Bipolar disorder

Bipolar disorder is another type of depression of great concern, and seems to be qualitatively different from major depression, dysthymia, and DDNOS.  Bipolar disorder Type I (manic depression) typically features episodes of major depression interspersed with periods of mania. A manic episode must meet the following criteria:

A. A discrete period of abnormal, persistently elevated, expansive, or irritable mood

B. At least three of the following in the same period:

1. Inflated self-esteem/grandiosity

2. Marked decrease in need for sleep

3. Pressured speech

4. Flight of ideas (racing thoughts)

5. Marked distractibility

6. Increased goal-directed activity or psychomotor agitation

7. Excessive involvement in pleasurable activities without regard for negative consequences

C. Symptoms must be severe enough to cause marked impairment in functioning or place self or others in danger

D. Symptoms must not be caused by schizophrenia or substance abuse

Walt has bipolar disorder. A big man, a truck driver, who seems pleasant and good-natured in his normal state, Walt has had trouble holding down a job for the past few years because of his erratic behavior. Sometimes he becomes sexually obsessed. He can’t get sex off his mind. If an attractive woman is anywhere near, he can’t concentrate on anything but his sexual fantasies. Sometimes he loses touch with reality enough to start believing that she returns his fantasies. When he’s in this state, he’ll spend money he doesn’t have on prostitutes, on gambling junkets, on anything to impress women. He believes he’s attractive, powerful, and charmed, and he feels he can do no wrong. Nothing bothers him. He can stay up for days, talking nonstop. He once showed up at my house, unannounced, to show me his new car—the only time I’ve ever had a client violate a boundary like that.  But Walt just wanted to share his joy.

At other times, Walt is severely depressed. He doesn’t believe he’s capable of anything. He hardly has the energy to get out of bed. He tries to go to work, but his lack of confidence makes his employers distrust him. He develops obsessive anxiety symptoms—going back into the house ten times to make sure the coffee pot is unplugged. He’s constantly apologizing for himself.

The mean age of onset for bipolar disorder is the early twenties. It affects men and women equally; it’s reported that over the course of their lifetime, between 0.4 and 1.2 percent of men and women will develop bipolar disorder. At any given time, between 0.1 and 0.6 percent of the population are suffering from an episode. I suspect that the actual incidence of bipolar disorder, or the more severe forms of bipolar II, are really much higher than these formal statistics.  There is a high genetic correlation; first-degree relatives of bipolar patients have a 12 percent lifetime incidence, while another 12 percent will experience major depression.

Untreated, a manic episode will last an average of six months, and a major depressive episode eight to ten months; over time, the manic episodes become more frequent. There is a high mortality rate, due to suicide (15 percent of untreated patients), accidental death due to risky behavior, and concurrent illness. Many people with untreated bipolar disorder will die from alcoholism, lung cancer, accidents, or sexually transmitted disease; feeling so invulnerable during an episode, they simply do not take the precautions that most of us have come to accept as part of a sensible lifestyle.

There are other subtypes of bipolar disorder.  Bipolar Disorder Type II features episodes of major depression alternating with hypomania (an abnormally elevated or expansive mood that does not interfere with your ability to see reality objectively;  “hypo” = “less than” mania).  These people make up a distinct subcategory; anyone who can go from the depths of major depression to a giddy, excited, or highly focused and productive state, and do it over and over, is not your usual depressive.

Then there are bipolars Type III, III ½, IV, and IV ½.  I’m not kidding, and researchers squabble about these distinctions, though they might seem petty.  One definition of Type III, for example, refers to people with depression who take an antidepressant (or switch to another) that suddenly triggers a full-blown manic episode, a phenomenon that is not that rare.  Other people define Bipolar III in an entirely different way, so I’ll just leave the subject alone.  If someone gives you one of these diagnoses, be sure you get a very clear understanding of what they’re talking about, especially before taking an antidepressant.

I said in the first edition of Undoing Depression that bipolar disorder (Type I) seemed to be a different kettle of fish from other kinds of depression—different mechanisms in the brain involved—though the depressive episodes may look and feel the same as major depression.  I argued that Bipolar I has such a high degree of genetic loading, the manic episodes are so distinctive and limited to the disease, and the disease itself has such a unique response to a specific medication (lithium) that it makes sense to think of it as primarily a biogenetic disease causing a chemical imbalance in the brain that leads to the unique mood swings.

But the unexplained fact that sometimes taking an SSRI may send a garden-variety depressive off on a full-blown manic episode suggests that there may be more connections than meet the eye.  And, I keep running into people who think of themselves as bipolar I who have all the childhood history—emotional neglect, loss, abuse—that goes with major depression or dysthymia.  Many clinicians expect that, within the next few years, we will see a breakthrough in understanding the connections in the brain and the genes between mania and depression—and anxiety, ADHD, and PTSD—which may lead to better medications and improved treatment for all.

