DSM IV Criteria for Bipolar Disorder
Manic episodes are characterized by:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant/irrelevant external stimuli).
- Increase in goal-directed activity (socially, at work or sexually) or psychomotor agitation.
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (overspending, sexual indiscretions or foolish business investments)
- The symptoms do not meet criteria for a Mixed Episode
- The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
- The symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, medication or other treatment) or a general medical condition (e.g., hyperthyroidism).
Hypomanic episodes are characterized by:
- A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood.
- During the period of mood disturbance, three (or more) of the symptoms listed above have persisted (four if the mood is only irritable) and have been present to a significant degree.
- The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
- The disturbance in mood and the change in functioning are observable by others.
- The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
Impaired awareness of illness
Approximately 40% of individuals with bipolar disorder do not believe they are sick, and that what they think and feel is real. Impaired awareness of illness, or anosognosia is the single largest reason why individuals with bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere. When taking medications, awareness of illness improves.
Denial is a psychological mechanism. Impaired awareness of illness, on the other hand, has a biological basis and is caused by damage to the brain, especially the right brain hemisphere. The specific brain areas which appear to be most involved are the frontal lobe and part of the parietal lobe. Some individuals’ awareness of their illness fluctuates over time, being more aware when they are in remission but losing the awareness when they relapse. Awareness improves amongst those who take medication.
People resist accepting a diagnosis of mental illness because of denial, a common first reaction; because they are grieving the loss of their dreams; because it means accepting the need for long-term treatment; as a means of preserving self-esteem, and because of delusional thinking, poor judgment or poor reality testing. They resist taking medication because it means admitting that they have a mental illness, because they do not want to relinquish control, and because many manics prefer their unmedicated high-energy state to a lower-energy medicated one.
Mania is the defining feature of bipolar disorder. Mania is a distinct period of elevated or irritable mood, which can take the form of euphoria, and lasts for at least a week (less if hospitalization is required). People with mania commonly experience an increase in energy and a decreased need for sleep, with many often getting as little as three or four hours of sleep per night. Some can go days without sleeping. A manic person may exhibit pressured speech, with thoughts experienced as racing. They laugh and smile without cause. Attention span is low, and a person in a manic state may be easily distracted. Judgment may be impaired, and sufferers may go on spending sprees, engage in risky behavior that is not normal for them, and make decisions lacking insight. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive, intolerant, or intrusive. They may feel out of control or unstoppable, or as if they have been "chosen" and are "on a special mission," or have other grandiose or delusional ideas. Sexual drive may increase.
Dysphoric mania, or mixed mania, is the combination of mania and agitated depression. A person with this mood swing is agitated, uncomfortable, irritated, depressed, pessimistic and filled with negative energy. They don't sleep well, if at all, and ultimately their behaviors are destructive and sometimes life threatening.
False euphoria is the beginning stage of true bipolar disorder. Behavior is similar to that seen with drug use, a cocaine-like high. People with euphoric mania say they feel great/wonderful/beautiful/fantastic, but make many mistakes such as recklessly spending too much money, having sex with anyone who looks appealing, sleeping a lot less and not getting tired and ultimately making very poor life decisions. It's common for people with full-blown euphoric mania to stay up for weeks, start very risky businesses or simply pick up and leave their current life. Euphoric mania can be very cruel and selfish as the emphasis is strictly on the person with bipolar. The person can be extremely reckless and unable to judge the safety or effect of their behaviors. There will be rapid and sometimes violent mood swings, rage alternating with maniacal laughter. This type of mania can lead to a lot of drug and alcohol use as the person feels so good they lose perspective on the amount they consume. Euphoric mania always starts out feeling great, but ultimately the person comes down and often sees a path of destruction that is hard to clean up. Bipolar patients have difficulty seeing that their behavior is out of line in an acute manic episode. The massive high, which seems abnormal to us, seems normal to them, and there is an unfortunate tendency to self medicate.
At more extreme levels, up to 70% of people in a manic state and 50% of all individuals with bipolar disorder experience psychosis, or a break with reality, along with loss of ability to reason. Of this 70%, over half are euphoric psychotic manias, which are particularly difficult to diagnose as they can be so appealing and fun to the people around the manic person. Manic behavior attracts people who want to join in on the ride. Left unmedicated, people experiencing bipolar psychosis will resist treatment, as they are convinced nothing is wrong with them, they are sure of their reasoning and enjoy the high. Three-quarters of manic episodes involve delusions wherein the person truly believes in ideas beyond reason or logic. This can occasionally lead to violent behaviors. Some people in a manic state experience severe anxiety and are irritable to the point of rage, while others are euphoric and grandiose. The severity of manic symptoms can be measured by rating scales such as the Altman Self-Rating Mania Scale and clinician-based Young Mania Rating Scale.
During a manic episode, the person's behavior feels "right," obvious and makes very clear sense, even if it makes no sense to those around the patient or is extremely risky. After the manic episode has run its course, it may be possible for the patient to see how unrealistic, unreal and out-of-touch with reality they were, but this isn't possible during a manic episode.
The onset of a manic episode is often foreshadowed by sleep disturbances. Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.
A review seeking to identify the more consistent findings suggested several genes related to serotonin (SLC6A4 and TPH2), dopamine (DRD4 and SLC6A3), glutamate (DAOA and DTNBP1), and cell growth and/or maintenance pathways (NRG1, DISC1 and BDNF), although noting a high risk of false positives in the published literature. It was also suggested that individual genes are likely to have only a small effect and to be involved in some aspect related to the disorder (and a broad range of "normal" human behavior) rather than the disorder per se.
Functional MRI findings suggest that abnormal modulation between ventral prefrontal and limbic regions (amygdala) likely contribute to poor emotional regulation and mood symptoms.
The neurotransmitter associated with psychosis is dopamine. Antipsychotics that work on the dopamine system effectively decrease psychotic symptoms. Most researchers believe other neurotransmitters are involved as well: serotonin and norepinephrine are also closely linked to bipolar disorder.
There are structural differences in the brains of people who experience psychosis. There can be a chronic shut down of the frontal lobes and there is a particular part of the limbic system called the septal area where the dopamine system is especially hyperactive. Antipsychotic medications work by blocking dopamine in this area. The limbic system, the emotional part of the brain, is also central to the causes and ultimately treatment of bipolar psychosis.
Average age of onset of bipolar disorder is 21; first manifestations are common between the ages of 20-24. Many start feeling depressed between the ages of 15-25. Symptoms in teenagers focus on lack of judgment and risky behavior: drunk driving, substance abuse. The younger the age of onset of bipolar disorder, the more likely it is to find a significant family history of bipolar, depression and/or dementia. In 10% of bipolar cases, a manic episode occurred around age 50. As an individual ages, s/he may develop new-onset mania associated with vascular changes, or become manic only after recurrent depressive episodes. In the elderly, recognition and treatment of bipolar disorder may be complicated by the presence of dementia or the side effects of medications being taken for other conditions.
The vast majority of patients with bipolar disorder have multiple recurrences (Keller et al, 1993), and it is very rare for patients to have a single episode of hypomania or depression in bipolar disorder over a lifetime. The length of symptom-free intervals often decreases with age.
Untreated bipolar disorder is commonly associated with substance use, abuse and dependence (Tohen et al, 1995); school and work failure; interpersonal dysfunction and relationship breakdown. Personality dysfunction could be the result of a turbulent clinical course at crucial stages of development. The lifetime risk of suicide is 10-20% (Tsuang et al, 1978) compared with a suicide risk of 0.01% for the general population; and there is an increased risk of violence and homicide, especially with poorly controlled psychotic bipolar disorder.
Studies have shown a link between bipolar disorder and Tourette’s syndrome, between bipolar disorder and autoimmune thyroid disease, between bipolar and heart disease, and between autoimmune diseases and schizophrenia.
There is some debate about a causal relationship between the use of cannabis and bipolar disorder. Substance abuse may predate the appearance of bipolar symptoms.
Caffeine can significantly increase anxiety; it should be limited to 250 mg/day (two cups of coffee or one cup of coffee and one caffeinated soda).
Prevention of bipolar has focused on stress which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness. Common triggers include alcohol abuse, drug abuse, a stressful work environment, travel across time zones.
Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or involuntary.
Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing early symptoms before full-blown recurrence, and helping the patient maintain remission. Cognitive-behavioral therapy and family-focused therapy are the most effective in preventing relapses, while interpersonal and cognitive-behavioral therapy effectively reduce residual depressive symptoms. Treatment during the acute phase can be a particular challenge.
