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Living with Bipolar
A Guide to Understanding and Managing the Disorder
By Lesley Berk, Michael Berk, Daid Castle, Sue Lauder
Allen & UnwinCopyright © 2008 Lesley Berk, Michael Berk, David Castles and Sue Lauder
All rights reserved.
WHAT IS BIPOLAR DISORDER?
Being diagnosed with bipolar disorder meant that finally not only did my moods have a name but there was also something I could do to get them more under control. This name did not capture all my experience and the impact that bipolar disorder had on my life but it provided an explanation and a way forward. Phillip
Bipolar disorder involves biological changes in mood that are more noticeable, severe, longer lasting and often more disruptive than everyday ups and downs. Recognition of the difficulties and the burdens experienced by people with these extreme mood swings intensified the search for a common language to help describe and treat bipolar disorder. The typical mood changes that occur in the disorder have been organised into specific categories to make them easier to understand, diagnose and treat. In this chapter we discuss the current classification of bipolar disorder. People with bipolar disorder experience the illness differently depending on their symptoms, how often they occur and how their lives are affected. Knowing the current classifications and how they apply to your own experience may assist you in managing your illness.
It is also helpful to be aware of and to recognise symptoms from other disorders, such as drug and alcohol abuse and anxiety, that may be causing additional distress. As we find out more about bipolar disorder, the current diagnostic system may be refined to include milder manifestations of the illness and take into account areas of overlap with other mood disorders.
A BIT OF HISTORY
Bipolar disorder is not a new illness. In ancient Greece, people were aware of melancholia (depression) and mania. In 1851, the French psychiatrist Jean-Pierre Falret described bipolar disorder as la folie circulaire, involving changes from mania to melancholia, and in 1854 neurologist Jules Baillarger described these changes as two different stages of the same illness (folie à double forme). Towards the end of that century, the German psychiatrist Emil Kraepelin distinguished schizophrenia, which involves psychotic symptoms such as delusions and hallucinations without the extreme mood symptoms, from manic depression. Much later, in 1979, Karl Leonhard separated bipolar disorder from unipolar depression, which is the experience of depression with no mania or hypomania, and so the idea of 'bipolar disorder' was conceptualised (Goodwin & Redfield Jamison, 2007).
THE DIAGNOSIS OF BIPOLAR DISORDER
Unlike physical illnesses such as diabetes and stroke, bipolar disorder cannot be diagnosed by a medical test such as a blood test or brain scan. Instead, diagnosis relies on identifying your current and past symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 2000) and the International Classification of Diseases (ICD-10) (World Health Organisation, 2006) stipulate certain criteria as a guide for diagnosis.
This illness usually starts in adolescence or the early twenties, but can occur later or in earlier childhood where it can present a little differently (see the website attached to this book for resources on bipolar in childhood). Many people report that it took a long time for their bipolar disorder to be correctly diagnosed and treated.
Episodes of illness
Bipolar disorder involves 'episodes' of illness. For a diagnosis of bipolar disorder to be made, you will have experienced an episode of mania or hypomania, or a mixed episode, at some stage in your life. Most people experience depressive episodes and milder forms of depression. Episodes differ in severity, occur when you are acutely ill, and exhibit a number of symptoms over a specific period. Once you have experienced an episode of bipolar disorder, the chances of having another episode are high, but ongoing treatment can help to prevent relapse.
An episode of major depression
A depressive episode occurs when you experience depressive symptoms for at least two weeks that cause you distress and affect your relationships, work or daily activities. According to DSM-IV classification, an episode of depression is diagnosed when you have five or more of the symptoms listed below. At least one of these symptoms is:
depressed mood, which may include intense sadness, emptiness, tearfulness or irritability, or
a loss of interest or pleasure in things, which lasts nearly all day, nearly every day.
The other possible symptoms include:
lack of energy, and constant tiredness
restlessness or alternatively a marked lack of activity, known as lethargy, which is noticeable by others
noticeable changes in appetite and weight, either up or down
sleep problems, which might involve difficulty in falling asleep, waking up a lot during the night, or waking up early in the morning and being unable to return to sleep; or equally, sleeping too much
feelings of worthlessness and excessive guilt
difficulty in concentration and/or poor memory or difficulties in making decisions
persistent thoughts about death and suicide or hopelessness.
Some people have psychotic symptoms as part of their depression. This can include delusions (strong beliefs that have no connection with reality) and/or hallucinations (seeing, hearing or smelling things that are not actually there).
An episode of mania
According to the DSM-IV classification, an episode of mania is diagnosed when your mood is excessively happy, elevated, or irritable for at least a week or has led to your being admitted to hospital. At least three of the following symptoms (four if the mood is irritable) must be present:
needing less sleep than usual
thoughts racing so quickly that you may get confused and find it difficult to articulate what you want to say
talking much more than usual or feeling a pressure to keep talking
being easily distracted from tasks to attend to irrelevant or unimportant things
feeling a marked increase in self-esteem or thinking you have unique gifts or talents that you do not have
increasing activity directed to achieving goals (at work, school or sexually) or increasing restlessness and agitation
participating excessively in pleasurable activities with no regard for the consequences, for example, massive buying sprees, gambling, irresponsible investments, high sex drive and sexual indiscretions.
Mania is diagnosed if these symptoms are severe enough to cause serious disruption to your work or social activities. As with depression, mania may include the presence of psychotic symptoms, including hallucinations and delusions, related to your mood. Extremely disordered or confused thinking is another psychotic symptom that can occur in mania.
The diagnosis of hypomania is based on similar symptom criteria as mania, except that hypomania is milder or briefer. Although you have symptoms, they are not necessarily disruptive and you may be able to carry out your normal day-to-day activities. Still, the changes in your behaviour are obvious enough to be noticed by others. To be classified as a hypomanic episode, the symptoms must last for at least four days. Hypomania does not involve psychotic symptoms.
You may have thought that having bipolar disorder means that you experience either the lows or the highs, but many people experience a simultaneous mix of these two opposite poles. At first glance this makes no sense, like being hot and cold or black and white at the same time. However, it is possible to have some symptoms of mania and some of depression at the same time. Recognising this combination is vital, as it has specific implications for your treatment. This is explained in more detail in chapter 7 on medications.
According to the DSM-IV classification, a mixed episode occurs when you have a manic and a depressive episode at the same time for at least a week and the symptoms cause significant disruption to your daily life, sometimes necessitating hospitalisation. For example, you experience rapid mood swings (happy, sad, irritable), you need less sleep, your appetite is affected, and you are restless and uptight, undertake risky activities, and may have delusions of excessive unrealistic guilt and suicidal thinking.
Other classifications of mixed states do not require that you have full manic and depressive episodes at the same time (Benazzi, 2007; Cassidy et al., 2007). It is common for people who are depressed to have a few manic symptoms, such as racing thoughts, restlessness or a decreased need for sleep, and for people who are manic to experience isolated symptoms of depression, irritability or suicidal thoughts. Mixed states may be divided into depressive and manic mixed states, depending on which type of symptoms predominate. Marcel, a patient of ours, describes his experience of mixed states:
During these patches, I am miserable and agitated. I feel impatient, and am so irritable and angry I am scared of what I could do. The way I feel switches from moment to moment. My thoughts are churning like a washing machine. I am very negative, and thoughts of suicide keep intruding. I have harmed myself before when I feel like this. I am restless, feel as though I have to do stuff and keep moving, although I get very disorganised. I can't sleep.
Although some people are just prone to mixed states, in other people illicit drug use may have a role in developing mixed states. For some people, certain antidepressants may exacerbate mixed states.
People with mixed states are more vulnerable to developing symptoms of psychosis, such as hearing voices or having paranoid ideas. As in depressive episodes, there is an increased risk of suicidal ideas and attempts in mixed episodes. Ways of managing this risk are discussed in chapter 13.
TYPES OF BIPOLAR DISORDER
People experience different patterns of episodes which characterise their specific type of bipolar disorder. The dominant patterns outlined in DSM-IV are bipolar I and bipolar II disorder; other categories are cyclothymic disorder, and bipolar disorder not otherwise specified (NOS). These patterns may occur with or without other features, such as rapid cycling or psychotic symptoms. The severity of symptoms varies widely between individuals and in the same person over time.
Bipolar I disorder
This type of bipolar disorder is diagnosed if you have had one or more full manic or mixed episode(s), although you may have had depressive episodes as well, as shown in figure 1.1. Although less common, some people experience episodes of mania without ever experiencing a depressive episode.
Mary, who has bipolar I disorder, describes her experience:
I was hospitalised five years ago after a manic episode. It was a scary experience for all of us. I did not think there was anything wrong with me but I was behaving so strangely, speaking very fast and increasingly incoherently, spending money we did not have, staying up all night and going to parties on my own and inviting people to join my 'grand' schemes, that my husband took me to the doctor. I had married the man of my dreams and we had just had a beautiful baby daughter. The diagnosis of bipolar I disorder sounded cold and clinical and definitely had nothing to do with me. In the next few years I was again hospitalised a few times for mania and once because I was feeling very depressed and suicidal. I have been quite well now for two years and what has helped has been getting to know this illness rather than running away from it. As with any other illness, medication helps, and I have found other strategies that work for me.
