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What Bipolar Is (and What It Isn’t)
Bipolar Disorder, once commonly known as manic-depression, refers to a class of psychiatric disorders involving severe, intermittent mood swings. The word “bipolar” means “two poles.” Just as the North Pole and South Pole represent the furthest points on the globe, bipolar mood swings span the length of the emotional spectrum. While many of us can experience mood swings through our lives for a variety of reasons, Bipolar Disorder maintains a distinct quality in that the cycles of mania and depression can both present destructive consequences to the health and well-being of the individual.
Although we call Bipolar Disorder a “mental disorder,” its foundations appear mostly to be genetic (hereditary); that is, it begins in how the brain develops from the person’s genes located in cell DNA. It is nobody’s fault that someone has the foundations in place for Bipolar Disorder—it is not, for example, the direct result of bad parenting or a psychological trauma. Some researchers believe parts of the brain that typically regulate emotions in people are not designed well to the job in those with Bipolar Disorder. As an individual gets older, life presents various stressors and challenges, and the person’s brain has to find a way to deal with these problems. Depression and anxiety may be present very early in life, but we often see the symptoms of bipolar emerge in adolescence or early adulthood, with the average starting age at 20 years old. This usually happens because the rigors of developing into an individual, and all the added responsibilities that go into it, can trigger the person’s first “manic episode.” If that person has struggled with traumatic experiences, either in the present or earlier in life, then the symptoms can form sooner and/or more severely. So, Bipolar is genetic in its foundations, but life events can trigger the symptoms or serve to make them worse.
Much of what we use to diagnose Bipolar Disorder comes from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised (DSM-IV-TR) (1). Very soon, a fifth edition will be available to better clarify key concepts. The following is intended to break down clinical information to something that may look more familiar to the daily life of a bipolar person.
A person is typically diagnosed with Bipolar Disorder if he or she has had at least one definable manic episode in their lifetime, and the duration of the episode lasts at least one week (unless the person is treated in a hospital within that week). The manic person’s mood is often described as abnormally elevated, euphoric, or expansive; or it can be very irritable. Essentially, the mood state in mania can easily look like the person is on some kind mind-altering drug that makes them appear “high” or “cranked.” However, to have the correct diagnosis of a manic episode, it has to be clear that it is not a direct consequence of drugs, or another medical or psychiatric problem.
During the period of the manic mood state, three or more of the following must be present (or four if the mood is only irritable):
Inflated self-esteem or grandiosity. Individuals in a manic episode will often see themselves as far greater or more special than people around them. They may suddenly view themselves as incapable of defeat or free from negative consequences, as if they are “bullet-proof” from the world around them. They may also feel that they have a special purpose or message to send to the world. Those with psychotic features, which will be addressed later, may see themselves as a “messenger from God,” or have lost touch with their own sense of mortality.
Decreased need for sleep. This is different from what we usually think of as insomnia. Unlike patients with a form of sleep impairment, manic persons generally do not want to sleep; instead they desire to keep going with various tasks, some productive, some quite non-productive, and some that are ultimately destructive. Artists, composers, inventors and entertainers who have mania will often work themselves to exhaustion, but not until their manic phase is over. But even so, they will frequently defend their lack of sleep. They maybe heard saying, “I don’t need it. I feel great if I get just 2 hours!”
More talkative than usual, pressured speech or pressure to keep talking. Manic persons can be delightful, charming, annoying, bizarre or sometimes even scary when attempting to communicate with others. They are typically difficult to interrupt and can be tangential; that is, they can go on different subjects as if they are authorities on each one, but they often fail to talk succinctly and with purpose.
Flight of ideas or racing thoughts. Related to the above-described pressured speech, manic persons can go on and on with various and fragmented thoughts, more often feeling as if they are in a period of hyper-creativity. Sometimes, however, they will admit the constant barrage of thoughts can be overwhelming and debilitating. The difference usually relates to the type of mood they have in mania. With elevated or euphoric mania, individuals will revel in their thoughts, often believing that they can formulate new and powerful theories or wildly exciting accomplishments. With irritability, they may become frustrated with their own madness or with how others are easily “turned off” by their rants.
