Mood

Bipolar Disorder FAQ - Overview

Your definitive cheat sheet.

This bipolar disorder FAQ is intended to give you an introductory overview of bipolar disorder. The FAQ is divided into three parts. Part I discusses the nature of bipolar disorder, its symptoms and causes, how it affects both mind and body, its impact on kids, and seeking out treatment.

Part II deals with medical and therapeutic and complimentary treatments. Part III looks at various rcovery strategies.

What is bipolar disorder?

Bipolar disorder, also known as manic depression, is a mood disorder characterized by extreme shifts in mood, from depressive lows to manic highs.

What are the different types of bipolar disorder?

The American Psychiatric Association's Diagnostic and Statistical Manual Fourth Edition (DSM-IV) has divided bipolar disorder into two types, Bipolar I and Bipolar II, both which are severe and debilitating. In addition, the DSM-IV lists as separate disorders "Cyclothymia," which can be described as a "bipolar lite," and schizoaffective disorder, which borders on schizophrenia.

What are the symptoms of bipolar I?

Bipolar I requires only the presence of a single manic episode, though just about all people with bipolar I experience major depressive episodes, as well. The DSM describes an episode of mania as "a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week" (or requiring hospitalization). In addition, the DSM requires at least four of the following seven symptoms (three if merely irritable): 1) Inflated self-esteem or grandiosity, 2) decreased need for sleep, 3) More talkative than usual, 4) Flight of ideas, racing thoughts 5) Distractibility, 6) Increase in goal-setting activity or psychomotor agitation 7) Excessive involvement in pleasurable activities (such as buying sprees, sexual indiscretions, or foolish business investments).

The DSM goes on to say that the symptoms must be severe enough to interfere with work or social relations or necessitate hospitalization to prevent harm to one's self or others.

Those manic highs must be a lot of fun.

Not really. People on manic highs are out of control, and people out of control quickly get into trouble. Ruined careers, personal bankruptcy, and wrecked relationships are par for the course, and hospitalization, incarceration, and homelessness are far too common. Moreover the intoxicating high of mania (euphoria) can turn on itself into a raging agitation (dysphoria) that creates a state of internal hell. Also, most people in a manic episode experience at least one psychotic symptom (such as delusional thoughts or hallucinations). Finally, there are "mixed" states where one is literally both manic and depressed.

What are the symptoms of bipolar II?

The DSM mandates the presence or history of at least one major depressive episode. Because major depression is such a common feature of bipolar II, it is a mistake to regard bipolar II as somehow milder than bipolar I. The DSM also mandates the presence or history of at least one hypomanic episode. Hypomania can be described as "mild" mania, with the same symptoms, but where the symptoms are not severe enough to interfere with work or social functioning, though they are observable by others.

Those hypomanic highs must be fun.

Yes, definitely, but we are learning that many people who are hypomanic can be irritable, your classic road rage cases. Otherwise, one can define hypomania as "life of the party" behavior with "salesperson of the month" productivity. Unfortunately, because everything seems so "right" in a state of hypomania, people experiencing these episodes are unaware that there is anything wrong, and fail to seek help. Nothing lasts forever, however, and inevitably there is a crash into depression or an escalation into mania. People with bipolar I often experience hypomania as a prelude to mania.

Can you elaborate on nothing lasts forever.

Let me qualify my statement above. There are some people whose success seems attributable to a perpetual state of hypomania. Because they are successful they don't come to the attention of the psychiatric profession. Noted bipolar authority Kay Jamison PhD at a conference in 2002 described Teddy Roosevelt as "hypomanic on a mild day." And Bill Clinton, one could argue, is a walking hypomania poster boy.

What are the symptoms of cyclothymia?

One can think of cyclothymia as "bipolar lite," characterized by mood swings from hypomania to mild depression.

What about "soft" bipolar?

Clinicians and patients are both waking up to the fact that many people with so-called unipolar depression may in fact be suffering from a "soft" form of bipolar. By loosening the diagnostic criteria for bipolar - say by reducing the time minimum for hypomania from four days to two - the population of bipolars would jump from one or two percent to as high as five or six percent. Many of these people never fully experience the highs of bipolar, but their depressions cycle in a pattern similar to bipolar, or they may be experiencing mania and hypomania features within their depressions. Why this is important is that standard depression treatments may not work for these people. Whether you call them bipolar or not, they may need bipolar meds.

I've heard that soft bipolar and bipolar II is just the flavor of the month.

The idea is part of the concept of the mood spectrum, which has represented leading expert opinion since the early twentieth century, so we are not talking flavor of the month. The people spouting flavor of the month tend to be antipsychiatrists, who think every effort to be smart about our diagnosis is just a drug industry plot to medicate us for an illness we don't have. The irony is that many of us are already being medicated for an illness we don't have. If various attempts on antidepressants have failed, you need to consider the possibility of a bipolar diagnosis. Even if you fail to meet the full diagnostic criteria for bipolar, you may need to be treated as if you have bipolar.

What are the symptoms of schizoaffective disorder?

