Since his late adolescence, 26-year old Duncan* has experienced a “rollercoaster” of moods in his life. For months on end, he gets so depressed that life seems meaningless and he has difficulty even getting out of bed. Then, abruptly, he experiences a period of elation in which anything seems possible. At the height of his “good mood”, he talks incessantly, keeps tables entertained with witty jokes and has so much energy that he barely sleeps. Sometimes, he even has auditory delusions in which he believes God is talking to him.
Although these symptoms may appear strange at first, they are in fact distinctive features of a psychiatric disorder known as bipolar or manic depression in which people have mood swings out of proportion to things going on in their lives. A person’s mood can alternate between mania (feeling overly elated, energised or irritable) to depression (feeling very sad, pessimistic, lethargic) and back again, with period of normality in between. In the United States, over 1.2% of the adult population has this disorder. There is a strong genetic component to bipolar – 50% of all bipolar patients have at least one parent with a mood disorder.
Over the course of bipolar mood disorder, five variants of mood episodes can occur: mania; hypomania (milder form of mania); major depression, mixed episode (both mania and depression occurring at the same time or alternating frequently), and rapid cycling (appearance of four or more episodes in any twelve month period). People vary in the type of episodes they have and how often they become ill. Episodes can last days, months or even years.
The two most common patterns are known as bipolar 1 disorder and bipolar 2 disorder. Even in bipolar 1, the depressive episodes outnumber the manic episodes. If you have become ill for the first time and it was with a manic episode, you are still considered to have bipolar disorder. In bipolar 2 disorder, the major depressive episodes dominate, alternating occasionally with hypomania. In these cases, doctors have to be careful not to assume that depressed patients are suffering from unipolar depression.
It is important to be able to recognise a manic or hypomanic episode in a bipolar patient. The criteria for a manic episode involves a patient experiencing an elevated, expansive “high” lasting for at least one week, along with at least three or more of the following symptoms: an inflated self-esteem; decreased need for sleep without fatigue; more talkative than usual or pressure to keep talking; racing thoughts; distractibility; increase in goal-directed activity and a perchance for doing reckless things without concern about possible bad consequences e.g.: spending too much money, inappropriate sexual activities. Initially panic patients have a pleasurable sense of increased energy, creativity and social ease, but this progresses to irritability, agitation, restlessness and, sometimes, physical aggression. Delusions present in 75% of manic patients. Normally manic patients will lack insight into their illness and deny that anything is wrong.
Dr Ian Westmore, a psychiatrist from Bloemfontein warns that medical professionals need to be cautious when diagnosing bipolar disorder in patients, “It is especially important to eliminate other ‘imitators’ of manic episodes,” he says. These include HIV infection, neurosyphilis and hyper-thyroidism and certain types of epilepsy. Substance abuse also needs to be ruled out as patients who abuse cannabis can appear to be manic or hypomanic. Benzodiazepine withdrawal can cause patients to have an irritable mood whilst the use of stimulants or slimming tablets can cause patients to appear manic. Alcohol withdrawal can cause patients to have mood swings. The situation is further complicated by the fact that bipolar patients notoriously self-medicate with many of the substances just mentioned. “A thorough medical check-up is essential before any diagnosis is made,” says Dr. Westmore.
In her successful novel: “Prozac Nation”, Elizabeth Wurtzel describes her battle with a disabling depression. At one stage, whilst she is working as a journalist at a Texas newspaper, she experiences a manic phase: “I wrote like crazy ….. I wrote like my life depended on it, which it kind of did …. I could barely sleep and my nights passed fitfully ….. Between so much writing and so much chatting, my weeks were too packed for me to notice my emotional state at all ….. I was so nervous all the time …. Always feeling at the mercy of something that felt like a hive of bees buzzing in my head.”
Major depression, the other side of bipolar, is characterized by a period of prolonged sadness that involves symptoms such as significant changes in appetite or sleep patterns; increased irritability and agitation; loss of energy; feelings of guilt or worthlessness; inability to concentrate; inability to take pleasure in former interests; unexplained aches and recurring thoughts of death or suicide.
If left untreated, bipolar tends to worsen. Sufferers are linked with a high risk of suicide, alcohol or substance abuse, marital and work problems. Treatment should be threefold involving medication, psychotherapy and education.
Initially, medication should treat the acute episode at hand. Antianxiety and antipsychotic drugs can be used to treat delusions, hallucinations or agitation. In the long term, mood stabilizers, such as lithium, are needed to prevent further episodes. Antidepressants can also be used to treat major depression. Once patients are feeling better, they are often tempted to come off their medication, although in most cases experts strongly recommend preventative medication indefinitely. Adjustments in dosages of medication is often a routine part of bipolar treatment. Electro Convulsive Therapy (ECT) has also been found to be very effective with certain cases of bipolar.
There are a variety of therapeutic modes that can help with bipolar management including behavioral, cognitive and interpersonal therapy. In cognitive therapy, sufferers are taught to identify and challenge their pessimistic thoughts and beliefs that underlie their depressive episodes. Interpersonal therapy involves reducing the strain a mood disorder can have on relationships. Often family therapy is very beneficial as bipolar disorder can disrupt the structure of an entire family.
It is vital that bipolar sufferers are educated about their illness and lifestyle changes that they should maintain as a result. Sufferers can empower themselves by joining support groups that provide a sense of acceptance and understanding. The Depression and Anxiety Support Group open 8am to 7pm Monday to Friday, 8am to 5pm on Saturdays, and 9am to 1pm Sundays provides counseling, referrals and information. The Support Group can be contacted on (011) 783-1474/6 or 884-1797.
The good news is that, with the right management, bipolar is a highly treatable illness. Duncan has since moved onto lithium. He is beginning to feel a stable control over his life that has been missing for a long time. Sharon*, another bipolar sufferer, has been battling with the disorder for most of he life. “Religious faith and perseverance have also helped me get through it,” she says. “I also find that it helps to counsel other people in similar circumstances.”
* not his real name
* not her real name