Bipolar Disorder: Perspectives on Diagnosis and Treatment

Bipolar Disorder



or Bipolar Disorder?


Disorder: Calming the Storms


Wide Spectrum of Mood Disorders


Treatment for Bipolar Disorder


Disorder and Family Therapy


Swings and Drugs

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Disorder: Calming the Storms

Glenn Brynes,

Ph.D., M.D.

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

this group.

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.



MM, Bruce ML, Leaf PJ, Florio LP, Holzer III CE: Affective disorders, in

Psychiatric Disorders in America. Edited by Robins L, Regier DA. New York, Free

Press, 1990


Coryell W,

Scheftner W, Keller, Endicott J, Maser J, Klerman GL: The enduring psychosocial

consequences of mania and depression. Am J Psychiatry 1993; 150:720-727



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

overall mood.

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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


ECT helps

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

blood tests.

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.

Selected References:

Gershon ES:

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

Kukopulos A,

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.


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Web Site

Copyright 2007


E. Watkins, M.D.

Glenn Brynes, Ph.D., M.D.