Professor Patrick McKeon is a Consultant Psychiatrist and Medical Director at St Patrick’s Hospital, Dublin. He is also Medical Adviser to Aware, and an Aware board member, and was instrumental in the setting up of the organisation. In July of 2005, he delivered a lecture on bipolar disorder as part of the Aware Monthly Lecture Series. The following notes, taken by Sandra Hogan, are from that lecture.
Contents
1. Intro: the importance of knowledge
2. Issues
3. Types of bipolar
4. Symptoms of bipolar disorder
5. Difficulties
6. What can we do?
7. Q & A
Bipolar Disorder: The importance of knowledge
Professor McKeon began his lecture by reminding us all of the importance of information and knowledge about this type of depression. Hearing more about the illness is especially important for those who may be recently diagnosed, and for their families. The success of treatment for bipolar disorder is also very dependent on getting the correct diagnosis. Both the treating doctor and the individual involved have a vital role in building an accurate picture of the particular pattern the illness takes, so that the precise and best treatment is put in place. If the illness is not viewed as a whole, there is a risk that treatment of one aspect of the illness will exacerbate other areas of the illness.
Issues
Bipolar disorder (previously known as 'manic depression') involves both 'highs' (manic periods) and 'lows' (depressions). However, while a lot of sufferers will experience quite severe highs, which may be obvious to themselves and those around them, others will experience lesser highs – upward shifts in mood, which might not be particularly remarkable, but which will, nonetheless, have an impact on the individual’s life.
Unfortunately, many people will only seek medical advice for their low periods.
But if highs are present and not noticed, or indeed not reported to the treating doctor, the usual treatments for depressed mood, will not work effectively, and indeed in some cases may exacerbate the highs and create a cyclical pattern to the illness – where the mood cycles from low to high and continues in this way.
Even those who experience relatively small highs will have problems if these are not acknowledged in the treatment plan.
Core Aspects
Bipolar disorder can manifest itself in a number of different ways. The following shows how the different types of the illness vary:
This is characterised by a large high or elation. The high will generally last a week or more and has a disruptive effect with the sufferer often overactive and overtalkative.
In this type there is a slight high, which is not generally severe or disruptive, but is nonetheless important, as it is associated with severe depressive episodes.
This involves a small high which is induced by chemicals such as drink, drugs or in some cases, anti-depressants.
Basic Symptoms
Professor McKeon reviewed the symptoms of depression, identifying the illness as a disturbance of feeling, energy, sleep, thinking, interest, value (especially self-value), and one that can include physical aches and pains associated with anxiety, stress and tension, as well as a distortion of how people view their life and their desire to live.
When someone is depressed, they often complain of feeling down, sad and anxious, and some people have described feeling 'as if someone had filled their head with cement' when depressed. When depressed, the sufferer will often have broken sleep, slowed thinking, lack of focus, and they may even feel as if they are damned or wicked, and about to die from some awful illness. They may feel increasingly tense, with raised anxiety levels, and in some cases a hypersensitivity to noise.
For those who are in the midst of an elation, on the other hand, there will be little need for sleep, with boundless energy, no fatigue, speeded-up thinking (often, people will be aware of the individual’s eyes 'darting' rapidly, as if they are following several thoughts at once, jumping from one to the other), an inflated sense of self and in some cases, a sense of being invincible. In such a manic episode, people may often feel pressure in the head, as if the mind is about to 'explode'.
Family members can sometimes miss the high in someone's illness. It can take quite some time to become familiar with behaviour that suggests a high, as opposed to someone who is just in good form i.e. not in a depressed state.
Difficulties
The central difficulty with bipolar disorder lies in the fact that sufferers generally go to their doctor because of their depressive symptoms: and of course if they only report their depressive symptoms and are treated with antidepressant medication, their high periods will become more severe, and the following depressive episode is likely to be worse also.
