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From MSN Health
   A Day in the Life: Bipolar Disorder Posted Tue, Oct
09, 2007, 5:55 pm PDT By David Neubauer, M.D.
We could tell something was
wrong the moment she opened her front door. She stood there with a blank stare, saying nothing. Every other time we'd visited
her, she was very animated, smiled broadly, & seemed to talk nonstop. It was a worrisome contrast in this patient with
bipolar disorder.
This was supposed to be a
routine home visit with a patient who's receiving our Psychiatry Mobile Treatment Services. She was the last home visit for
the day. I & one of the program's therapists had been driving across Baltimore since early in the morning. It was lucky
that we made this 13th house call.
She slowly led us into her
apartment & we all sat down. She sat motionless & initially said nothing. Here's how it went:
Me: How are you feeling?
Her: (long pause) I'm scared.
Me: What are you worried about?
Her: (long pause) I'm going to be homeless.
Me: I know the landlord is
selling the house & you have to move, but we can help you find another apartment.
Her: (long pause) I'm going to be homeless & lose everything.
Me: Things don't seem that
bad. We'll help you find another place.
Her: (long pause) I think I should die.
Me: I think that your mood
is so low & you're viewing things very negatively because you're experiencing a depressive episode from your bipolar
disorder.
Her: (long pause) I deserve to die. I can turn on the gas. (long
pause) Is there really a devil?
This woman in her early 50s
had been doing very well since joining our program earlier in the year. She was doing fine living independently & she was involved in various community activities. A staff person from our Mobile Treatment program saw her at least
weekly. She insisted that she was taking her medications regularly.
It was obvious that this was
a dangerous situation. Fortunately, she was willing to come along with us to the Emergency Department. She gathered a few
items & willingly got into my car to ride to the hospital. I made some phone calls so that she could be admitted to our
inpatient psychiatric unit. We weren't about to leave her in her apartment alone with severe depression, delusional thinking & a plan to kill herself.
Bipolar disorder, or manic-depressive
illness, is characterized by moods that swing between two opposite poles:
Although chemical
imbalances in the brain are a key component of bipolar disorder, it is a complex condition
that involves genetic, environmental & other factors.
Moody kids / normal or not?
For some children, bipolar disorder could
be the culprit
By Victoria Clayton
Contributor
Updated: 9:16 p.m. ET March
16, 2004
Consider this scenario:
At 8 a.m. your 12 yr. old is so irritable & hard to wake you nearly have to drag her out of bed, dress her & roll her on a skateboard to make the bus.
By 11 shes a prodigy, delivering the most
poignant speech her sociology teacher has ever heard on the civil rights movement.
At 2, though, her English teacher claims
she's the class clown, refusing to sit still & focus on her assignments & by bedtime she often acts as if shes downed
a gallon of espresso.
As a parent, do you chalk this up to normal
prepubescent moodiness? If so, you may be right. Then again, warns Dr. Kelly Botteron, you could be in denial.
"Parents sometimes
try to explain away a psychological problem," notes Botteron, an associate professor of psychiatry at Washington Univ.
School of Medicine in St. Louis, who specializes in juvenile mood disorders.
"They'll say, oh, kids can
be erratic & kids can be moody & difficult," she says. "But in fact they aren't as moody & difficult & erratic
as their reputation. Most studies show that they aren't as unusual & strange as they sort of have this cultural myth as
being."
Indeed, at times most children
can go from irritable, easily annoyed, angry moods to silly, goofy, giddy elation but, says Botteron, there's an easy way to determine if you have a problem: persistent trouble-making.
"If you have a child who is
moody to the point of causing problems in school, at home or with friends, that's usually not a normal thing," she says.
One possible explanation is drug use. Another is that the child is suffering from a serious psychological illness & one that's woefully underdiagnosed:
bipolar disorder.
Much more common than thought. Also called manic-depression,
bipolar disorder is a mental illness that causes a person to cycle thru abnormally high
& low moods. It was once thought to be rare in children, so little attention was paid to the issue. But the latest research shows that not only can bipolar disorder begin very early in life, as early as age 5, though it typically manifests in
kids around the onset of puberty, it's much more common than ever imagined.
In fact, according to
the Juvenile Bipolar Research Foundation, the condition is now diagnosed in close to 1 million
children & adolescents in the US each year.