Bipolar II disorder
This type involves one or more episodes of hypomania and one or more episodes of depression, but no mania, as illustrated in figure 1.2. If you have bipolar II disorder, you may find that you experience depression more often than hypomania.
Grant discovered he had bipolar II disorder about ten years after his first episode of depression. He explains:
When I think back, I realise that for years I have had distinct patches lasting a few weeks when I feel much more confident than usual, think and do things more quickly, and have new ideas and goals. I don't need much sleep and instead I get so much done. At this time, my social life peaks and my family remark about my 'unusual energy'. Everything is in technicolour. Then there are months when things are more grey and sombre and I feel empty and exhausted. Nothing is enjoyable and eventually it becomes a struggle even to get out of bed. For a long time these dark depressions dominated my life. My previous doctor never enquired about my technicolour patches, and they were not disturbing, so I never mentioned them. Recently [my current] doctor asked me about hypomania and we discussed changing my treatment.
Cyclothymia refers to a pattern involving hypomanic and mild depressive symptoms that have been experienced for two or more years. Although milder than bipolar I or II, the symptoms of cyclothymic disorder are still severe enough to cause difficulties at work, in education, employment and relationships. Bipolar disorder and cyclothymia exist on a continuum.
Bipolar disorder not otherwise specified
Bipolar disorder NOS is used to diagnose illness episodes that do not last long enough to be described as manic, hypomanic, mixed or major depressive episodes, or which do not have the required number of symptoms.
There is some debate about whether to categorise particular temperaments as bipolar disorder NOS, or to subdivide bipolar disorder further on a continuum from its more severe to its milder presentations. Some people may have temperaments that look like very mild bipolar symptoms and which sometimes later develop into more established forms of bipolar disorder (Akiskal et al., 1998).
hyperthymic: very cheerful, optimistic, extroverted, confident, always busy
cyclothymic: fluctuating mild mood changes, changing levels of self-esteem
dysthymic: usually joyless, lacking energy but not as severe as depression
depressive mixed: mild symptoms of anxiety, irritability, restlessness, sadness. The bipolar spectrum
For people who have never experienced mania or hypomania, a diagnosis of unipolar illness may be clear. Many people view bipolar disorder as distinct from unipolar disorder. In reality, the difference is less clear-cut. For example, you may have predominant symptoms of depression as well as minor experiences of mood elevation that are too mild or brief to be diagnosed as having bipolar disorder. These symptoms fall into the bipolar spectrum, however, and you may find that you benefit from treatments that are usually used for bipolar disorder. Similarly, some people diagnosed with unipolar depression develop hypomania when taking antidepressant treatment. The boundaries of the spectrum are controversial, but it is likely that almost half of all people who experience diagnosed depression have some form of bipolar disorder. People whose illness falls into the bipolar spectrum are more likely to have depression associated with increased sleep and marked fatigue, and to experience feelings of flatness, rather than sadness.
Cycling occurs when you swing from one episode of illness, such as depression, into another, such as mania or a mixed state. According to DSM-IV, rapid cycling occurs when you have at least four episodes of illness, either mania or depression, in a calendar year — but rapid cycling can be far more frequent than that, with some people cycling within weeks or even days. Rapid cycling is not rare, occurring in somewhere between 15 and 25 per cent of people who suffer from bipolar disorder. The treatment for people who have a pattern of rapid cycling differs significantly from the treatment for people who don't, so it is important to recognise if this is your pattern.
People who suffer from rapid cycling are more likely to be female and younger, or to have become ill later in life, and may have more episodes and hospitalisations. Thyroid problems and antidepressants may contribute to rapid cycling. For some people, although they cycle from depression to mania, the dominant experience is depression.
Some people find that they usually have episodes at a particular time of year. You may find that you tend to develop a major depressive episode in winter or autumn and/or a hypomanic or manic episode in spring or summer. Knowing these patterns can be useful as you can find ways of preventing or reducing the severity of the episode.
Excerpted from Living with Bipolar by Lesley Berk, Michael Berk, Daid Castle, Sue Lauder. Copyright © 2008 Lesley Berk, Michael Berk, David Castles and Sue Lauder. Excerpted by permission of Allen & Unwin.
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