Bipolar Disorder

To learn more about Bipolar Disorder watch back Dr Patrick McKeon’s lecture directly below or download our 24 page booklet also written by Dr McKeon further below.

If you wish to access support locally, please check Aware’s support group listings to find your nearest free-of-charge,volunteer facilitated, weekly support group meeting.

Dr Patrick McKeon, Consultant Psychiatrist, St. Patrick’s University Hospital provides an informative lecture (2014) about:

•    Understanding bipolar disorder
•    The signs and symptoms
•    The causes
•    The impact on people’s lives
•    Treatment
•    The skills needed for staying well.

 

Bipolar Disorder – A Practical Guidebook

by Dr Patrick McKeon  2002

Note: To save or print a copy of this 24 page booklet in PDF format, please click here and select either ‘Save a copy’ or ‘Print’ from the toolbar menu. You will need Adobe Acrobat Reader (download for free here) or another compatible program to view this file.

Contents

  1. Introduction
  2. Signs and symptoms – depressed phases
  3. Signs and symptoms – elation
  4. Bipolar disorder mood patterns
  5. Personal experience #1 – Tom’s Story
  6. What causes bipolar disorder?
  7. Personal experience #2 – Joan’s Story
  8. Complications and treatment
  9. Help and further reading

Bipolar disorder or manic-depressive illness is a serious medical illness in which a person experiences depression lasting weeks or months, alternating with bouts of ‘highs’ or mania of variable duration. For months, even years, the persons mood is otherwise perfectly normal. The term bipolar disorder is replacing the term manic- depressive illness, in that it refers to both phases of mood disturbance. For people with mania, who do not have the accompanying depressive episodes, it is still referred to as bipolar disorder.

We are all familiar with the shifts and moods of everyday life, but the mood-swings of bipolar disorder are much more intense and prolonged. They also disturb the persons everyday pattern of living to a considerable degree. Another distinguishing factor is that the person cannot either snap out of the depression nor stop their “high” behaviour completely.

Bipolar disorder begins between the early teens and forties, but may start at any age. It affects men and women equally.

Recognition
Depression is usually a painful experience in that the person knows there is something wrong. The feelings of anxiety or depression will often be intense, leaving the person in no doubt about what is wrong. Sometimes extreme fatigue or anxiety may be the principal symptom, so one may think that they are anaemic or worried about some matter, and not realise they are depressed.

Signs and symptoms of the depressed phase of bipolar disorder

  • A persistently sad, empty or anxious feeling.
  • Loss of interest in food, sex, work and other activities.
  • Tiredness and feeling slowed down, despite rest.
  • Trouble getting to sleep, wakening too early or over sleeping.
  • Reduced or increased appetite and weight disturbance.
  • Poor concentration and indecision.
  • Feelings of guilt and worthlessness.
  • Chronic aches and pains without a physical cause.
  • Thoughts of death or suicide.

Mania or in its less intense form, hypomania, is less readily apparent to the individual sufferer, as it is frequently a pleasurable experience. Intense manic episodes rarelygo undiagnosed for long, as the person is restless, over-talkative, incessant in their pursuits and sleeps little. It is immediately evident to family and friends that the person is acting out of character. However, hypomania where there are fewer symptoms of elation, may be unrecognised for years, as the person will regard this phase as a time when they feel uncharacteristically well. Not infrequently, where the person has, what appears to be, recurring depressive episodes, there are intervening hypomanic episodes that they neither complain of, nor are they recognised by the doctor. Family members, if specifically asked, will have observed these mild highs during which the person’s mood is unusually buoyant and optimistic.

Signs and symptom of elation or mania
In mania there is a change in the level of feeling and rates of thinking that is excessive for that individual.

  • Feeling “high”, “on top of the world”, “better then normal” or “better than ever before”.
  • Uncharacteristic anger or irritability,
  • Great energy and not needing to rest.
  • Overactive, restless and distractible.
  • Racing mind that cannot be switched off – “pressure in the head”.
  • Talking rapidly and jumping from one topic to another.
  • Decreased need for sleep.
  • Excessive and unrealistic belief in ones abilities
  • Poor judgment.
  • Increased interest in pleasurable activities; new ventures, sex, alcohol, street drugs, religion, music or art.
  • Demanding, pushy, insistent. domineering or provocative behaviour, not able to see the changes from ones usual self – “There is nothing wrong with me”.
  • Delusions (false ideas) and or hallucinations visions or voices) may occur and they usually relate to grandiose ideas about religion, creativity, sex, politics or business.

Who gets bipolar disorder?

  • 40,000 Irish people suffer from this illness.
  • It affects men and women equally.
  • It usually starts between puberty and the age of 40, but can begin at any age.
  • People from all walks of life, from presidents to porters, have had this illness.
  • Michelangelo, Vincent Van Gogh, Robert Schumann, Vivian Leigh, Isaac Newton, Shelley and Byron knew intimately about bipolar disorder.
  • People hid their mood-swings in the past through shame. Now successful treatments are available and it is a shame to conceal it.