The most shocking revelation,
however, is that because many healthcare professionals haven't been trained in childhood bipolar,
kids afflicted w/this illness may be misdiagnosed & given medication that actually worsens their symptoms or doesn't help
them at all.
"At least 20% of kids
initially diagnosed w/[attention deficit hyperactivity disorder] actually turn out to have bipolar disorder," says Dr. David Fassler, a child & adolescent
psychiatrist in Burlington, Vt. & a clinical associate professor of psychiatry at the University of Vermont College of
Medicine.
It's a situation Dr. Demitri
Papolos, an associate professor of psychiatry at Albert Einstein College of Medicine in New York City & director of research
for the Juvenile Bipolar Research Foundation, says amounts to a national healthcare nightmare.
Prescriptions for stimulants, which are used to treat ADHD & antidepressants are increasing in children, "& you have these kids who are undiagnosed as bipolar but
diagnosed w/everything else being treated w/these drugs," says Papolos, who is co-author w/Janice Papolos of "The Bipolar
Child."
The wrong medications, he says, can be dire, causing increased cycling that spells rapid & profound mood fluctuations, increased aggression & often psychosis.
"This is the sort of thing
that really makes life horrible for these kids," he says. "It's clear to me, although we dont have data to support this, that
it's much, much harder to stabilize kids w/the usual mood stabilizers after they've been through these trials of [antidepressants & stimulants]."
Left untreated or mistreated,
bipolar children & teens can face a lifetime of trouble. They have an increased likelihood
of failing in school, alienating friends, developing substance abuse problems, getting in trouble w/the law, becoming pregnant & even committing suicide.
Getting the right help
With the correct diagnosis
& treatment, bipolar children can have a bright future even though the illness is chronic
& requires a lifetime of treatment.
Papolos calls bipolar children "national resource treasures" because of their creativity, intelligence & drive. American
explorer Meriwether Lewis, in fact, is thought now to have suffered from bipolar disorder.
"If you channel it in the
right direction perhaps it can pay off, which is what we try to help parents do w/these kids. But they have very little control over their impulses & it can become a horrendous scene [if untreated]," he warns.
Talk therapy may be used to help bipolar children & their families deal w/the illness & its
fallout, but mood-stabilizing medications such as lithium & tegretol are the cornerstones of treatment.
Botteron, who does brain imaging
research, says parents shouldn't be fearful of the proper medications. Her research has found that untreated psychological illnesses can reduce gray matter in certain areas of the brain but proper medication can help counter this damage.
The sooner treatment starts,
the better, she says. "It looks like some of the damage may be able to be prevented or is less the more treatment & the
longer treatment youve had."
The first step is for parents
to recognize the potential problem & seek proper medical attention.
While a trip to the
pediatrician or family practitioner may be the first stop, parents should realize that he or she probably isnt trained to
pick up on the symptoms of bipolar disorder, many of which mimic other more common disorders.
Since bipolar has a strong genetic link, they should ask for a referral to a child psychiatrist or a psychiatrist who specializes in bipolar disorder, particularly if they know the illness is present in
their family.
Could there be a problem?
Attentive parents are a bipolar child's best chance at getting vital treatment. If you answer yes to the majority of the following
questions, consider having your child evaluated by a child psychiatrist or clinical therapist who specializes in bipolar disorder.
- Does your child have rapidly alternating moods that fluctuate
numerous times a day from being elated to being extremely irritable?
- Is your child incredibly hard to wake up & equally hard
to get to sleep?
- Have other parents warned you that your child tends to be aggressive with their children or does your child get into fights?
- Is your child explosive at times?
- Would you describe your child as unstoppable once he or she
gets a notion to obtain something? (i.e. Have you ever gone out to pick up pizza, ice cream or
a video just to stop the tension your child is causing in the home?)
- Does your child often describe activities that are enjoyable
to most children as boring or not stimulating enough?
- Have others described your child as withdrawn?
- Is your child often sad without a reason?
- Does your teen drive erratically or engage in other highly
risky behavior (i.e. Promiscuity or substance abuse)?
- Has your child been diagnosed w/attention deficit hyperactivity disorder or depression, but doesn't seem to respond well to treatment?
- Does your child have trouble maintaining friendships?
- Has your child been in trouble numerous times at school?
* Remember, no one of these
symptoms by itself constitutes bipolar disorder. And, most importantly, in order for any
problem to reach the level of a psychiatric disorder, it needs to be interfering with the child's life. The bottom line is that parents must ask themselves if their child's behavior is
causing him or her not to function at home, at school or w/friends.
