What is bipolar disorder?

Coping with Bipolar Disorder
by Steven Jones, Ph.D., Peter Hayward, Ph.D., Dominic Lam, Ph.D.

Coping with Bipolar Disorder is designed specifically for sufferers or bipolar disorder, their carers, friends and family. It combines definitive coverage of the condition and information about treatment, with a new approach which encourages patients to manage their own psychological health using cognitive behaviour therapy, as well as the more traditional medication regimes. The result is a straightforward and readable book which will empower sufferers, in addition to giving them necessary advice on such key areas as sleep habits, coping with stress and anger, and relating to family and friends.

• authors draw widely on case studies, and on their own therapeutic work with clients

• one of the few books in this area to reveal that the individual living with bipolar disorder can play a key part in managing their own psychological health

Introduction

This book is intended to provide information for people who are experiencing bipolar disorder, along with their relatives, friends and other interested lay people. Bipolar disorder is the term that is now used to describe what was formerly known as manic depressive illness. The focus of this book will be on providing useful information about the nature of this illness and its treatment. This information will include both traditional treatment approaches and more recently developed psychological treatments. It is not the intention of this book to imply that people with illness should treat themselves, but rather that by having access to relevant information they can take an active and influential role in the course of their own treatment. As authors we have both clinical and research experience that attests to the usefulness of psychological approaches to bipolar disorder. We are also well aware that at present these are most effective when used in combination with more traditional forms of psychiatric treatment, in particular with appropriate forms of medication.

How common is it?

Bipolar disorder is not uncommon. Around 1-1.5% of the -population in both Britain and the United States are expected to be suffering from bipolar disorder at any time. This translates to around one in every hundred people having a form of bipolar disorder that would be recognised by psychiatrists. This figure alone indicates that a large number of people are living with bipolar disorder and this does not take account of milder forms of mood difficulties that would not be diagnosed as bipolar disorder but could still cause significant problems for the sufferer. This includes cyclothymic disorder, in which the individual tends to experience relatively frequent changes of mood (both elevated and depressed) but in which no single episode is so severe as to require a clinical diagnosis of mania or depression.

Symptoms of bipolar disorder

It is important to note first that in the press and elsewhere there is at times confusion between bipolar disorder and other psychiatric disorders, such as schizophrenia or personality problems. In actual fact the symptoms that identify bipolar disorder are quite specific. Bipolar disorder is a severe form of mood disorder during the course of which the sufferer experiences both extremes (low and high) of mood. Extreme low mood is diagnosed as depression. There are several different means by which a clinician can diagnose clinical depression, but all these means of diagnosis identify certain essential symptoms.

Depression is characterised by persistent low mood and loss of interest in previously valued activities. Sleep is often disturbed, as is weight, and both can either increase or decrease when someone is depressed. Feeling extremely tired is common as are feeling either very slowed down or very keyed up. People will commonly feel guilty for no good reason when depressed and tend to be extremely critical of themselves. Thinking can feel difficult and attending even to quite straightforward tasks can seem to be a great burden. Thoughts of ending life or of wishing no longer to be alive can also occur.

It should be emphasised that people with depression differ substantially. Just as people are individual in the absence of mood disorder, so they are when they experience psychological distress. Whilst one person may feel agitated, guilty and indecisive, someone else may feel exhausted, slowed down and constantly in need of sleep. These symptoms need also to be present for a significant period of time, at least a couple of weeks, so that someone feeling depressed for a day or two even if they felt very low would not normally be diagnosed with depression if the problem then resolved or significantly improved. Clearly, everyone experiences mood changes and experiencing a significantly low mood is a common experience. It is the severity, duration and extent of impact of symptoms that differentiates clinical depression from 'feeling depressed'. Following is an example of depression.

Laverne currently suffers from depression. She is now forty-one years old. She had two episodes of mania in her early twenties, but none recently. Her main problem is that her mood is low and negative most of the time. She has raised her daughter alone, in spite of her mental health problems, and her daughter as a young adult is now attending college and doing well. Laverne is, however, very critical of herself. She sees herself as a failure and struggles to maintain employment as a cleaner. She thinks a lot about what she sees as her own shortcomings. She has described herself as 'Jonah, cursed by fate'.

Mania is usually thought of as being the polar opposite of depression. However, this is not entirely accurate. Whilst some people with mania can indeed feel elated or very happy, it is not necessarily the case and irritability or short temperedness are common.

Common symptoms of mania include feeling oneself to be superior to others; this can be intellectually, physically, in appearance or in terms of specific talents. People during mania often need less sleep and sometimes might go for days at a time without sleeping. There is usually a tendency to be more talkative than usual and to speak more rapidly. The listener can therefore sometimes feel bombarded by the rate, volume and length of conversation of someone in a manic phase. Ideas will often seem to appear one on top of another, cascading out in speech that can then be hard to follow as the person with mania struggles to keep up with the rate of different and divergent thoughts that they want to express. Intense interest in work, hobbies or new projects may become apparent - working excessive hours without rest or sleep in following up a big idea. Because of the person's often high self-esteem during this phase there will be a tendency to continue putting effort into plans even when others reject and try to dissuade the person from engaging in them. The smallest element of praise can at this stage be interpreted as a ringing endorsement. When in a manic phase concentration can be poor because of easy distraction by other things. There is also an increased danger of engaging in risk-taking activities when in the manic phase. These might involve increases in sexual promiscuity, thrill seeking, drug or alcohol use. Often this pattern will be grossly outside the person's 'normal' character.