The DSM lists schizoaffective disorder under "Schizophrenia and Other Psychotic Disorders," but a strong body of opinion suggests that even though bipolar and schizophrenia are distinct disorders, they form part of a spectrum with overlapping features. Schizoaffective disorder occupies the middle ground between bipolar and schizophrenia, characterized by mania and depression as well as psychosis (delusions, incoherent speech, hallucinations) or other features of schizophrenia.

I have my up moods and down moods, my bad days and good. Does this mean I have bipolar disorder?

Not necessarily. Mood swings are normal, as are the many features of mood, including elation, grief, and anger. But when your behavior begins to affect your work and social relations or is noticeable by others, you may have a problem.

So with mania and hypomania we're talking over the top behavior.

Here's how one reader describes the experience: "Thursday night I was so angry it was difficult to keep from throwing and breaking everything within reach. Friday I was elated, giddy, fun to be around. Saturday seemed fine, happy but calm. Sunday morning I woke up and started cleaning the apartment...I moved furniture, on hands and knees I scrubbed every bit of carpet and floor, I vacuumed, I mopped, I took the vacuum and cleaned out all the vents and heaters, I reorganized my closets ..."

Can you talk about the depression side of the equation?

By all means. Mania gets all the attention, but bipolar patients are actually depressed three times more than they are manic or hypomanic (37 times more in depression for those with bipolar II), and the depressed phase of the illness results in more hospitalizations than the manic side. Moreover, depression accounts for nearly all of the bipolar suicides, one in five among those untreated. This amounts to double decimation, as decimation literally means one in ten.

Is bipolar depression different than unipolar depression?

Unfortunately, bipolar depression has been little studied, as the depressive side of the equation until very recently was taken for granted by researchers and clinicians. Based on what we know, it appears many people with bipolar suffer from "atypical" depression rather than "melancholic" depression, such as eating and sleeping too much (as opposed to eating too little and insomnia), sensitivity to rejection, and leaden paralysis. It also appears bipolar depression may be even more severe and debilitating than unipolar depression, if such a thing is possible. For a full discussion of depression, please see Part I of the Depression FAQ.

Tell me about rapid-cycling.

The DSM's idea of rapid is at least four episodes over one year. Rapid-cyclers, however, tend to change form one mood to the other and back again at far shorter intervals, sometimes several times a day and even several times an hour and in rare cases in the space of minutes. Because those who rapid-cycle represent a moving target, and because of the instability of their condition, this group of people are notoriously difficult to treat, with high rates of failure. Women are more likely than men to be rapid-cyclers.

So bipolar is just a mood disorder. Simple as that, right?

Wrong. The conventional wisdom has been that bipolar is an episodic illness affecting mood, with often long periods of remission between moods while an illness such as schizophrenia is a chronic illness affecting cognition that progressively worsens. Now psychiatry is revisiting that distinction. What the experts are finding is that even between episodes, many people with bipolar experience residual symptoms and subtle cognitive deficits that can get worse over time.

That's the last thing I need to hear.

Don't panic. The brain also has infinite ways of repairing itself. But brain imaging studies and studies of post-mortem brains do show smaller volumes in certain parts of the brain and larger volumes in others for bipolar patients, which may affect learning and memory and function. The good news is that some of the medications for bipolar may protect against further deterioration and even reverse the damage. Studies on rats have found that two bipolar meds, lithium and Depakote, cause new brain cells to grow, and a study on humans found lithium produced the same result. Also, nutritional supplements may be good brain food.

Is there anything else I should know about the nature of bipolar disorder?

Yes. People with bipolar disorder tend to suffer from at least one other mental illness, as well, including anxiety and panic, and alcohol and substance use. According to one major study, 61 percent of people with bipolar I have a lifetime substance use disorder (note, the percentage at any one time would be a lot smaller).

What if I have bipolar disorder and a substance use problem?

The Substance Abuse and Mental Health Services Administration recommends treating both illnesses simultaneously, ideally in an integrated setting in the same facility, at the very least with the different treatment providers working together.

Does bipolar disorder affect other areas of the body?

Yes, unfortunately. People with bipolar disorder die seven years younger than those in the general population, independent of suicide. Most of the research on the mind-body connection relates to depression, but we can apply much of those findings to bipolar.

Such as?

The risk of heart disease is doubled in people with depression, and a previous depression is often the greatest risk factor for heart disease and other ills, over smoking, drinking, high blood sugar, and previous heart attacks. Depression has also been connected to diabetes, bone loss, stroke, irritable bowel syndrome, and possibly cancer.

How serious a problem is bipolar disorder?

The Stanley Bipolar Foundation Network, which admittedly gets the sickest patients in its clinics, recently released this data: 85.1 percent had been hospitalized in the past, on average three times. The rate of suicide attempts was 50.3 percent. A third were currently married, another third single, and the rest were separated, divorced, or widowed. Despite the fact that approximately 90 percent had high school diplomas and a third had completed college, almost 65 percent were unemployed and 40 percent were on welfare or disability. According to Mark Bauer MD of Brown University, speaking at a conference in 2001, thirty to 50 percent of bipolar patients remain chronically ill.