Distractibility. No matter how great their ideas or how goal-directed they may seem to be, they can still get easily distracted with unrelated things or actions in their environment. They may also become hyper-focused on a single thing, to the detriment of any other important task that actually needs to be completed. If successful manic persons cannot avoid becoming distracted at the height of their creative moments, they typically have others in their life work to compensate for their inability to get essential things done.
Increase in goal-directed activity or psychomotor agitation. This in effect separates manic thoughts and speech from actually doing things that are manic in action. Manic individuals can create intense and complex social situations entangling others in the process; become hyperactive in their jobs or school, or overextended with various responsibilities; or follow-though with poorly planned ideas. Psychomotor agitation refers to a significant type of physical restlessness that includes muscle tension or anxiety. Pacing, hand-wringing, and the inability to stay seated are some examples of what psychomotor agitation looks like.
Excessive involvement in pleasurable or risky behaviors that have a high potential for painful consequences. If there is one symptom of mania that will bring that greatest attention to the disorder and the need for treatment, it’s this one. Manic persons can often go on buying sprees or invest impulsively to the point of bankruptcy. They may go on alcoholic or drug binges, or act-out sexually through promiscuity or other risky indiscretions. They may also pursue any number of potentially harmful acts fulfilling the need for “an adrenaline rush.” Extreme irritability can result in hostile or even violent and destructive behaviors. In either case, there is an absence of any reasonable judgment or insight into the long-term effects of their decisions. The result of these actions can mean legal or medical emergencies, and frequently, broken relationships.
While the above helps define the manic episode, the depression end of the bipolar cycle can be even more devastating. Here, the mood is intensely sad, dark and overwhelming. Often the depressed bipolar is experiencing the painful effects of the manic episode, and the previously inflated self-esteem has now turned into shame and despair. Alcohol and drug abuse have turned away from a manic-style party, and more toward self-medication. Suicidal thoughts and self-harm, or the potential to harm others, are of great concern during this time. Sometimes when depressed bipolar persons are admitted to inpatient or outpatient treatment, their history of mania is not evident. They instead may be initially diagnosed with Major Depressive Disorder. Precise treatment choices require a full history to know if the patient is “coming down” from a manic episode, which could be many days, months, or even years in the making.
Types of Bipolar Disorder
There are four types of Bipolar Disorder: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Not Otherwise Specified (NOS). Bipolar I is marked by severe manic episodes, what people often call “full-blown” mania. This is generally believed to be the worst form of the disorder, and while it may be easier to diagnose than the other types, it is harder to treat over the course of the illness. The person with Bipolar I will suffer more extreme mood swings, and therefore will experience more consequences. They may have more opportunities available for treatment since the more severe level of the disorder tends to get more attention, but their consistent participation in care is more difficult to sustain.
Bipolar II is marked by manic episodes of less intensity, known as hypomania (literally “under mania”). The same manic symptoms may be present as in Bipolar I, but the hypomanic episode tends to last at least four days (instead of one week), and thus can do somewhat less damage to the individual’s life, at least in shorter-term. The depressive episodes, however, can be just as severe as in Bipolar I. Moreover, those with hypomanic episodes are harder to diagnose as such, because they may be viewed as simply active people who got too stressed out with life, or perhaps have another kind of mental health issue, such as anxiety or a personality disorder. Treatment is somewhat easier with hypomania compared to full-blown mania. However, because Bipolar II persons are often highly productive and more “functional” than in Bipolar I, they may not find the idea of mood regulation always to their benefit. People around the Bipolar II person would tend to disagree. The hypomanic episode represents a definite change in the person’s behavior compared to when there is no hypomania (or depression), and their daily life functioning is typically impaired as a result.