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Bipolar disorder mood patterns
Elation or mania can last for days, weeks or months, as can depression. There are different patterns of the illness. Some get major episodes of elation that last from weeks to months and these are known as Manic Disorder, while others get bouts that are short lived and less intense and are referred to as Hypomania. It is these lesser degrees of elevated mood that go often undetected. If the episode of elation is severe, in that it meets the criteria for Manic Disorder, this form of manic depression is called Bipolar I Disorder. Bipolar II refers to mood-swings where there are hypomanic and depression episodes. About 5% of people with bipolar disorder have manic or hypomanic episodes without depressions. The depressions that precede or follow manic episodes last days, weeks or months. Manic episodes are not always pleasant, in fact they can be extremely distressing and the person may feel tired, irritable, very distressed and complain of being “depressed”. Yet, the person will be generally overactive, talking a lot, look distressed rather than depressed and tend to sleep less. This unpleasant high, often referred to as a dysphoric manic state or “mixed” mood state, can be inadvertently diagnosed as depression.

If a person has had one episode of depression or elation, they have a 50% chance that it will not recur. However, if it does occur 2 or 3 times, it will have an extremely high chance of recurring again and again, unless some preventative mood stabilising medication is taken. Depression that has onset in winter and is followed by a period of elation during the summer months, will often recur at the same time each year.

It has been noted that some patients have several mood-swings in a year and that such pattern of mood disorder are not particularly responsive to what is generally regarded as the most effective mood stabiliser, Lithium. Where there are four or more episodes of depression or elation in one year, it is referred to as rapid cycling mood disorder.

Tom’s Story
I was always in trouble, I seemed to need the excitement. If someone suggested the most outlandish prank, I always seemed to be the dare devil. I was thrown out of school at 13 when I loosened the wheels of the English teacher’s car. School after school it was the same thing – I couldn’t settle down and concentrate – my mind was always all over the place. At home I was arguing with my father. He tried his best to get me to study, but I always managed to get out in the evenings. I was never asleep before 3 in the morning and was wide awake at 5 am.At other times I have felt like a lump of lead – I slept around the clock. My parents were convinced that I was on drugs – they searched my room and quizzed my friends.The summer I reached 16, it all came to a head. I was in the Gaeltacht and I felt very restless and couldn’t sit in class. For four nights in a row I walked the beaches when I couldn’t sleep. I began to feel a great exhilaration and enormous strength in my body. I remember it was the year of the World Cup and I became convinced that I was going to be called to play for the Republic of Ireland. The teachers had been watching me and they knew something w:as wrong. Eventually, my parents w:ere called and asked to take me to a doctor. Three days la1er I was admitted to a psychiatric hospital.It took me a long time to accept that I w as ill, that I had manic depression and that I had to stay on Lithium. But when I think of the four years or so in my early teens when I was just going up and down, messing in class and getting into trouble, all that time I’d wasted, and to think that others are still going through that – it gets me angry. What did help me to take all of this in, was the support groups I attended. I suppose it is only from people who have been down the road before you, and that understand where you’re at, that can really get through to you.

What causes bipolar disorder?

  • Bipolar disorder tends to run in families. Studies have shown that some 15% of the immediate relatives of bipolar disorder patients have a serious mood disorder. Research investigations over the past few decades have shown that on average 70% of the cause of bipolar disorder is genetic and the remaining 30% is due to environmental factors. For each person with bipolar disorder the relative importance of the genetic and environmental factors will vary. Some will have a very strong family history of the illness and in those instances it often only takes a slight environmental stress to unleash the genetic tendency towards the mood disorder. Others will develop bipolar disorder where there is only a minimal history of mood disorder in the family, when a number of major upsets occur in quick succession.
  • Environmental factors that are known to affect mood include stresses such as financial or family difficulties, losses such as bereavements, relationship breakups, and loss of employment. Losses and stresses appear to be particularly important prior to the first episode in that they tend to precipitate the illness, but subsequently mood-swings may occur without the same level of upsetting events occurring in the person’s life.
  • Alcohol, street drugs (Ecstasy, Cocaine, Hashish, Amphetamines, Magic Mushrooms), medication (steroids, certain blood pressure tablets and anti – Parkinson drugs’) can all cause depression or elation in people who are predisposed to mood-swings. While most peoples’ moods are minimally affected, at most, by these substances, people who have a biochemical tendency towards bipolar disorder, in that they have a family history or past history of the disorder, can often find that they experience a major depression or elation with these chemicals.
  • Our mood is regulated by a complex network of areas in the brain known as the limbic system. Brain tumours, trauma, haemorrhage, infection or multiple sclerosis, can produce mood-swings by damaging this network. These causes of bipolar disorder are rare and would routinely be considered by the doctor when bipolar disorder is diagnosed.
Joan’s Story
I just got so tired, everything was a huge effort. Just taking up my new baby – he seemed like the weight of the world. It was as if my brain had stopped and I couldn’t think. It took me weeks to get help – I thought that this was what mothers felt and John thought I was tired from feeding the baby during the night.After 3 months I went to my GP and he told me I had postnataI depression. He prescribed antidepressant tabIets which had me back on my feet in a short while. I was then abIe to enjoy my new baby.The following winter it happened again: the tiredness, the tightness in my forehead and sleeping aIl the time. This time I knew what to do. I got help quickly and everything seemed fine.But that was not the end of it. Over the years I got depressed several times, so much so that my doctor recommended that I should stay on tablets. However, the depression kept coming alI the same. I couldn’t understand this, it wasn’t as if I wasn’t taking the tablets.One day John happened to mention to me that I was in terrific form and taIking too much, and that he had noticed this happen each time I came out of depression. We talked it through with the doctor who concluded that I had mood-swings, a form of manic-depression. I was shocked at first when I heard this. Over the past two years my mood has been stable with different treatment and I have come to terms with the diagnosis. I know that if I do not stay on treatment it will be the same old story all over again.

Complications of bipolar disorder

  • Family disruption: Results from the elated person’s persistently domineering, demanding and sometimes aggressive behaviour.
  • Marital breakdown: The overspending, extra-marital affairs and abusive and occasionally, aggressive behaviour can, with repeated episodes of mania, lead to marital separation, even after years of marriage stability.
  • Poor work, or school, performance.
  • Loss of employment.
  • Bankruptcy
  • Alcohol and drug abuse.
  • Legal difficulties: From indiscreet or aggressive behavior or remarks, traffic violations, bizarre behaviour associated with over estimation of ones abilities.
  • Social isolation: Due to intense feelings of worthlessness and guilt in depression.
  • Suicidal behaviour in depressed and dysphoric manic states.

Can it be treated?

  • Most bipolar mood disorder illnesses can be successfully treated with mood stabilising medication. Almost all will have substantial relief of symptoms with present-day treatments.
  • Medications are the main forms of treatment for this illness. Psychotherapy or counselling is helpful in providing support and guidance for both patient and family and with coming to terms with the illness. It can also be of great benefit in helping to identify relapses at an early stage and enable early treatment intervention. However, it has no effect on controlling or stabilising bipolar mood disorder.
  • Lithium is the first-line treatment most commonly prescribed mood stabilising agent. It is prescribed as a treatment to shorten the duration of a manic episode and then for longer term use. It works effectively for some 75% of bipolar disorder patients. When Lithium fails to prevent recurring mood-swings, other treatments, alone or in combination with Lithium, such as Carbamazepine, Valproate, antidepressant and anti-elatant medication are used.
  • Effective antidepressant medications are available to defeat intense depressive episodes. However, they are used sparingly in bipolar depressions, as they tend to precipitate mania or destabilise mood patterns.
  • While Lithium is prescribed to cut short a manic episode, it takes three or more weeks to take effect. While awaiting the antimanic effect of Lithium to occur, some quick acting drugs known as the neuroleptics, such as chlorpromazine or haloperidol are prescribed to contain the mood disturbance.
  • Only about 30% of rapid cycling mood disorders are successfully treated with Lithium. Carbamazepine, alone or with Lithium is more successful.
  • Mood stabilising treatments, such as Lithium, are not cures – they control moods. Where Lithium has stabilised bipolar mood-swings, 80% will experience a relapse of their symptoms if the Lithium is discontinued.

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What you can do to stay well

  • Learn what you can about bipolar disorder from books, lectures and support groups. It is useful to talk to other sufferers who have achieved mood stability. Their words of wisdom can often be a great source of comfort when trying to come to terms with the illness.
  • Comply with the treatment recommendations your doctor has set out for you. If you have side effects with the medication, have worries about its long term effects or feel that you are not making the progress you would have wished, discuss this with your doctor rather than going your own way. The most common reason for treatment failure in bipolar disorder is that the treatment is not being taken as prescribed
  • Encourage your family to get involved in helping you deal with the illness. They are concerned about you and there is a lot that they can do to assist. They can benefit a lot from getting a factual understanding of the illness, just as you have.
  • Families can also derive great benefit from meeting relatives of other sufferers and support group meetings provide them with the ideal opportunity to discuss their concerns and difficulties with other carers.
  • It takes time to come to terms with a diagnosis such as bipolar disorder, particularly if it implies the need for long term medication. The support of family, friends, your doctor and other sufferers can be of enormous value. Many people find attendance at support groups such as those run by Aware, where they can share their experiences in an open and uncritical forum, to be the key to gaining an understanding of their illness and how to come to terms with it.
  • Choose a close relative or friend to help you spot a relapse. Probably the most difficult aspect of mood-swings that people have to come to terms with is that they may be the last person to realise that their mood has changed, particularly if they are going through a period of elation. Depression, being a painful experience, will more often be recognised by the sufferer before anybody else, but with elation your close family and friends will tend to identify the mood shift before you do. Even when you do recognise the mood shift, the chances are that you have underestimated its severity.
    Because of the delay that may occur in identifying a manic relapse, a considerable period of time may have elapsed and the indiscretions, overspending and family turmoil may have occurred before any treatment has started. Sometimes these complications of bipolar disorder leave their scars and they can never be resolved. It is vital to prevent these complications by prompt recognition of mood relapses. If a mood shift can be identified at an early stage, these complications can be prevented and treatment undertaken without the need for admission to hospital.
    While it is reasonable to consider the main symptoms of elation, such as over talkativeness sleep disturbance and overactivity as indicators that your mood has shifted, it is best to rely on a close relative or friend, whom you see frequently, to help you spot the emergence of the mood-swing. You should ask such a person to undertake this task and you should give them an undertaking that you will follow their recommendations, such as getting in touch with your doctor, stopping driving, limiting your spending power or whatever they recommend. It is essential to trust the judgment of somebody who you know is acting in your interest, rather than relying your own assessment at a time when your own mood is unstable. This is not an easy matter to come to terms with, but inevitably it must be faced if the complications are to be prevented and the mood mastered.
  • It is essential when your mood stabilises that you discuss with family members, friends and work colleagues any matters that you may have been a source of friction with them during the time of your mood disturbance. There is a natural tendency to avoid this; you may feel embarrassed about what happened and they may be afraid to raise the matter in case it upsets you. It is better that you encourage them to talk about it, as if they harbour hurt feelings about the issues, they only tend to multiply, particularly if the same topic is brought up each time there is a mood-swing. These unspoken of and unresolved issues are the very reason that people with mood disorders can find themselves losing friends, their work or their marriage.
  • Your family and friends also need time to adapt to your illness. Those close to you will be concerned about your welfare, even after you feel well. The restrictions that were necessary when your mood was unstable but are now not needed may still be clung to by them as they are slow to let go of these controls for various reasons. After a few months of mood stability, most will begin to trust your recovery and feel confident about the future. If you feel that despite a lengthy period of wellness you have not been enable to return to your former position within the family or with your friends, it is worthwhile discussing this with your doctor.
  • Bipolar disorder is usually treatable, but how quickly and how successfully this happens depends most of a11 on, how readily the patient and family can come to terms with the diagnosis.

Where to get help

  • Anybody with bipolar disorder should be under the care of a psychiatrist, at least until their mood-swings have been stabilised. A knowledgeable General Practitioner can be of, invaluable help to you.
  • Psychologists, social workers and nurses can help in supporting the patient and family cope with the illness, and this is as important as any as any medication that is prescribed.
  • Aware provides:
    1. support group meetings for patients and relatives throughout Ireland.
    2. a telephone helpline (loCall 1890 303 302).
    3. publications on various aspects of depression, available in our Literature section and in our Online Store.
  • It is usually possible to lead an active, enjoyable and fulfilling life despite the illness.

Suggestions for Further Reading
Brown, G.W. and Harris, T., Social Origins of Depression, London, Tavistock Publication, 1979.
Corry, M., Postnatal Depression – A Guide for Mothers and Families, Dublin, Aware Publication, 1991.
Duke, P., and Hochman, G., A Brilliant Madness – Living with Manic-Depressive Illness, New York, Bantam Books, 1992.
Fieve, R., Moodswing, New York, William Morrow, 1989.
Goodwin, F.K. and Jamison R.K., Manic-Depressive Illness, New York Oxford University Press 1990.
Griest J.H. and Jefferson, J.W., Depression and its Treatment, Washington D.C, copyright 1992 by John H. Griest and James W. Jefferson.
Jamison Redfield K, An Unquiet Mind, New York, Pan Publication cons 1997.
Kelleher, M.J., Cabamazepine in Mood Disorder – a Practical Guide, Dublin, Aware publication 1992.
Milligan, S. and Clare A., Depression and How to survive it, London, Ebury, 1993.
McKeon, P., 0 Brien, S., and Fehily, J., Lithium: A Practical Guide, Dublin Aware Publication 1987.
Paykel, E., Handbook of Affective Disorders, London, Churchill Livingstone 1992.
Scholl, M., Lithium Treatment of Manic- Depressive Illness, Basel, Karger, 1989.
Winokur, G., Depression – The Facts, Oxford, University Press 1981.

 

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