That's pretty depressing news.

Yes it is. The good news is we can dramatically improve our chances by being smart in managing our illness, which involves a good working relationship with your psychiatrist to get you on the right meds (and then being compliant with those right meds), and making treatment and lifestyle choices that contribute to our mental and physical well-being (more on this in Part II and Part III).

Can you talk about the demographics of bipolar disorder?

Yes. Approximately two to three percent of the population suffers from bipolar disorder, but some experts push the figure up to as high as six percent by adopting softer criteria for the illness. Equal numbers of men and women suffer from the illness. People tend to have their first episode in their late teens or early twenties, though they may have experienced some of the symptoms much earlier.

Can kids get bipolar disorder?

Yes, and sad to say it appears to be far more frequent than in the past. Moreover, studies are finding that bipolar kids are sicker than bipolar adults. A bipolar kid can rage out of control for hours on end and literally hold his family hostage. Because the illness on the surface appears similar to ADHD or conduct disorder, kids are usually misdiagnosed - often by psychiatrists who refuse to believe that kids can get bipolar - and are treated with the wrong drugs that make their condition worse.

So how do you tell a bipolar kid from one who has ADHD or conduct disorder?

Only by careful observation and long conversations with the parents. As opposed to those with ADHD or conduct disorder, for example, bipolar kids tend to be risk-seeking and grandiose, with nonstop flight of thoughts.

How controversial is the topic of bipolar disorder in kids?

Very, especially with groups oppsed to all forms of psychiatry getting in on the act. Much of the controversy centers on whether we should be giving kids meds that are intended for adults.

What causes bipolar disorder?

We don't really know, though we do know that genes predispose people to the illness, and that stress can trigger an episode. Various neurotransmitter systems such as dopamine and glutamate also tend to loom large. Inside the neuron, there is a lot of talk about signal transduction pathways that are responsible for optimizing cellular function. In turn, ion channels that penetrate the cell membrane act as sort of go-betweens between neurotransmitters and signal pathways. There is also some evidence that vitamin or mineral deficiencies may play a role. In all likelihood, several processes are occurring at once, and not necessarily the same ones individual to individual.

I think I may have bipolar disorder. What is my first stop?

If you are in a life-threatening situation, or if you may be a danger to others, your first stop is the emergency room of your local hospital. Otherwise, you should book an appointment with a psychiatrist.

Why a psychiatrist?

First, because medications are the cornerstone of bipolar treatment, and only medical doctors such as psychiatrists can prescribe medications, unlike a psychologist who specializes in talking therapy. Second, because of their training and experience, psychiatrists are far more likely to give a correct diagnosis than going to your family doctor.

What should I expect from a psychiatric examination?

You can expect questions ranging from how you are feeling to how you are faring at work and at home to any family history of mental illness, if any. All the while, the psychiatrist will be probing for unusual behavior, such as spending sprees or talking too fast. Unfortunately, it takes bipolar I patients six years and bipolar II patients more than 11 years between first contact with the medical system and a correct diagnoses. This puts a considerable onus on you to reveal as much as you can to your psychiatrist. Basically, your psychiatrist is only as good as what you tell him or her.

So what should I be telling my psychiatrist?

Focus on all those times you didn't feel your normal self or too much like your normal self. You might want to go back over those times in your life you would rather forget - such as embarrassing yourself in public or attacking your spouse or walking off your job or getting arrested - or where you were unusually productive - working 20-hour days, cleaning the house in the middle of the night, writing a term paper in three hours - and try to remember what you were feeling during the time and the times that led up to these events. If you felt you were smarter than the rest of the world, describe it. If you were in a raging white heat, fill in the details. If you were in an incapacitating blue funk, describe how hard it was to get out of bed. If possible, try to write down everything you can recall in order to organize your thoughts.

To paraphrase Jack Nicholson, I can't handle the truth.

Admitting that there may be something wrong with you is one of the most difficult tasks there is. Add to that fear and ignorance and stigma, and you begin to appreciate why so few people seek help or get a correct diagnosis.

I have been diagnosed with bipolar disorder. Who should I let know?

As few people as possible, at first. It is important to know that this illness carries a much greater stigma than depression, and you run a high risk of alienating friends and associates simply by breathing the word. Legally, in the US, you should not have to reveal your illness to your employer or prospective employer, but companies may require employees to have an in-house physical where one must disclose one's medications. If there is any consolation, some of history's most talented - as well as most notorious - individuals have had bipolar, including Ludwig von Beethoven, Michelangelo, Isaac Newton, Vincent Van Gogh, Ernest Hemingway, Virginia Woolf, Hitler, Stalin, and Napoleon.

Having said all that, it's essential to have support. So if you feel you can trust certain friends and are willing to take the risk of losing them, then by all means disclose your illness. Some of them may have suspected you had bipolar disorder, all along.

Hopefully, enough of us will go public, which is ultimately the only way of ending the stigma and gaining acceptance for this illness. But don't feel you have be the one to change the world.

Updated Feb 10, 2008