Cyclothymia literally means “cycling emotions.” This form of bipolar is marked by less severe, but more frequent changes in mood, and forms a chronic, consistent pattern that lasts at least two years. Bipolar Not Otherwise Specified (NOS) is simply a diagnosis a clinician can use if there isn’t enough information available to make a clear distinction among the other types of bipolar.
There are also several subtypes for more precise diagnosing. “Mixed episode” and “rapid cycling” are examples that help to define some of the variations of how bipolar persons can experience their emotional changes. In some cases, a bipolar person can become psychotic when either manic or depressed. A loss of one’s sense of reality can include delusional thinking, paranoia, or hallucinations.
Why Bipolar Disorder is difficult to diagnose
When students of the mental health professions are preparing for their careers, they learn the importance of what is called differential diagnosis. After they become practicing clinicians, they must spend the rest of their careers perfecting this skill. Differential diagnosis refers to the logical process necessary to separate one mental disorder from another, especially when different disorders share some of the same psychiatric symptoms. This is quite important with Bipolar Disorder, which can be misdiagnosed or confused with other similar disorders.
As mentioned earlier, a history of at least one manic or hypomanic episode is all it takes to assign a Bipolar Disorder diagnosis. When a person presents to a mental health professional in a depressed state, it is necessary for the clinician to know that history. If the question isn’t asked about mania, the patient fails to mention it, or the patient just doesn’t realize what mania is, then typically only a diagnosis of Major Depression is made. This is important since certain medications for depression, when taken alone, could force a manic episode, making the entire condition worse.
Another common problem is found in differentiating Bipolar Disorder with Attention Deficit Hyperactivity Disorder (ADHD). Distractibility, increased activity, agitation and hyper-focus are attributes usually found in both disorders. ADHD also has an “inattentive type” qualifier that applies to people who consistently cannot focus on topics in school or work, but show no significant signs of hyperactivity. However, they may exhibit anxiety that can be mistaken for bipolar-like agitation.
Bipolar and ADHD are frequently confused for each other, especially in adolescents. In fact, an adolescent could also be suffering from a Major Depression or an anxiety disorder, but their agitation and excessive emotional upset can result in acting-out behaviors that appear manic or hyperactive as in ADHD. Generally, adults are easier to diagnose for these and some other mental disorders, therefore a mental health professional or medical provider who specializes in children and teenagers is preferred to better differentiate these separate problems.
There are other disorders that have some similarities to Bipolar, as well. One is Obsessive Compulsive Disorder (OCD), which is an anxiety disorder involving frequent and intrusive repetitive thoughts (obsessions) and/or behaviors (compulsions). The fundamental aspect of this disorder is that OCD persons are attempting to stave off intense anxiety or fears, which are usually irrational or unconscious. They eventually realize that the recurrent thoughts and actions are creating greater problems in their lives, but cannot by will alone stop OCD symptoms, which will in time come to overwhelm them. People with entrenched, persistent compulsions can go about these behaviors in a ritualize manner that requires considerable drive and energy. Thus, compulsive behaviors can appear to be manic in nature, particular if the compulsions keep a person completely occupied through day and night. Like Major Depression, OCD is often treated with antidepressant medications, which by itself can induce mania in people who actually have Bipolar Disorder instead.
Some personality disorders also mimic signs of mania. Personality disorders are sometimes referred to as characterological disorders because they reflect severe and pervasive impairments in the individual’s psychological or moral disposition. Among all personality disorders, borderline, narcissistic, and antisocial personality disorders can have some of the closest similarities to bipolar mania.
Borderline persons can typically display stark emotional changes, turbulent relationship patterns, and irresponsible or risky personal behaviors. A key component of borderline personality is known as idealization/devaluation, or “splitting.” This means that a borderline person can idealize another person in a relationship (including a therapist during the course of therapy), as if that person is “all good,” or a “perfect soul mate.” Later, and usually without much real provocation, that same person that was regarded as amazingly terrific, will be devalued as “all bad,” or “useless.” These harsh instabilities in mood, relationships and social behavior can at times look manic, and differentiation is further complicated by the fact that borderlines can suffer severe depression with suicidal thoughts and actions, much in the way bipolar persons can.
