Bipolar disorder, formerly called manic-depressive illness, is one of several disorders known as mood disorders. Mania and depression alone or in combination are the hallmarks of the mood disorders. Mania is characterized by a feeling of euphoria in which the individual has grandiose ideas, exhibits boundless energy, needs little sleep, and exhibits great self-assurance. While in a manic state people's thoughts race, they speak too fast, and they demonstrate poor judgment. Manics may impulsively spend too much money, commit sexual indiscretions, and alienate people with their irritability and impatience. Hypomania refers to a milder form of mania that is an excessive amount of elation but does not significantly impair the individual's life.
Depression can be characterized by many symptoms, including feelings of worthlessness, guilt, and sadness. When one is depressed, life seems empty and overwhelming. The depressed individual has difficulty concentrating, cannot make decisions, lacks confidence, and cannot enjoy activities that previously were pleasurable. Physical symptoms may include gaining or losing weight, sleeping too much or too little, agitation, or lethargy. Depressed individuals may be preoccupied with death or suicide. They may believe that they have committed the unpardonable sin and that loved ones would be better off without them.
Bipolar disorder is so named because those afflicted with it experience both mania and depression, in contrast to those with unipolar disorders, who experience only one extreme, usually depression. Bipolar disorders are categorized into two types, Bipolar I and Bipolar II. In Bipolar I the individual experiences both mania and depression; in Bipolar II the individual experiences hypomania and depression. Mania or hypomania is the key to diagnosing bipolar disorder. A person who experiences a manic state even once is presumed to have bipolar disorder. Manic and depressive states may immediately precede or follow one another or may be separated by long time intervals, and the individual may have more episodes of one pole than the other. Some individuals, known as rapid cyclers, will experience four or more episodes per year.
The age of onset for bipolar disorder is younger than for unipolar depression and usually begins in the late teens or twenties but seldom begins after age 40. In some cases it is preceded by a disorder named cyclothymia, which is a milder form of mood disorder, characterized by marked moodiness and mood swings for at least two years. Bipolar disorder is a chronic disorder and even with treatment less than half of the individuals who experience it go five years without a manic or a depressive episode. People with bipolar are at risk for suicide in the depressive phase and are more prone to accidental death in the manic phase due to impulsiveness and poor judgment.
The causes of bipolar disorder are unclear, but it is probably determined by multiple factors. Family and adoption studies have consistently indicated a genetic predisposition toward mood disorders. First-degree relatives of persons with bipolar disorder are much more likely than the general population to experience bipolar depression, unipolar depression, and anxiety. At this point, however, there is no clear evidence that a particular gene is linked to the transmission of bipolar disorder; instead it seems that a family history increases vulnerability to several disorders.
Neurotransmitters in the brain have been widely investigated and are very likely involved in bipolar disorder but in complex and interactional ways not yet understood. The relationship between neurotransmitters and the hormones secreted by the hypothalamus, pituitary, and adrenal glands seems to be significant. There is also speculation that bipolar disorder may be related to circadian rhythms because some people with bipolar disorder are especially light-sensitive and show abnormalities in sleep patterns such as entering REM sleep too quickly, dreaming intensely, and missing the deeper stages of sleep.
Stressful life events may precipitate episodes of mania or depression but do not seem to be the primary cause of bipolar disorder. Psychosocial factors such as attributional style, learned helplessness, attitudes, and interpersonal relationships all seem to be correlated with bipolar disorder but have not been identified as causes; they are often the result of having such a disorder. It seems that a genetic vulnerability coupled with stressful psychological and sociocultural events may result in bipolar disorder.
Three primary treatment modalities are most frequently used for bipolar disorder. Medication is commonly used, especially lithium. For reasons not yet fully understood, lithium reduces the frequency of episodes, and many persons with bipolar disorder are maintained on lithium for long periods. Lithium levels must be carefully monitored through blood tests, and there may be side effects such as weight gain, lethargy, and kidney malfunction. Because of the side effects of medication and because they miss the energy of hypomania and manic states, people with bipolar disorder may discontinue their medications. The newer antidepressants that affect serotonin levels are often used, but there is some suspicion that they may contribute to more rapid cycling. Antiseizure medication, such as carbamazepine, is also being used.
A second treatment approach that is sometimes used is electroconvulsive therapy (ECT). This approach is used only in severe cases in which uncontrollable behavior or the threat of suicide makes it impossible to wait the two to three weeks for medication to take effect. ECT, used to treat people who have not responded to other forms of treatment, is often effective but is subject to side effects: temporary short-term memory loss and confusion immediately after treatment.
Psychotherapy is the third treatment approach. While many psychotherapeutic approaches have been tried, cognitive therapy and interpersonal therapy are currently the most popular. Cognitive therapy focuses on identifying and correcting faulty thinking and attributional styles, so that the client can gain cognitive control of emotions. Interpersonal therapy focuses on developing the skills to identify and resolve interpersonal conflicts, which frequently accompany bipolar disorder. Both of these psychotherapies are highly structured and short-term. Many people receive a combination of both medication and psychotherapy to stabilize them and prevent relapse.
In addition to addressing the potential causes of bipolar disorder, psychotherapists help people cope with a number of problems that arise in living with the disorder. One is the difficulty of living with interruptions to one's life that manic and depressive states bring. People may be too ill to work or parent and may even be hospitalized. Another problem is undoing or coping with inappropriate behavior that was performed during a manic state, when the individual may have recklessly spent money, made grandiose promises, or said inappropriate things. A third common problem is dealing with negative reactions and the distrust of family, friends, and co-workers who have been affected by the individual's extreme mood swings. Taking medication regularly is a struggle for some people, a struggle that is compounded by the tendency for people in a manic or hypomanic state to feel that they do not need medication. People with bipolar disorder deal with the constant anxiety that their feelings may spin out of control. They often feel powerless and as though their illness is in control and may take over any time. There is also the question of why God allows people to go through such struggles. People with bipolar disorder need therapists who help them exercise cognitive control over their emotions, recognize when they are getting too high or too low, manage interpersonal relationships, cope with life stresses, and understand how to accept and live successfully with bipolar disorder.
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