Time magazine’s Man of the Year in 1992, Ted Turner, may have been the first to come out of the closet regarding his psychiatric treatment. His story is fascinating for those who are interested in the problems men have with success and intimacy, and for those who are interested in the mix of genetics, biochemistry, and family dynamics that underlies depression and bipolar disorder.

For many years Turner was troubled by the obsessive thought that he would not live longer than his father had, because his father had killed himself at age 53. (This is a common fear among suicides’ children.)  Ted talked of suicide rather often, and drove himself mercilessly to succeed in joyless pursuits. After all the time he put in sailing, including winning the America’s Cup, he told a friend repeatedly that he never enjoyed the sport. “I got cold and I got wet.” His eye was always on the finish line, always looking for some achievement that would finally be enough to make him feel good about himself.

Turner’s father, Ed, by all accounts was a tortured man who inflicted psychological torture on his son. Young Turner was beaten with a coat hanger when he let his father down; when Ted did something really bad, his father had Ted beat him with a razor strap. When Ed served in the navy during World War II, he had his wife and daughter move from base to base with him but left Ted, only six, behind at a boarding school. From fifth grade on, Ted was sent to military academies. No grade he ever got was good enough, no achievement great enough, to please his father. Ed shot himself when Ted was in his early twenties, leaving Ted to rescue the family billboard business, which had sunk into debt. By working feverishly and gambling recklessly, he not only rebuilt the business, he began the communications empire that became CNN.

But with his father dead, Turner had no yardstick to measure his success against. He drank, womanized, alternately neglected and bullied his own children, and apparently was sheer hell as a boss. Finally, in 1985, he sought help, and began to work with a psychiatrist in Atlanta.

The psychiatrist first put Turner on lithium, a reliable treatment for bipolar disorder. Because in this disorder patients may have great self-confidence and energy, may go without sleep, may believe they are capable of great achievements, may enjoy taking risks, for someone like Turner it can be hard to tell where disease ends and personality begins. It can also be hard to get the patient to accept treatment for symptoms that in many ways have paid off. But Turner was a cooperative patient.

As Turner began to be stabilized by the lithium in his system, therapy helped him deal with the shadow of his father. Like most men with critical, emotionally rejecting fathers, Turner had developed no internal mechanism for feeling good about himself. Like most family members of suicide victims, he was haunted by the idea that the suicide had the truly accurate perspective on life: that it’s not worth the trouble. Time could not get the psychiatrist to talk about the details of Turner’s case, but it’s clear that Turner had to work hard to make peace with his own children and with the women in his life.

Turner is a classic example of the observation that achievement doesn’t mean happiness; instead, it’s how we live rather than what we do that leads to peace.

If you have bipolar disorder, it’s essential to get good psychiatric treatment as well as psychotherapy. Lithium for bipolar disorder is as close comes to a specific cure for a specific disease.  It was until recently the treatment of choice for bipolar disorder, and many MDs still prescribe it first, despite the blandishments of the newer, more expensive drugs.   Lithium in the correct dose reduces the chances of another manic episode within a year by about fifty percent.  Mood swings become fewer, shorter, and less severe.  It’s also helpful for the depressed phase of bipolar disorder.  The success rate for lithium treatment approaches seventy percent, and twenty percent of patients become symptom free.  It is generally seen as a maintenance drug—once on, the patient is on for life—and its long-term effectiveness is proven. Compliance is an issue for many patients, partly because some miss the manic highs that come with the disease.  Side effects, including weight gain and skin rashes, also make it difficult for some patients to follow their prescription.  The most important drawback is that lithium can be toxic to the liver and must be used carefully.  It should only be dispensed by a psychiatrist who is familiar with its use, not by a general practitioner.  Because it can gradually build up to toxic levels, patients must have the amount of lithium in their blood checked monthly.  These factors make it difficult to use lithium effectively with patients who are disorganized or impulsive, a frequent problem with bipolar disorder.  There are other mood stabilizers used for bipolar disorder, some of which have demonstrated their effectiveness—see the section on Medications for Depression [link].

In the past decade we began to see an increase in the number of adolescents and children, especially boys, diagnosed with bipolar disorder and treated with some of the newer mood stabilizers.  I strongly suspect that this trend was a result of Big Pharma promoting some of its new drugs for off-label uses in different populations.  There was no reason to suspect a genuine increase in incidence of this condition, and there was little evidence that the medication was effective.  If your child’s MD wants to prescribe Neurontin or Lamictal for his behavior problems, I strongly suggest you take your child to the best university psychiatric center in your area and get a thorough workup that considers depression, anxiety, learning difficulties, and attentional problems.

 

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