Narcissistic personality disorder is marked by inflated self-esteem, grandiose self-regard and unrealistic standards about love and achievement. Again, these features can appear to be manic, especially if narcissistic persons experience personal frustration, because they can often respond with high levels of irritability and anger. Both borderlines and narcissists have low frustration tolerance, and they tend to externalize blame for their own life failures.
Antisocial personality disorder includes not only severe impairments in personal relationships, but also a callous disregard for rules, laws and social norms. Antisocial activity often results in constant run-ins with authority figures, just as manic persons can with irresponsible behaviors associated with mania. One of the inevitable questions is how the criminal justice system handles individuals who violate the law as a result of uncontrolled manic behavior, but who may otherwise desire to live as productive, law-abiding citizens.
This is not to say that both Bipolar Disorder and a personality disorder cannot coexist in the same person. They sometimes do, but too often, one is mistaken for the other, and that can result in delayed or ineffective treatment approaches.
Schizophrenia is a psychotic disorder that involves persistent delusional or disorganized thinking, and frequently is marked by hallucinations, mostly auditory (“hearing voices”). Delusions are false beliefs that reflect a gross absence of reality, and can often have wild, paranoid features. Some people with severe Bipolar I can experience similar Schizophrenic-like symptoms, either in the manic phase or in the depressed phase. As one might image, the type of delusion psychotic bipolar persons may have will likely follow which phase they are in. Delusions in the depressed phase can be dreadful, persecutory and filled with self-hatred. Manic delusions are spectacular, often replete with fantasies of stardom, glory and demagoguery. These are both referred to as mood-congruent delusions, since the content of the delusion matches the emotional state. Typically, there are no psychotic symptoms evident if they are in an in-between state, that is, neither manic nor depressed. Schizophrenics, however, rarely have vast mood changes or an abatement of psychotic symptoms along with a mood changes as one sees in Bipolar Disorder.
Substance Abuse occurs frequently with Bipolar Disorder, and can often make existing symptoms worse. Diagnosing Bipolar as separate from drug and alcohol abuse can be difficult since it is important to know which problem came first, or figuring out which is the main problem that may be driving the other. This is particularly true when it comes to severe stimulant abuse with drugs like methamphetamine and cocaine. These drugs can induce intense euphoria followed by grandiose feelings, pressured speech and flight of ideas. These are highly addictive substances that can over time also produce paranoia and psychotic symptoms. Alcohol is the more commonly used and abused drug, which can increase irritability, hostility, and even violent thoughts and actions. Frequently abusing alcohol to quell agitation or lift depressed mood can also lead to dependency.
Several other medical disorders can likewise mimic bipolar symptoms. For that reason, a complete medical work-up should be performed once a preliminary diagnosis of Bipolar Disorder is made. A history of thyroid imbalances (hypothyroidism or hyperthyroidism) could preclude a diagnosis of bipolar. Post partum hormonal imbalances in new mothers can induce any number of psychiatric problems, including Bipolar. Traumatic brain injury, seizure disorders and tumors can also cause a bipolar-type presentation in those with primary neurological disorders. Since Bipolar Disorder typically emerges early in life, older persons who show symptoms for the first time, especially if they have a significant history of good mental health, suggest a distinct underlying medical cause for their psychiatric symptoms.
There are different assessment methods available to establish a good diagnosis, and sometimes even an additional opinion from a different mental health professional will help to fully support a diagnosis of bipolar, or rule out that diagnosis if appropriate. Many patients and their families have gone through several professionals, different therapies or hospitalizations without success because a clear diagnosis was not made in the first place. With the proper knowledge of bipolar symptoms and the ability to differentiate from other psychiatric problems, a precise assessment will represent a good start in forming a viable treatment plan. But while everyone needs a good start, bigger complications for the bipolar patient and the family are right around the corner.
(1) 1994, American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision