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The Natural Medicine Guide to Bipolar Disorder
By Stephanie Marohn
Hampton Roads Publishing Company, Inc.Copyright © 2011 Stephanie Marohn
All rights reserved.
What Is Bipolar Disorder and Who Suffers from It?
The often outrageous, flamboyant behavior associated with the manic pole of bipolar disorder has garnered both media attention and public fascination, but many people remain unaware of the painful, debilitating, and devastating aspects of the illness—on both ends of the mood spectrum
While a stressful event may trigger an episode, often the mood swings of bipolar disorder are inexplicable, bearing no apparent relation to what is happening in a person's life. Far beyond happy or sad moods, the condition is often agonizing and even life threatening. It wreaks havoc in careers, relationships, lives.
The medical and psychiatric professions classify bipolar disorder as a mental illness, and more specifically, as a mood disorder, or affective disorder. The psychiatric and medical professions regard bipolar disorder as a biological brain condition, which has a genetic basis and involves disturbed brain chemistry. Formerly known as manic-depression, it is characterized by periods of depression and mania, with wide variation in the length, frequency, severity, and fluctuation of these periods. Each episode can last days or months, and there may or may not be intervals of normal mood states between episodes. When there are such intervals, they can extend to days, months, or even many years.
Mania is characterized by an elevated, expansive, or irritable and angry mood with increased activity and energy; thought and speech that is more rapid than usual; reduced need for sleep; and grandiosity, distractibility, impulsiveness, inflated self-esteem, poor judgment, and/or recklessness, as in questionable sexual behavior and lavish spending sprees. In extreme episodes, delusions or hallucinations can occur.
Episodes of depression are characterized by persistent sadness or a feeling of flatness, pessimism, hopelessness, significantly reduced interest or pleasure, significant change in weight or appetite, insomnia or oversleeping, feelings of worthlessness or excessive or inappropriate guilt, problems thinking, concentrating, or making decisions, lethargy or restlessness and agitation, lack of energy, and/or recurrent thoughts of death or suicide. Delusions, and less often, hallucinations, can occur in depressive episodes as well as in manic.
While the name "bipolar disorder" reflects two distinct mood poles, the separation of mania and depression in this way is misleading in regard to what many people who suffer from the disorder actually experience, which is often an overlapping, mixed mood state. For this reason, Kay Redfield Jamison, PhD, an authority on the disorder and a person who suffered from it from the age of 17, prefers the former name, "manic-depression," as more accurately descriptive. "This polarization of two clinical states flies in the face of everything that we know about the cauldronous, fluctuating nature of manic-depressive illness; it ignores the question of whether mania is, ultimately, simply an extreme form of depression; and it minimizes the importance of mixed manic-and-depressive states, conditions that are common ..."
Bipolar disorder tends to run in families and usually manifests in late adolescence or early adulthood, but onset can also occur during preteen and later adult years. The peak age of onset is the mid-twenties, although that average may be dropping as more young children are developing the disorder (see "Children/Teens and Bipolar Disorder," which follows). While there is no one pattern of progression in bipolar disorder, when untreated, it tends over time to escalate both in frequency and severity of episodes.
Unfortunately, only one in three people with a major mood disorder seeks help. Many people are not aware that they are suffering from bipolar disorder and so do not seek treatment. Even if they do, they may not get a proper diagnosis. There is no test for bipolar disorder, and diagnosis is based largely on family history and the patient's pattern of mood swings. It is not unusual for people to endure the emotional roller coaster of bipolar disorder for a decade or more (the average is eight years between onset and diagnosis) before a particularly bad episode finally results in a diagnosis and subsequent treatment. Sadly, suicide claims many people before they get the help they need.
Bipolar disorder can be a corollary of other medical conditions such as an underactive thyroid (see chapter 2), and there is a comorbidity factor with substance abuse, obsessive-compulsive disorder, and panic disorder. Comorbidity means that two disorders exist together. In the case of substance abuse, more than 60 percent of people with bipolar disorder abuse drugs or alcohol. Though the motivation may be self-medication to numb the pain of depression or calm the agitation of mania, in the case of alcohol, and to increase or induce the high of mania or attempt to lift depression, in the case of stimulants such as cocaine and amphetamines, the combination of bipolar disorder and substance abuse worsens the outcome of the illness. Those who abuse substances tend to have the irritable and paranoid, rather than the elated, type of mania, are more at risk for relapse, are more at risk for lithium not working for them, and experience 50 percent more hospitalizations. Alcohol abuse also increases the likelihood of suicide, as alcohol features in 30 percent of all suicides.
