Disorder: Calming the Storms
Mood, like the weather, is always
changing. For most people, the emotional climate remains within predictable
limits—not too high and not too low. For a person with bipolar disorder the
barometer of life will at times seem to fall from a temperate normal mood, to
the bleak chill of depression. It can also shoot up to the bright heights of
hypomania or beyond to the brilliant blaze of mania.
Bipolar Disorder, as its name suggests,
is a condition characterized by periods of high mood in addition to the low
moods that occur in the more common “unipolar” depression. Studies show that
1.5% of the population will have at least one hypomanic or manic episode in
their adult lives.
When a person is hypomanic, they may
feel unusually good and competent, or simply irritable. Their thoughts race and
consequently their speech is often pressured; they may be distractible and flit
from topic to topic. They apply their heightened energy to multiple projects.
Sleep seems less necessary. There is a drive for pleasurable activities with
uncharacteristic disregard for risk. Friends and relatives who know the person
recognize that they are behaving differently—out of character. If the symptoms
are so severe that they cause marked impairment in work or social functioning,
then the condition is called mania.
Depression, the other pole of Bipolar
Disorder, may also vary in severity from a relative decrease in enjoyment and
interest, to a complete and painful lack of pleasure in anything. Often there
are disturbances in concentration, sleep, appetite and energy as well as
paralysis of decision making. Guilt and low self-esteem are common.
Without treatment, bipolar disorder can
be devastating. People with this condition divorce 2-3 times more commonly and
show decline in occupational functioning twice as commonly as the average
population. Proper treatment can lower the elevated suicide mortality rate in
Fortunately, there are a number of good
treatments available for Bipolar Disorder. The first step in treatment is
appropriate evaluation and diagnosis. Usually medication can help control the
mood swings. It is essential to develop a trusting relationship between the
psychiatrist and patient, especially since many patients initially don’t
recognize or don’t want to recognize the danger of an elevated mood. If a
strong alliance is present, medication can often be started sooner—before a
crisis develops—and prevent a full-blown mood swing. It is often a turning
point in treatment when the patient accepts the need to monitor their own mood
and to ask for help early on.
A, Standish-Barry H, Bailey J, Houston G, Silcocks P, Hermon C: Does lithium
reduce the mortality of recurrent mood disorders? J Affect Disord 1991; 23:1-7
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Wide Spectrum of Mood Disorders
E. Watkins, M.D., Glenn Brynes, Ph.D., M.D.
The wide variety of
emotions, joy, grief and sadness, are an integral part of the rich tapestry of
human experience. Without them we would lose part of what it is to be an
individual. However, mood swings or chronic depression can become so intense or
fixed that they interfere with our lives or even put us in dangerous situations.
Mood disorders can also co-exist with other problems such as anxiety or
attention deficit disorder. Accurate diagnosis is important because we can often
tailor psychotherapy, medication and other treatments for specific types of mood
Disorder with Depressed Mood: Mild to moderate depression that develops
within 3 months of a significant life stress.
Although this may resemble depression, it is generally not classified as a
mental disorder. Sometimes, though, it may develop into a clinical depression.
Depressive Disorder: At least 2 weeks of depressed mood. Changes in
sleep, appetite and energy are common. Guilt, impaired concentration, and
suicidal thoughts may be present.
Disorder: Milder but more chronic depressive symptoms. It must be
present for at least 2 years in an adult or 1 year in a child or adolescent.
Dysthymia may be present between episodes of Major Depression. If so, it is
commonly called “Double Depression.”
Disorder: The DSM-IV lists six diagnostic categories for bipolar
disorder. The two main subdivisions are Bipolar I and Bipolar II Disorder.
I Disorder: The individual must have had at least one episode of true
mania. Mania consists of at least a week of an abnormally elevated, irritable
or grandiose mood. The affected individual may experience decreased need for
sleep, pressured speech, racing thoughts, physical agitation, distractibility,
and grandiose psychosis. Individuals often experience depressive episodes or
mixed mood states.
