Wednesday, July 16, 2008

Bipolar Disorder

I have neglected so far to discuss a very important diagnostic category: bipolar disorder.

In bipolar disorder, there can be episodes of severe depression, in fact this may be the presenting or initial problem. Bipolar disorder is strongly heritable (it runs in families), even more strongly than other types of mental illness. Yet there are cases in which bipolar disorder can arise in an individual without an obvious family history.

The other "pole" in bipolar disorder is mania: this is a state in which mood is abnormally elevated or irritable, with a variety of other accompanying symptoms-
-increased energy (in its extreme form, severe uncontrollable physical agitation)
-decreased need for sleep (in its extreme form, no sleep at all despite high energy)
-racing thoughts or speech (in its extreme form, leading to incomprehensible speech)
-elevated self-esteem (in its extreme form, delusions of grandeur such as believing oneself to have supernatural powers)
-reckless and uncharacteristic behaviour (such as driving dangerously, taking other unusual risks such as substance use or gambling)
-uncharacteristic increase or change in social behaviour (e.g. promiscuity, socializing freely with strangers)
-increased spending (sometimes this leads to financial catastrophe, giving away one's savings, buying new cars, etc.)
-there may be psychotic symptoms such as hallucinations, paranoia, or severely disorganized thinking
-increased "goal-directed activity": many new plans, ideas, and actions, but often these are disorganized and chaotic
-usually these symptoms last for weeks or months at a time. For some people their symptoms fluctuate much more rapidly, sometimes between depressed symptoms and manic symptoms, or some combination simultaneously. This is so-called "rapid cycling".

A manic state can be very severe, leading to the police needing to bring the afflicted person to the hospital. There can be catastrophic life consequences, affecting relationships, finances, or physical health.

In other cases, though, a manic state can be quite mild (a so-called "hypomanic" state), and may even be quite a pleasant and productive period of time.

For any person seeking treatment for depression, it is extremely important to examine closely whether there have been any manic symptoms in the past--even mild ones--or if there is a family history of bipolar disorder. One important reason for this is that antidepressants can provoke manic episodes in persons with bipolar disorder. Treating depression in bipolar disorder requires extra care to prevent a manic episode from arising. This can involve a so-called "mood-stabilizer" drug such as lithium carbonate. Or, it can involve choosing a different type of treatment for the depression, such as a newer drug called lamotrigine, which can help with bipolar depression without causing mania.


Anonymous said...

Why is the usual age of the first manic break in late adolescence or early adulthood? Does the evidence support this myth or is it just a reporting/diagnosing bias?

Is there something specific changing at the neurological level?

Is it true and if so why, is rapid cycling more common is women?

GK said...

Good questions, I don't know the answers for sure.

Here are some speculations about this issue:
1) A variety of major mental illnesses, such as schizophrenia or bipolar disorder, may have subtle prodromes during childhood (e.g. fluctuating sleep disturbances, behavioural problems, social withdrawal, etc.), but may only have their first overt or severe manifestations in late teens or early adulthood. These prodromes are not specific to the subsequent illness, since many others could experience similar phenomena for other reasons.
2) There probably are specific neurologic changes happening at this time of life, influencing times of onset for manic episodes, etc. Parts of the brain are still maturing in a histological sense, well into one's twenties (e.g. myelination). And, of course, there are significant hormonal changes.
3) There are huge developmental stresses in late teens & early twenties--academic pressures, social pressures and frustrations, leaving home, financial pressure, increased freedom, autonomy & responsibility. There is more access to environmental harms, such as street drugs. There is more freedom to adopt unhealthy or unstructured lifestyle practices, such as staying up all night partying, or studying, or playing video games, etc. All of these pressures seem likely to exacerbate any tendency to have symptoms of any kind, including a manic break. (I'm not saying that all those who have episodes of mood disorder have engaged in unhealthy lifestyle practices--since many people with extremely healthy, stable lifestyles have episodes of major mental illnesses, but I am saying that lifestyle variables may substantially affect risk).
To prove this association, it may be interesting to look at other cultures in which there is much less developmental pressure, or where this pressure develops at a later (or earlier) age, and to see if this affects the ages at which first manic breaks occur most often. There may be studies of this sort, I'll have to take a look for some.

With respect to rapid cycling, hard to say why it's diagnosed more commonly in women. I suspect it really is more common in women, and is not merely a reporting bias. Female hormones oscillate to a greater degree than male hormones, perhaps this is a factor. It may be, at least in our current cultural circumstances, that social, neurological, and environmental stress may be more likely to cause fluctuating mood symptoms in women, but fluctuating conduct problems in men. Finally, though, I can only speculate about these things without acquainting myself more deeply with the research literature on this subject, but I'm pretty sure there has been some interesting research about these questions, both from the medical/psychiatric side, but also from sociology & anthropology, etc.

Anonymous said...

GK: I highly appreciate your blog, and I'm deeply impressed by your wisdom, knowledge and empathy. Thank you!

You've written about stimulants. But I wonder what you think of dopamine agonists and their potential(?) for treating some subtypes of depression?

Also, I would love to hear your thoughts and experiences when it comes to bipolar II disorder.