Mood stabilizers reverse manic or depressive episodes and prevent relapses. The “gold standard” mood stabilizer is lithium, which is effective in treating acute manic depressive episodes and preventing relapses. Treatment with lithium carbonate has been strongly linked to a reduced risk of suicide, self-harm, and death in people with bipolar disorder. Lamotrigine has been shown to have some efficacy in treating bipolar depression, and this benefit is greatest in more severe depression. In both acute and long-term treatment, the combination of lithium carbonate (Eskalith), lamotrigine (Lamictal) and aripiprazole (Abilify) is used. New treatments include Repetitive Transcranial Magnetic Stimulation (rTMS), which places electromagnets next to the frontal part of the skull to change underlying brain activity and alter mood.
Bipolar in the family and the workplace
Mood disorders affect not only the bipolar individual, but also his spouse, family, friends and co-workers. The root cause of all these impacts is the degraded ability the victim has to "perform" in these different areas of his/her life. Thus a seriously depressed person will become morose, incommunicative, withdrawn, and unable to participate actively in what is going on. In the depressed phase, family members and friends have to compensate for the loss of social contributions that would be expected of him in the normal family setting. In the manic phase, the individual argues, spends irresponsibly, ignores commitments and breaks agreements unilaterally.
It is impossible even to estimate the amount of emotional pain, stress and loss family members experience in trying to deal with, and ultimately to help, a mentally ill person in the household. In many cases, their lives are seriously disrupted, becoming a kind of living hell. Family members are confused and alienated by a person not acting like himself, becoming a person they don’t know and can’t communicate with. Unpredictable moods leave family members feeling like they’re on an out-of-control roller coaster. Perhaps nothing is more awful than to see someone you love severely degraded by an illness you don't fully understand, to do everything you can think of to help, and have none of it work.
There is no cure for bipolar disorder and so the bipolar medication must be taken for life. Finding the right combination of medication may take as long as several years, and over time they may stop working. For family caregivers, coping with someone who is bipolar, manic or depressed, takes a heavy emotional toll and strains the relationship, often to the breaking point.
How can family members help? Get educated, so you have realistic expectations and coping options. Learn about the illness, its symptoms and early warning signs; learn about treatment and side effects. Make it a family matter: acknowledge that the illness affects everyone in the family. Help find clinicians, schedule appointments, keep track of medication, report changes in behavior to the doctor. Let your family member know you are concerned and want to work with him to get well. Take care of yourself. Find support. Prepare for ups and downs. Have hope. On the other hand, refuse to take abuse from your loved one. This is not your fault. Don’t accept anger and blame.
At work, degraded performance shades into incapacity. In a depressive phase, the individual may begin to be routinely late for work, be unable to make decisions or handle the workload on the job, and eventually will be perceived as an unsatisfactory employee. In mania, the individual will make quick but bad decisions based on little or no knowledge or data, will take serious risks with business assets, become insubordinate or otherwise disrupt the normal chain of command, and will be perceived as unreliable, though energetic, and therefore an unacceptable risk. In a manic phase, bipolar sufferers are particularly resistant to seeking treatment.
The loss of a permanent, well-paying job is one of the worst things that can happen to someone with mental illness. First, it means direct loss of income, perhaps the main source of income in the family. Second, it may mean loss of medical insurance, which may be badly needed in the weeks and months ahead. Third, it means an unsatisfactory performance rating in one's personnel file, which may come back to haunt the victim again and again as he/she tries to find further employment. Fourth, it is a serious blow to the self-esteem of a depressive, whereas a manic may not even consider the loss worth notice. These difficulties are all magnified and accelerated if the victim is the principal wage-earner for a family. In such cases, the role and value of the bipolar individual as an effective spouse or parent erodes quickly, and a separation or divorce often ensues.
People with bipolar disorder are at much higher risk for suicide. Don’t be afraid to ask, "Are you having thoughts of hurting yourself?" and listen for messages of desperation. Depressed people sometimes develop a higher risk for hurting themselves as they begin to get better and their energy level and ability to act improve. Patients having mixed symptoms - depressed mood and agitated, restless, hyperactive behavior - may also be at higher risk for self-harm. Substance abuse, particularly alcohol abuse, increases the risk of self-harm.
The hardest lesson is that there is no way that anyone can force a person to take responsibility for his illness and treatment. Unless the patient makes the commitment to do so, no amount of love, support, understanding, even threatening, can make someone take this step. It is normal to feel guilty and angry about not being able to get your loved one to seek treatment.