II Disorder: multiple episodes of depression and at least one episode
of hypomania (mild to moderately elevated mood)
Affective Disorder: Recurrent depression or bipolar disorder associated
with specific times of the year.
Disorder: Repeated periods of hypomania alternating with mild
Mood Disorder: Depression or other mood swings that occur only during
intoxication or withdrawal from an alcohol drugs, or prescription medications.
Disorder Due to a Medical Condition: Mood changes specifically related
to a medical condition such as pancreatic cancer.
Disorder: This condition has some features of schizophrenia and the
mood disorders. Psychotic thoughts are often unrelated to the individual’s
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Treatment for Bipolar Disorder
Glenn Brynes, PhD,
Bipolar Disorder (or Manic
Depressive Illness) involves prominent mood swings. The individual has periods
of depression, and periods when they feel either unusually good or pressured and
irritable. It affects 1-2% of the population. Genetics plays a significant role.
About 15% of children with one bipolar parent develop the disorder.
Treatments include medication,
supportive psychotherapy and occasionally ECT. Medications include lithium,
anticonvulsant drugs (carbamazepine (Tegretol), valproate (Depakote), gabapentin
(Neurontin) and lamotrigine Lamictal), antidepressants (such as bupropion (Wellbutrin)or
sertraline (Zoloft)), neuroleptics (e.g. haloperidol) and benzodiazepines (e.g.
lorazepam) Treatment choices depend on the type and phase of the illness. There
is growing evidence that patients with less frequent and more intense mood
swings respond best to lithium, while those with more than 4 mood swings per
year respond best to the ‘anticonvulsant’ mood stabilizers. When a person is
acutely manic, they may require hospitalization. Lithium or an anticonvulsant
mood stabilizer can be quite effective, but may take several days or weeks to
take effect. Antipsychotic and antianxiety drugs can help control symptoms
during this period.
The depressive phase may not respond
as well to lithium and most anticonvulsants. While antidepressants can help,
they carry a moderate risk of overshooting into mania; thus they are generally
used with a mood stabilizer. One promising drug, lamotrigine (Lamictal), may
have specific antidepressant in addition to anti-manic properties. Lamotrigine
is usually increased slowly to minimize the chance that it might cause a
severe depression or mania. It is most often used when medication doesn’t work
or is unsafe.
Lithium is a top choice for acute
mania and for maintenance in ‘classic’ bipolar disorder. Because of its
narrow therapeutic range, blood levels must be monitored; also heart and kidney
function (EKG, blood and urine tests). Medications such as diuretics, that block
its excretion require caution.
Anticonvulsants have an edge with
rapid-cycling and mixed mood states (e.g. depression with racing thoughts).
Except for gabapentin (Neurontin) and lamotrigine (Lamictal), they require blood
tests. Carbamazepine (Tegretol) is monitored with blood levels; also CBC,
platelets and liver function tests. Valproate (Depakote) requires CBC, platelet
count and liver function tests; blood levels may be helpful. Lamotrigine (Lamictal)
requires caution because of its association with a rare but dangerous skin rash
(exfoliative dermatitis); risk can be minimized by starting with low doses and
increasing gradually. Use lower doses with medications that slow lamotrigine
metabolism (e.g. valproate). Gabapentin is generally safe and does not require
It is not unusual for patients to
need more than one mood stabilizing medication for best results.
Because bipolar disorders are
generally recurrent, maintenance treatment is usually needed. This is especially
true when there have been multiple episodes, a clear family history of bipolar
disorder or symptom onset before age 18. Effective maintenance requires full
doses of mood stabilizing medications and ongoing medical monitoring.
Psychotherapy can help patients and their families understand the illness, can
teach the importance of early relapse detection, and ensure compliance with
medication. In therapy, patients can deal with past instability and prepare
constructively for the future.