Bipolar Disorder Categories
Bipolar disorder is classified according to the pattern & severity of
the symptoms as bipolar disorder I, bipolar disorder II, or cyclothymic disorder. Patients with one type may develop another.
Nevertheless, they're distinct enough to merit separate classifications
& some experts believe these conditions are actually separate disorders with different biologic factors that account for
their differences.
Bipolar Disorder I. Bipolar disorder I is characterized by at
least one manic episode, with or without major depression. In 60 - 70% of cases, manic episodes
precede or follow depressive episodes in a regular pattern. Episodes are more acute & severe than in the other 2
categories.
Without treatment, patients average 4 episodes of dysregulated mood
each year. With mania, either euphoria or irritability may mark the phase.
In addition, there are significant negative effects (such as sexual recklessness, excessive & impulsive shopping & sudden traveling) on
a patient's social life, performance at work, or both.
Untreated mania lasts
at least a week & it can last for months. Typically, depressive episodes tend to last 6 to 12 months, if left untreated.
Bipolar Disorder II & Hypomania. Bipolar disorder
II is characterized by predominantly depressive symptoms with occasional episodes of hypomania.
Hypomania is similar to mania, but the symptoms (typically euphoria) are less severe & don't last as long.
Bipolar Disorder: More Common Than Expected?
Study: Bipolar,
Related Disorders Cut Productivity More Than Depression Alone
By Miranda Hitti
WebMD Medical News
June 17, 2005 -- A new study
says that bipolar disorder, while still rare, may be more common than previously thought.
Face-to-face interviews w/more
than 9,200 U.S. adults showed that 4.3% had symptoms of bipolar disorder or related syndromes,
say the researchers, who included Ronald Kessler, PhD, of Harvard Medical School.
Kessler's study also says
that some people w/major depressive disorder also have bipolar symptoms. Bipolar symptoms
impair life more than major depression alone, says the study.
The findings were presented
in Pittsburgh during the International Conference on Bipolar Disorders.
About Bipolar Disorder
Bipolar disorder, formerly
called manic depression, is a brain disorder. It causes unusual shifts in a person's mood, energy & ability to function, says the National Institute
of Mental Health (NIMH).
Bipolar disorder is severe.
It's not the same as the normal ups & downs of life. Bipolar disorder can have extreme
effects, raising suicide risk.
Like other mental illnesses,
bipolar disorder is treatable. However, it needs consistent attention. In that regard, it's like diabetes or heart disease - long-term illnesses that take a lifetime of careful
management, says the NIMH.
As w/any other serious health
condition, don't try to handle any mental illness alone. Seeking help is the first step toward a better life. Resources include
doctors, psychiatrists, mental health professionals, social workers & other trained counselors.
Parsing the Numbers
Kessler's figure is higher
than the NIMH's estimate. The NIMH says that in any given year, about 1% of U.S. adults -- roughly
2 million people -- have bipolar disorder.
However, Kessler's number
goes a bit beyond the strict definition of bipolar disorder. It also includes "sub-threshold" bipolar disorder, says a news release. People w/that condition
don't quite meet the bipolar diagnosis but are still severely impaired in their ability
to lead a normal life.
Participants didn't have to
say they had been diagnosed w/bipolar disorder. They answered a battery of questions, which the researchers screened for symptoms.
Interviews weren't done w/ homeless people or those in institutions.
Bipolar Disorder, Depression Sometimes Overlap
Kessler's study says a "substantial
proportion" of people with major depression also have bipolar symptoms, including a history of euphoria & irritability. Those people often reported irritability as a prominent feature of their depressive episodes, says the study.
Bipolar disorder has a significantly
greater impact on a person's ability to go to work or be productive at work than major depression alone, says the study.
The researchers estimate that
on an annual basis, about 50 days are "lost" for someone with bipolar disorder, compared
with 32 days for someone with major depression. The national yearly price tag for bipolar disorder totals more than $25 billion, says
a news release.
"We conclude that previous
research has overestimated the societal costs of major depressive disorder & underestimated the costs of bipolar disorder," say the researchers.
Funding Sources
Funding for the study came from the John D. & Catherine T. MacArthur
Foundation, the U.S. Public Health Service, the Fogarty International Ctr. & the Pan American Health Org.
