.”
Serenity is my ultimate mental health goal. I have nearly achieved it by eliminating nearly most stressors in my life and it feels great. No problem distracts or bothers me anymore, most likely due to having already survived the worst that can happen to me at both extremes of bipolar mania and depression. In addition to Psychiatric and Psychological help are voluntary support groups, both physical and online. Internet forums and communities, if their members stay on-track, can be quite helpful for depressed and manic-depressive folks as episodes, doctors, medications and the like are hashed over and common ground is established for self-revelation, sharing and caring.
I am often asked whether there is 1) a greater number of mentally ill persons today, 2) if the bar is being lowered by the Psychiatric community to drum up more patients, or 3) whether there have always been so many of us in the past who were misunderstood, misdiagnosed or ignored. I am inclined to say that it is an amalgam of all three at the risk of sounding simplistic or “politically correct.” I say this because I believe all three propositions can easily be tied to the increasingly rapid advance of technology’s increasing impact on mankind over the decades. But I’m certainly open for any suggestions to the contrary.
In conclusion, “manic-depression” remains a “hot-button” topic today among health professionals, the media, patients and a confused public. Well-meaning websites and blogs litter the internet with both accurate and erroneous content and advice, and these venues must be fact-checked and negotiated with care. Although not up to academic standards, a Wikipedia search of “bipolar disorder” is probably the most handy and accurate source for the average inquisitor. Having read it myself, this mental patient recommends it for all concerned.