Genetics, in Manic-Depressive Illness. Edited by Goodwin FK, Jamison KR. New
York, Oxford University Press, 1990, pp 373—401
APA Textbook of Psychiatry 2nd Ed. Ch. 27
(Dunner and Fieve 1974; Prien et al. 1984; Wehr et al. 1988).
Dunner DL, Fieve RR: Clinical factors in lithium carbonate prophylaxis failure. Arch
Gen Psychiatry 30:229–233, 1974
Caliari B, Tundo A, et al: Rapid cyclers, temperament, and antidepressants. Compr
Psychiatry 24: 249–258, 1983
Disorder and Family Therapy
Carol E. Watkins,
Most professionals agree that Bipolar
Disorder is a biologically-based mental illness. Medication is a critical part
of the treatment. However, the emotional swings, the medication side effects,
the disruptions in work or school all take place within an individual-and that
individual usually lives in a family.
Mark was having a successful season in
his sales job. His boss then increased his responsibilities. Mark began to work
extended hours and go without sleep. While his sales were phenomenal, he was
irritable and even threatening to his wife and children. After two days without
sleep, he got into an argument with a police officer and was arrested. His wife
had to leave the children with a neighbor to meet her husband at an emergency
room. A week later, still somewhat manic, he was discharged. His wife and family
were afraid. Who was this man who was coming home to live with them?*
An episode of mania or depression can
make a familiar family member seem like a stranger. The experience can be
frightening and disorganizing for the entire family. In such a state, the family
members may become hostile, fearful and controlling. They may blame themselves
or the affected individual.
Bipolar disorder may involve long
periods of remission between episodes. Everyone can be lulled into a false sense
of security. This fosters denial of the illness and premature medication
cessation. Some individuals who are usually quite responsible may temporarily
lose their insight during the early stages of an acute episode.
Family therapy can help the entire
family unit regain healthy relationships after a period of mania or depression.
It can help the patient and family identify and deal with the stresses that may
trigger acute episodes. The patient and family may need to distinguish the
patient’s long-term personality traits from an exacerbation of the bipolar
disorder. On one hand, the patient and family need to work through denial and
learn to accept this as a biological condition. However, excessive vigilance,
relating every personality quirk to the illness, can be counterproductive.
Families do not cause bipolar disorder,
but they can do a lot to support treatment, speed recovery, and help the
individual identify early recurrence.
Carol E. Watkins, M.D.
*Vignette is fictional but typical of actual
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Swings and Drugs
Which came first, the chicken or the
Which came first, the drugs or the
mood swings? Too often, I have to figure this out. His parents or teachers sent
him to see me because he have had mood swings, verbal explosions and sleep
problems. The drug screen comes back positive for cocaine and marijuana, and the
garbage can search reveals empty wine bottles.
He has a problem with drugs and
alcohol. He has mood swings. Drugs can cause mood swings. On the other hand,
someone with depression or mania may use drugs to take away the pain of
uncontrollable mood changes. Figuring out the answer often requires some expert
detective work. He need to open up and give me a detailed, honest history. His
family members must also be frank about their own drug and psychiatric
histories. No more secrets.
Adolescents may abuse drugs for a
variety of reasons. These often include peer group pressure, parental drug and
alcohol use, depression or just a desire for a new experience.
No adolescent should use alcohol or
illegal drugs. However, there are certain individuals who are at increased risk.
These individuals should be cautious even as adults. Some people can drink for
quite a while before running into problems. Others have problems after that
first drink. If close family members have had problems with drugs or alcohol,
you are at increased risk. If you are depressed or already have trouble with
mood swings, you are more likely to become addicted, and may have more trouble
getting off drugs. There is evidence that drug use may cause an individual with
a biological tendency toward bipolar disorder to develop the illness earlier in
life. High school is difficult enough; you don’t need this too. Talk to a
trusted adult and get help early.
E. Watkins, M.D.
related to Depression and Bipolar Disorder
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suicide is usually due to treatable mental illness. There is also
information and support for survivors.