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Bipolar Disorder: When the Mind Goes to Extremes - 09/04/2007

Stephanie (not her real name) was in her late 20s, with a good career at a large corporation. She enjoyed her profession, gladly putting in extra hours and often taking classes to further her knowledge.

At the end of the workday one Friday, Stephanie discovered she hadn’t been given credit for some work she’d performed. This would annoy a lot of people, who would probably bring it up with the boss Monday. But the incident triggered something in Stephanie. Her initial upset quickly spiraled into obsession. Through the entire weekend, the scenario of not getting credit for her work kept replaying in her head — to the point where she could think of nothing else. “I couldn’t concentrate,” Stephanie says. “I couldn’t eat; I couldn’t sleep. I was up for hours and hours thinking about it, pacing the floor.” At one point she got into her car and just sat there. “I couldn’t remember how to drive,” she says. “I’d been driving for at least eight years of my life, and I couldn’t remember how to drive.”

Realizing something was very wrong, Stephanie took a cab to her primary care physician’s office. She saw three doctors that day in 1989 and ended up in the hospital, where she was diagnosed with bipolar disorder. “I had no idea what that was,” says Stephanie, now 45.“I’d never experienced anything like it before.” It was the first of several hospitalizations over the years, and the beginning of a lifelong regimen that includes medication, counseling and constant vigilance for the signs of another approaching episode.

An estimated 5.7 million American adults — about 2.6 percent — have bipolar disorder, according to the National Institute of Mental Health, the lead federal agency for research on mental and behavioral disorders. Also called manic-depressive disorder or manic depression, bipolar disorder causes unusual and often extreme shifts in mood, energy and ability to function. Manic symptoms include excessive energy, euphoria and inability to concentrate; depressive symptoms include feelings of emptiness, hopelessness and/ or guilt and decreased energy (see sidebar).
“We’re not talking about the normal ups and downs most people experience,” says Michael Balkunas, M.D., chief of psychiatry at The Hospital of Central Connecticut, which treats bipolar disorder at its acute-care inpatient psychiatric unit, Outpatient Services and Clinical Research Center. “Bipolar symptoms are severe. People with the disorder can feel on top of the world one day and suicidal another. It has a major impact on their relationships, job performance and other aspects of their lives.”

A difficult diagnosis
Bipolar disorder usually develops in late adolescence or early adulthood, but can manifest any time. Jane (not her real name), 59, believes she’s had the disorder since childhood, though she didn’t get help until she was in her 40s. Jane often engaged in risky behaviors — a little shoplifting, gambling and drug use. She could never seem to hold a job.

To look at Jane, you’d never guess she has bipolar disorder. Dressed in a red top, with sparkly red and pink earrings and lipstick to match, she looks like someone who’s fun to be around. Some of her ebullience is certainly natural, but she knows the mania contributes to it, making her think and talk too much and too fast. And while she can be lively and upbeat, Jane can quickly become agitated. “I can be in a good mood, but if I get triggered, I turn on a dime,” she says. “I get moody, frustrated.” Much of Jane’s frustration — which is exacerbated by the bipolar disorder — stems from the fact that many people judge her on behavior she can’t always control. “They don’t know how hard this is to live with,” Jane says. “And it’s incurable.”

It’s also difficult to diagnose and treat, in large part because definitive physical causes haven’t yet been found, Balkunas says. Some studies point to structural abnormalities in the brain; others to levels of serotonin, norepinephrine and dopamine — chemicals that stimulate neurons in the brain and help regulate mood. Children with one parent who has the disorder have about a 15 percent chance of getting it, which probably indicates a genetic link. Researchers have just begun studying the effects of various genes on mental health. “Until a physical cause is found, we’re diagnosing and treating people
based on non-physiological symptoms — mood, actions, thoughts,” Balkunas says. Even those can be difficult to categorize, says Steven D. Moore, Ph.D., director of Outpatient Psychiatry and Behavioral Health for the hospital. Bipolar disorder can be depicted as a line, with extreme mania on one end and extreme depression on the other. Bipolar symptoms can fall anywhere on that line, which means the severity and length of each manic and depressive episode can vary. One person might experience extreme, lengthy depression, but milder mania, or vice versa. Sometimes people can have mania and depression together. “Bipolar disorder seems to be one thing in one person and another in somebody else,” Moore says.