Grants also came from several drug companies, including Eli Lilly,
Ortho-McNeil Pharmaceutical, GlaxoSmithKline, Bristol-Myers Squibb & the Pfizer Foundation.
SOURCES: International Conference on Bipolar Disorder,
Pittsburgh, June 16-18, 2005. National Institute of Mental Health: "Bipolar Disorder." News release, University of Pittsburgh
Medical Center.
Patients don't experience
manic or mixed episodes & most return to fully functional levels between episodes. However, bipolar II patients have a
more chronic course, significantly more depressive episodes & shorter periods of being well between episodes than patients
with type I have. It's highly associated with the risk for suicide.
Cyclothymic
Disorder. While cyclothymic disorder isn't as severe as either bipolar disorder II or I, the condition is
more chronic. Hypomanic symptoms tend toward irritability as compared to the more euphoric
symptoms of bipolar II. (One report, in fact, referred to these patients as having "darker"
natures while bipolar II patients were "sunnier.")
The disorder lasts at least 2
years, with single episodes persisting for more than 2 months. Cyclothymic disorder
may be a precursor to full-blown bipolar disorder in some people or it may continue as a low-grade chronic condition.
what is bipolar disorder?
Bipolar Disorder - Fact Sheet from
the National Institute of Mental Health
yet one that feels psychological in the experience
of it.
An illness that is unique in conferring advantage & pleasure, yet one that brings in its wake
almost unendurable suffering & not infrequently, suicide.
"I am fortunate that I haven't died from my illness, fortunate in having received the best medical care available & fortunate in having the friends, colleagues & family that I do."
Kay Redfield Jamison,
Ph.D., An Unquiet Mind, 1995, p.
6.
(Reprinted w/permission from Alfred A. Knopf, a division of Random House, Inc.)
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy & ability to function.
Different from the normal ups & downs that everyone goes thru, the symptoms of bipolar disorder are severe. They can result
in:
- damaged relationships
- poor job or school performance
- even suicide
But there's good news: bipolar
disorder can be treated & people
w/this illness can lead full & productive lives.
More than 2 million American
adults,1 or about 1 % of the population age 18 & older in any given year,2 have bipolar disorder.
Bipolar disorder typically develops in late adolescence or early adulthood.
However, some people have
their first symptoms during childhood, & some develop them late in life. It's often not recognized as an illness & people may suffer for years before it's properly diagnosed & treated.
Like diabetes or heart disease, bipolar disorder
is a long-term illness that must be carefully managed throughout
a person's life.
Course of the Illness
Bipolar disorder
can be severe & long-term, or it can be mild with infrequent episodes. The usual pattern of bipolar disorder is one of
increasing intensity & duration of symptoms that progresses slowly over many years. (Patients
with the disease, however, may experience symptoms in very different ways.)
A typical bipolar disorder patient averages 8 to 10 manic or depressive episodes over a lifetime.
However, some people experience more & some fewer episodes.
Typical
Bipolar Cycles. In most cases of bipolar
disorder, the depressive phases far outnumber manic phases & the cycles of mania and depression are neither regular nor
predictable.
Many patients,
in fact, experience mixed mania, or a mixed state, in which both mania & depression coexist.
Rapid Cycling.
About 15% of patients with the disorder have a temporary, complicated phase known as rapid cycling. With this phase
the manic & depressive episodes alternate at least 4 times a year & in severe cases, can even progress to several
cycles a day.
Rapid cycling
tends to occur more often in women & in those with bipolar II. Typically, rapid cycling starts in the depressive phase
& frequent & severe episodes of depression may be the hallmark of this event.
This phase
is difficult to treat, particularly since antidepressants can trigger the switch to mania & set up a cyclical pattern.
Symptoms of Bipolar Disorder
Bipolar disorder causes dramatic
mood swings:
- from overly "high" &/or irritable to sad & hopeless
- then back again
- often with periods of normal mood in between
Severe changes in energy & behavior go along
with these changes in mood. The periods of highs & lows are called -
"episodes of mania & depression"
Signs & symptoms of mania (or a manic episode) include:
A manic episode is diagnosed
if elevated mood occurs with 3 or more of the other symptoms most of the day, nearly every day, for 1 week or longer.
If the mood is irritable, 4 additional symptoms must be present.
Signs & symptoms of depression (or a depressive episode) include:
A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.