Nearly one in five people with bipolar disorder commit suicide. The growing number of children with bipolar disorder may be a factor in the rising suicide rate among America's young. In 2007, the CDC reported a dramatic increase in teen suicide from 2003 to 2004 (the last year for which data are available): up 76 percent in girls aged ten to fourteen, up 32 percent in girls aged fifteen to nineteen, and up 9 percent in boys aged fifteen to nineteen. For youth between the ages of 15 and 24, suicide is now the third leading cause of death. For college students, it is the second leading cause. Note that in almost half of those with bipolar disorder, onset came before they were 21 years old. As the cycling of moods in bipolar children tends to be ultra-rapid, with several mood changes in the space of a day, you can imagine how difficult that makes life for these children.
The high incidence of suicide among people with bipolar disorder makes it important for both those with the condition and their family and friends to be aware of the warning signs of suicide. Being forewarned may enable you to prevent this tragedy from happening if the signs begin to manifest. A family history of suicide or a previous suicide attempt places one at increased risk of suicide. In addition, the warning signs of suicide are:
* feelings of hopelessness, worthlessness, anguish, or desperation
* withdrawal from people and activities
* preoccupation with death or morbid subjects
* sudden mood improvement or increased activity after a period of depression
* increase in risk-taking behaviors
* buying a gun
* putting affairs in order
* thinking, talking, or writing about a plan for committing suicide
If you think that you or someone you know is in danger of attempting suicide, call your doctor or a suicide hotline or get help from another qualified source. Know that there is help and, though it may be difficult to ask for it, a life may depend upon it.
Types of Bipolar Disorder
The numerous variations in the manifestation of bipolar disorder are reflected in the complicated array of psychiatric labels that fall under the heading of bipolar disorder. Further, the clinical status of a given episode can be specified as mild, moderate, or severe, with or without psychotic features, chronic, with rapid cycling, with catatonic features, or with melancholic features, among other classifications.
The following are subcategories of the bipolar psychiatric label, according to the diagnostic bible of the psychiatric profession, the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). A holistic medical approach does not use such diagnoses to determine the appropriate treatment course, focusing instead on the particular manifestations and underlying imbalances in the individual patient. Many people receive these labels, however, so it's helpful to know to what they refer.
Bipolar Disorder I
In simple terms, Bipolar Disorder I ranges the whole spectrum from severe depression to mania or mixed mania, with an emphasis on the manic end. In DSM-IV terms, diagnosis requires that the person has had one or more manic episodes or mixed episodes (see list), and often has had one or more major depressive episodes in addition. The average age of onset in men and women alike is 20 years old for this form of bipolar disorder.
A manic episode is defined as an abnormally elevated, expansive, or irritable mood persisting for at least one week (less if hospitalization ensues) and accompanied by at least three (four in the case of irritability only) of the following symptoms:
* inflated self-esteem or grandiosity
* reduced need for sleep
* increased or more continual talking than usual
* flight of ideas, racing thoughts
* increased activity and energy or agitation
* excessive engagement in high-consequence activities such as unrestrained shopping, foolish business investments, and questionable sexual liaisons
The mood alteration must also be severe enough to impair the person's functioning professionally, socially, or in relationships with others. The mania may also have psychotic features and/or require hospitalization. Paranoia may be part of the symptom picture.
A major depressive episode is defined as depressed mood or loss of interest lasting at least two weeks and accompanied by at least four of the following symptoms:
* persistent sadness
* significantly reduced interest or pleasure
* significant change in weight or appetite
* insomnia or oversleeping
* restlessness, agitation, or lethargy
* fatigue or lack of energy
* feelings of worthlessness or excessive or inappropriate guilt
* problems thinking, concentrating, or making decisions
* recurrent thoughts of death or suicide
When only major depressive episodes occur, without episodes of mania, the person is said to suffer from unipolar depression, also known as clinical depression.
* For information about unipolar depression, see my book The Natural Medicine Guide to Depression.
Bipolar Disorder II
Research suggests that this form of bipolar is more common than Bipolar Disorder I in general, and it appears to be more common among women. Bipolar Disorder II favors the depressive end of the mood spectrum, ranging from severe depression to hypomania (mild mania). Interestingly, men tend to experience as many or more hypomanic episodes as major depressive episodes, while for women the latter are more prevalent. For a diagnosis of Bipolar Disorder II, according to the DSM-IV, the person must have had one or more major depressive episodes and one or more hypomanic episodes, never had a manic episode or a mixed episode, and had the disturbance impair, or produce distress in, the person's professional, social, or other important functioning.
Hypomania is the same as mania, except the altered mood must last at least four days (rather than a week) and does not impair professional or social functioning, require hospitalization, or have psychotic features.
Cyclothymia ranges from mild or moderate depression (dysthymia) to hypomania. According to DSM-IV criteria for the diagnosis of cyclothymic disorder, the person must have had numerous periods of both hypomanic and depressive symptoms over at least two years, with no more than two months at a time free of symptoms, and with no major depressive episode, manic episode, or mixed episode during the first two years.
A mixed episode, also called a mixed state, mixed affective state, mixed mania, or dysphoric mania, is a manifestation of bipolar disorder in which depression and mania exist together in one episode. The DSM-IV defines it as a period of at least a week during which the person fits the picture for both a manic episode and a major depressive episode, with agitation, insomnia, psychotic features, and suicidal ideation often present.
Rapid Cycling, Ultra-Rapid Cycling
This refers to a pattern that can occur in Bipolar I and Bipolar II. In rapid cycling, the moods are the same as defined, but they change more frequently, with four or more episodes in the space of a year, marked by a switch to the other pole or a period of nonepisodic mood (neither mania nor depression). Ultra-rapid cycling, a relatively new term, refers to switching that happens in the space of a day or even from moment to moment.
While this disorder is listed under schizophrenia in the DSM-IV, it is defined as involving a major depressive, manic, or mixed episode in combination with two or more of the characteristic symptoms of schizophrenia: delusions, hallucinations, disorganized speech, catatonic or grossly disorganized behavior, or negative symptoms such as flat affect, lack of speech, or lack of volition. Schizoaffective disorder presents very much like bipolar disorder with psychotic features, the difference being that delusions and hallucinations in the latter case are part of the abnormal mood, while no such relationship exists in schizoaffective disorder.
People with bipolar disorder are frequently diagnosed with schizophrenia and vice versa. Others receive a dual diagnosis of schizophrenia and bipolar disorder, as was true with several of the people featured in cases in this book. The schizoaffective category highlights the confusion in attempting to distinguish between the disorders.
Bipolar Disorder and Creativity
There is another side to bipolar disorder, and that is its link to creativity. Madness in general has long been paired with genius in the arts. Investigation reveals that there is some substance behind what some dismiss as a romantic notion. Many people with bipolar disorder report that their creative output increases significantly when they are hypomanic. Researchers have cited "sharpened and unusually creative thinking" and "increased productivity" as two of the criteria in the diagnosis of hypomania.
As part of her investigation into the relationship between creativity and mood disorders, Dr. Jamison charted the works of composer Robert Schumann in relation to his bipolar episodes, and the results are significant. During the years in which he was severely depressed or attempted suicide, he produced no, or one to two, opuses. In 1840 and 1849, when he was hypomanic for the whole year, he composed 24 and 27 opuses, respectively.
There seems to be a preponderance of the affliction in artists and writers throughout history who were known to have mood disorders of some kind. This perception is borne out by a review of studies investigating the actual percentages in comparison with the population at large. An analysis of seven studies found that the rate of manic-depression and cyclothymia among artists and writers is 10 to 20 times higher than the rate in the general population; the rate of depression is 8 to 10 times higher; and the suicide rate is as much as 18 times higher.
It is not known why this is so. Does the artistic process promote madness, or are people suffering from mental illness temperamentally drawn to the arts? Whatever the reason for the greater incidence among the creative, it is important not to lose sight of the tragic aspect of the madness-genius equation, which can get lost in the romanticization of the artistic life. As Dr. Jamison observes, "No one is creative when paralytically depressed, psychotic, institutionalized, in restraints, or dead because of suicide."
The relationship between creativity and at least the milder form of mania makes treatment problematic for some people. The most common side effects that people on lithium report are "mental slowing" and "impaired concentration." This is enough for some people to stop taking lithium. While avoiding the more debilitating form of mania may be an incentive for treatment compliance, hypomania may be a compelling state. As Dr. Jamison poses it, "Who would not want an illness that has among its symptoms elevated and expansive mood, inflated self-esteem, abundance of energy, less need for sleep, intensified sexuality, ... sharpened and unusually creative thinking and increased productivity?"
It may not be only the hypomanic aspect of bipolar disorder that has an effect on creativity, "but rather the flux and tensions between the different mood states," explains psychiatrist and author Francis Mark Mondimore, MD. "Perhaps bipolar disorder stimulates creativity in part because its sufferers experience the world through the emotional prisms of its many and shifting moods ..."
Excerpted from The Natural Medicine Guide to Bipolar Disorder by Stephanie Marohn. Copyright © 2011 Stephanie Marohn. Excerpted by permission of Hampton Roads Publishing Company, Inc..
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