“You don’t know what you’ll do“
What Stephanie first experienced in 1989 — and a number of times after — is a classic manic episode, with racing thoughts, difficulty focusing, impaired memory and inability to sleep and eat, says social worker Teresa Works, MSW, LCSW, clinical director of the Counseling Center, part of the hospital’s Psychiatry and Behavioral Health Outpatient Services. Some people get “grandiose” ideas, feeling they can do anything. Stephanie recalls a manic episode when she was feeling so magnanimous, she tried to give her new car away. “The danger is that the mania feels good,” Works says. “The people experiencing it feel energized, alive, almost euphoric.” But over time, without proper treatment, there are fewer euphoric episodes and more manic episodes characterized by agitation, irritability, even violence, Balkunas says. Depressive episodes can be just as intense as the mania, and are usually much more frequent. About 15 percent of bipolar patients commit suicide, usually while depressed. Says Jane, “I want to sleep for
hours, but there’s always stuff racing through my head. I try not to think about suicide, but when you get weighed down in those moods you don’t know what you’ll do.”

Stephanie describes the depression as “a bottomless nothingness.” One of her worst depressions was triggered by a job layoff. It worsened significantly when her mother died. “Her death tore me to pieces because I thought I had contributed to it somehow, but I couldn’t remember how,” Stephanie says. “Every day was a nightmare.” For a month she plotted her own suicide, but her head was “too scrambled” to carry it out. She couldn’t get out of bed, but couldn’t sleep. She couldn’t eat and lost 40 pounds. Her depression lasted for months before she was hospitalized.

Finding a balance
While bipolar disorder can’t be cured, the right medications can lessen the intensity of mania and depression. Mood stabilizers, including lithium, Depakote and Lamictal, seem to work best for most people, Balkunas says. Anti-depressants have been used to treat depressive episodes, but these medications can have the opposite effect, pushing patients into mania. While medications are effective for most patients, they can have a wide range of unpleasant side effects, including weight gain, liver damage, gastrointestinal distress and others. These side effects — along with the positive feelings that can occur with mania — can cause many to stop taking their medications.

Jane is still searching for the medications that will work best. She is among nearly 50 people with bipolar disorder who have volunteered at The Hospital of Central Connecticut’s Psychiatry and Behavioral Health Clinical Research Center, where researchers are studying the effectiveness of new medications and combinations of medications and other therapies. Counseling is also a critical component of the hospital’s inpatient and outpatient treatment programs. It includes education on the disorder and symptom management, as well as individual, group and sometimes family therapy. “Medication can provide initial stabilization, but many people have had the disorder for awhile,” Moore says. “They tend to have disruptive relationships, and they’re living with the consequences of their inability to function during depressive episodes and impulsive behaviors during mania. Psychotherapy is critical to help them deal with the pressures of their lives.”

Many bipolar patients need help admitting they have a mental illness, Works says. “It’s hard for people to accept something’s wrong – particularly if they’re feeling ‘up’ during a manic episode,” Works says. “With the stigma surrounding mental illness, many people with bipolar disorder are ashamed to tell even family and close friends.” Even family members who know about the condition and are generally supportive can find the symptoms hard to deal with. “My family loves me, but sometimes they have to put me at a distance,” Jane says. “It’s just too much for them. I understand why they do it, but I still feel rejected sometimes.” Jane is determined to reach a point where she can hold a job, find a nice apartment and buy a car. She wants a normal life. “I can’t count the number of times I’ve been out somewhere and I see other people and think, ‘I want to be like them,’” she says. Stephanie has been coming to the outpatient Counseling Center consistently since 2002. In addition to taking medication, she meets at least weekly with Works. Stephanie also wants to work, but can’t due to the bipolar disorder and some physical problems. For now, caring for her son and herself is enough of a job, she says. “I still have ups and downs, but I’m getting better at controlling the symptoms,” she says. “Sometimes when I think about having this condition, it’s unimaginable to me. I really don’t know how I do it.”

Sidebar
Signs and symptoms of bipolar disorder

Mania (or a manic episode):
• Increased energy, activity, restlessness
• Overly good, euphoric mood
• Extreme irritability
• Racing thoughts and talking very fast; jumping from one idea to another
• Difficulty concentrating
• Little sleep needed
• Aggressive behavior
• Unrealistic beliefs in one’s abilities and powers
• Poor judgment
• Spending sprees
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
• Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for one week or longer. If the mood is irritable, four additional symptoms must be present.

Depression (or a depressive episode):
• Sleeping too much, or can’t sleep
• Change in appetite and/or unintended weight loss or gain
• Difficulty concentrating, remembering, making decisions
• Chronic pain or other persistent bodily symptoms with no physical cause
• Thoughts of death or suicide, or suicide attempts
• Restlessness or irritability
A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of two weeks or longer. If you or someone you know is experiencing these symptoms,see your doctor.

Source: National Institute of Mental Health