A mild to moderate level of mania is called hypomania. Hypomania may feel good
to the person who experiences it & may even be associated with good functioning & enhanced productivity. Thus even
when family & friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become
severe mania in some people or can switch into depression.
Sometimes, severe episodes
of mania or depression include symptoms of psychosis (or psychotic symptoms).
Common psychotic symptoms are:
- hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there)
- delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts)
Psychotic symptoms in bipolar disorder
tend to reflect the extreme mood state at the time. i.e.
- delusions of grandiosity: believing one is the President or has special powers or wealth - may occur during mania
- delusions of guilt or worthlessness: believing that one is ruined & penniless or has committed some terrible crime - may appear during depression
People w/bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.
It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one
end is severe depression, above which is moderate depression & then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic.
Then there is normal or balanced
mood, above which comes hypomania (mild to moderate mania), & then severe mania.
mixed bipolar state
In some people, symptoms of mania & depression may occur together in what
is called a mixed bipolar state.
Symptoms of a mixed state often include:
- agitation
- trouble sleeping
- significant change in appetite
- psychosis
- suicidal thinking
A person may have a very sad, hopeless mood while at the same time feeling extremely energized.
Bipolar disorder may appear to be
a problem other than mental illness, such as:
Such problems in fact may
be signs of an underlying mood disorder.
Diagnosis of Bipolar
Disorder
Like other mental
illnesses, bipolar disorder can't yet be identified physiologically - i.e., through a blood
test or a brain scan.
A diagnosis
of bipolar disorder is made on the basis of:
-
symptoms
-
course of illness
-
family history
The diagnostic
criteria for bipolar disorder are described in the Diagnostic & Statistical Manual
for Mental Disorders, fourth edition (DSM-IV).3
Descriptions offered by people w/bipolar disorder give valuable insights into the various mood states associated w/the illness:
Depression: I doubt completely my ability to do anything
well. It seems as though my mind has slowed down & burned out to the point of being virtually useless.
[I am] haunt[ed] w/the total,
the desperate hopelessness of it all. Others say, "It's only temporary, it'll pass, you'll get over it," but of course they haven't any idea of how
I feel, although they are certain they do.
If I can't feel, move, think or care, then what on earth is the point?
Hypomania: At first when I'm high, it's tremendous ideas are fast like shooting stars you follow until brighter ones appear.
All shyness disappears, the right words & gestures are suddenly there uninteresting people, things become intensely interesting.
Sensuality is pervasive, the
desire to seduce & be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria you can do anything but, somewhere this changes.
Mania: The fast ideas become too fast &
there are far too many overwhelming confusion replaces clarity you stop keeping up with it - memory goes. Infectious humor ceases to amuse. Your friends become frightened. everything is now against the grain you are irritable, angry, frightened, uncontrollable & trapped.
What Is the Course of Bipolar Disorder?
or what subtypes are there?
Episodes of mania
& depression typically recur across the life span. Between episodes, most people w/bipolar disorder are free of symptoms,
but as many as 1/3 of people have some residual symptoms.
A small percentage of people experience
chronic unremitting symptoms despite treatment.4
The classic form of the illness, which involves recurrent episodes of mania & depression,
is called bipolar I disorder.
Some people never develop severe mania but instead
experience milder episodes of hypomania that alternate w/depression - this form of the illness is called bipolar II disorder.
When 4 or more episodes of illness occur within
a 12-month period, a person is said to have rapid-cycling bipolar disorder.
Some people experience multiple episodes w/in
a single week, or even w/in a single day. Rapid cycling tends to develop later in the course of illness & is more common
among women than among men.
People w/bipolar disorder can lead healthy
& productive lives when the illness is effectively treated. Without treatment the natural course
of bipolar disorder tends to worsen.
Over time a person may suffer more frequent
(more rapid-cycling) & more severe manic & depressive episodes than those experienced when the illness first appeared.5
But in most cases, proper treatment can
help reduce the frequency & severity of episodes & can help people w/bipolar disorder maintain good quality of life.
Can Children & Adolescents Have Bipolar Disorder?
Both children & adolescents can develop
bipolar disorder. It's more likely to affect the children
of parents who have the illness.
Unlike many adults w/bipolar disorder,
whose episodes tend to be more clearly defined, children & young adolescents w/the illness often experience very fast
mood swings between depression & mania many times within a day.6
Children w/ mania are more likely to be
irritable & prone to d
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