By RICHARD A. FRIEDMAN, M.D.
At 45, my patient Bruce was at the pinnacle of his career, with a lucrative law practice. Then his life was cruelly turned upside down by two medical events, a crushing first episode of major depression and a series of strokes from untreated hypertension.
For many years, Bruce struggled with severe depression and high blood pressure without much headway. Then something strange happened.
He suddenly pulled out of the depression and dove into his work. Not only that, but he felt the surge of energy and self-confidence that he used to have. No hurdle seemed too high or problem unsolvable, he recently recalled.
No one questioned his renewed energy and vigor, because he had always been vivacious. Nor did his combative behavior and ever increasing volume of provocative e-mail messages to friends and colleagues raise a suspicion that something might be seriously amiss.
Betting that his future earnings would more than cover large expenses, he put off filing his state tax returns. No one seemed to recognize just how impaired his judgment had become. Even the judge who placed him on probation for failure to file tax returns missed the real story.
When I met Bruce in a consultation, he spoke loudly and rapidly, and I had difficulty interrupting him. It wasn't hard to figure out that he had been living with an unrecognized and untreated psychiatric illness that had driven him to the edge of ruin — bipolar disorder, also known as manic depression.
Like most diseases, bipolar disorder comes in different shapes and sizes and can be difficult to diagnose. Few people or physicians would miss classic bipolar disorder, with its cyclic episodes of severe depression and full-blown mania. After all, there is nothing subtle about mania, grandiose and often psychotic thinking, elated mood, superhuman energy and libido and reckless judgment.
But a milder form of mania, called hypomania, is not obvious at all, especially in someone like Bruce who happens to be temperamentally dramatic and lively. That is because hypomanic people feel very happy, have lots of energy, need little sleep and are generally fun to be with. And they certainly do not run to doctors complaining of happiness.
So it is easy to see how hypomania could masquerade as cheerful character. In the same way, dysthymia, hypomania's dark twin, has often been confused with gloomy temperament, when in fact it is a treatable form of low-grade depression.
Unlike depression, though, hypomania is intrinsically pleasurable. It is a better-than-well state that often confers a heightened sense of creativity and power.
So what is the down side to hypomania? Well, it can subtly and sometimes powerfully impair a person's judgment. After all, exuberance and supreme confidence can blind someone to the potential consequences of decisions.
Despite obvious financial constraints, Bruce went through long periods of extravagant spending with an inflated sense of his own power and ability. The results proved catastrophic. Not only that, but hypomania is very often an unstable state that cycles into periods of depression, which are sometimes very severe. When that happens, as in Bruce's case, it is called bipolar type 2 disorder.
Bipolar disorder is a potentially fatal illness, because 10 to 20 percent of patients commit suicide, the National Institute of Mental Health says.
According to a survey sponsored by the institute, the prevalence of bipolar disorder is 1.1 percent. That estimate covers just people with the classic form of the disorder.
A more recent survey by Dr. Robert M. Hirschfeld, published in The Journal of Clinical Psychiatry in 2003, found significant bipolar symptoms in 3.7 percent of the United States population. About 20 percent of people identified as bipolar in the survey had been given correct diagnoses, and most had not received effective treatment. The study also found a much higher rate of bipolar disorder, 9.3 percent, among patients 18 to 24 years of age.
The very different rates reported in these two surveys reflect different questions, definitions and methods to diagnose bipolar disorder. If a survey includes the milder types, as the above study did, the prevalence will be much higher.
In fact, the whole spectrum of bipolar disorder is very broad. Some people learn for the first time that they have bipolar disorder when they are treated for depression. That's because antidepressants can precipitate mania in 5 to 10 percent of people with no histories of mania.
Depression is associated with decreased activity of important neurotransmitters like serotonin and norepinephrine. The converse is hypothesized for mania. Because antidepressants significantly increase the availability of those neurotransmitters, they can spark mania in some biologically vulnerable people.
So can "recreational" drugs like cocaine and methamphetamine, which instantly flood the brain with another neurotransmitter that regulates mood, dopamine.
The problem is that the milder types of bipolar disorder are often hard to recognize as an illness because the symptoms are chronic and less severe. In contrast, a person who develops a florid acute disease, whether appendicitis or full-scale mania, is obviously ill to any casual observer, because the contrast between the normal base line and the illness is stark.
Bruce, his family and friends, as well as his physicians were all taken in by his hypomania masquerading as mere happiness. In effect, they mistook his bipolar illness for his personality.
In the end, Bruce has responded very well to lamotrigine, an anticonvulsant mood stabilizer. Some time after, he was calm and rational and had an even mood. It was only then that he was able to see clearly the illness that nearly destroyed him. Now he is beginning to put the pieces of his life back together.