Another difficulty is that some people who are experiencing an elation, will actually feel as if they are depressed, so it is hard to distinguish what is an elation from what is perceived to be a 'depression'.
The key difference in distinguishing a 'bad' elation from a depression can often be seen in the person's face. As depressive illness is a disorder of the rate of thinking and brain activity, those who experience the illness have either overactive brain activity or under-active brain activity. With a depressed state, the individual will show facial signs such as dull eyes, low voice, little expressiveness in facial features – there will be little or no facial engagement or animation. Whereas when someone is elated the face will be expressive with sparkling eyes and lots of energy and enthusiasm visible in the features.
Some people can experience an unpleasant high – this is known as dysphoric hypomania. So, the big question of how to tell if someone is actually elated but feeling depressed can be seen in the face, and also by watching for some of the following signs: trouble getting to sleep, anger, irritability, tendency to feel worse in the evening, sensitivity and weepiness. If this unpleasant high is treated with anti-depressants, the mood can actually start to cycle. Professor McKeon believes that the biggest shift in the management of bipolar disorder in the next five years, will be the recognition of this fact. So the central educational issue at the moment, is conveying this to general practice level.
He also believes that the frequency of bipolar disorder has increased since he began to practice some years ago: when he began his career the frequency of bipolar disorder was about 1%, whereas it has now increased to approximately 6%.
What can we do?
It is vital that the nature of bipolar disorder is understood, as once it is, it becomes easier to treat and individuals find it easier to understand treatment and what it is doing. The good news is that those who are diagnosed with bipolar disorder can go some way to facilitating the management of their illness.
Professor McKeon suggested the following for those who wish to improve their treatment plan:
- Keep a daily diary (sample template here) – note down one or two words to describe your sleep, energy, thinking, etc. on each day of a given month. As well as helping to graph your mood and any changes, you can also bring this along to your doctor at your next appointment so it is easier to recall how your mood was since the last appointment, and you can report more precisely exactly how you were.
- Plot a daily graph – before you go to bed, plot on the graph how your mood was during that day. Ask a close family member to also keep a graph plotting your mood. It is important that this graph is kept independent of you, so that you get an outside perspective on how your mood was – you may miss something important that a family member will pick up on.
Professor McKeon also spoke about the different treatments for those who experience bipolar disorder. For instance, someone who experiences big highs and lows will require different treatment (or a combination of treatments) than someone who experiences unipolar manic patterns (only highs – no lows). It is also vital that people face up to the illness – some can focus on side-effects of medication as a way of not confronting their illness. Taking medication as advised by your treating doctor is imperative. It is also important to remember that once treatment starts, it may take three-four months to see whether the treatment is working or not. This is where support proves so important. Families can help in terms of providing support for the individual, but it is a good idea to consider attending an Aware support group at this time. Talking to others who are in a similar situation can prove a huge relief, as are knowledgeable about getting through the worst stages of the illness from their own personal experience.
Questions & Answers
Professor McKeon was asked by a member of the audience if diet has an effect on depression. While it does not have a huge effect on the illness, things such as caffeine intake (tea, coffee, fizzy drinks) should be kept to a minimum as they do have an effect on mood, causing it to increase and then drop quite sharply.
Another attendee asked whether symptoms lessen as the individual gets older. Professor McKeon said that mania probably lessens in some cases, but the depressive symptoms may then come to the fore.
Professor McKeon was also asked whether someone suffering from rapidcycling bipolar can go through extremes of mood in a single day. He agreed that this was a possibility.
The final question of the evening centred around a situation where a person had been diagnosed with bipolar disorder some years ago, yet was still having difficulties with relationships/employment etc. Professor McKeon suggested that the individual might return to their doctor to examine whether a different diagnosis or treatment might now be needed. He also suggested that the individual examine whether they may have lifestyle issues which are preventing treatment working efficiently (e.g. alcohol use).
Professor McKeon’s book 'Coping with Depression and Elation' is available to order in the Aware Online Store.