Again, this is a pattern that needs to be present at a severe level for a significant period of time (at least a week) before a clinical diagnosis of mania can be made. As with depression, there is great individual variation. Some people will seem to have some elements of the above symptoms as part of their 'normal' character and therefore the manic phase is merely an extreme variation on this pattern. However, for other people the manic phase will involve behaviour and actions that appear entirely foreign to them when the phase has passed. One person might therefore experience a manic phase in which mood is elated andthey are carried away with a sense of their own inspiration and superiority, which feels initially very positive but becomes less so as acting in an impulsive manner starts to cause practical problems. Another person might experience mania as being associated with high, and therefore unpleasant, levels of irritability and agitation, in which talk is very rapid, many conflicting ideas are present at the same time and it is very hard to accomplish any tasks because of this combination of other symptoms. In the following example Donald shows, psychotic symptoms.

Donald is thirty-two and lives with his parents. He has been in hospital four times because of episodes of mania. The first occasion was as a student. Having been quite shy at home, he became more sociable and outgoing at university. He found his first girlfriend, started drinking and began to use cannabis. His mood became more expansive as the first year continued and he began to sleep less and less. He started to tell his friends that he was 'inspired' as a writer and had a great future. Over time both his writing and his speech became more rambling and incoherent and friends and family found him increasingly difficult to understand. He noticed that he had brilliant ideas that came into his head so fast that he couldn't follow them. Towards the end of his first year at university he was found wandering around the campus and talking incoherently. He was admitted to hospital at this point and treated with anti-psychotic medication and lithium.

Psychotic symptoms can occur in either depressed or manic states. The main psychotic symptoms that a person might experience are delusions or hallucinations. A delusion is a strongly held belief in something as a fact despite the clear presence of evidence indicating that it is not true. Hallucinations are the experiences of seeing, hearing, touching or smelling something when there is nothing there. Most common are auditory and then visual hallucinations. The following is an example of a delusional belief.

In her early twenties Laverne was admitted to hospital twice with manic episodes: during these episodes she believed that spirits were possessing her (a delusional belief). She slept very little and would stay up late at night listening to music and finding 'spiritual' meanings in lyrics to pop songs.

An additional feature of bipolar disorder is hypomania. People who experience hypomania will, as with mania, experience elevated mood, often increased self-esteem and greater sociability. Thoughts and speech may come more rapidly and risky behaviour (sexual, drug taking or other stimulation seeking) may increase. It is different from mania in that there are no associated psychotic symptoms and changes in hypomania will be less severe. Many people have experienced brief periods of hypomania as a positive state in which they have been creative and productive. However, as it persists there are substantial risks of the state worsening into depression or a full mania, as the following example demonstrates.

Melissa is twenty-eight years old and works in advertising. Her mood fluctuated in her teens and early twenties, generally between periods of low mood in winter and feeling energised, creative and sociable in summer. During one of these 'up' periods she ran up big debts on her credit cards. She allowed herself to be picked up by three men during this period and found herself involved in group sex. She found this degrading and upsetting and a period of low mood followed. Memories of this incident continued to trouble her for years after the event.

Causes

Bipolar disorder has a history of being seen as a clear example of a biological form of mental illness, that is, a disorder in which there is a medical brain problem that is in need of medical treatment to return the person to health. As will be described in more detail below, there is evidence that bipolar disorder can be inherited and also that there are important biological factors involved in developing this disorder. However, it is also clear that the relationship between inheritance, biology and bipolar disorder is far from being a simple one. In fact, there is additional evidence that experiences that individuals have in their lives, how they respond to such experiences and their general patterns of thoughts, feelings and relationships are also important factors in whether or not bipolar disorder might develop. The possible role for each of these factors is discussed below.

Genetic

The first genetic evidence came from studies into the extent to which bipolar disorder (then known as manic depression) ran in families. It was found that although not everyone with this disorder had relatives with a similar illness, many people seemed to. Overall, estimates seemed to indicate that if a person had bipolar disorder, there was approximately a 13% chance of that person having a relative with depression and a 7% chance of him or her having a relative with bipolar disorder. However, it is worth considering that this also means that the chances of a person with bipolar disorder not having a relative with either disorder are vastly higher (87% and 93% respectively). Even when studies have been undertaken of twins who share identical genes (monozygotic twins), the chances of the second twin having bipolar disorder if the first was a sufferer were not 100%. Around 67% of twin pairs who shared the same genes had bipolar disorder in both twins. This means that 33% of such twins did not share bipolar disorder in spite of being genetically identical.

Evidence to date does indicate that genes have a role in bipolar disorder. It is, however, also the case that many people with this diagnosis have no family history of this form of illness and, furthermore, many people with bipolar disorder go on to have children who are well. Therefore, the effects of genes on illness are complex and combine with many other different factors to determine whether or not a particular individual goes on to develop the illness itself. Recent information from the mapping of the human genome provided interesting evidence that the number of different genes in the human genome was much lower than that expected. Indeed, the figure reported was not substantially higher than that of lower mammals. This has been interpreted by geneticists as indicating that experiences after birth must have a greater impact in generating the diversity in human beings than had previously been supposed by scientists who were investigating primarily the biological and genetic elements of human functioning.

Organic

As bipolar disorder can involve many areas of human functioning, and also since there is evidence that drug treatments are effective for many people with bipolar disorder, a lot of research effort has gone into the investigation of possible abnormalities in brain function of people with bipolar disorder. Although there have been a number of studies that have seemed to show differences in brain chemistry between people with bipolar disorder and other groups, findings are not consistent. Also, there is at present insufficient evidence to link any one specific abnormality to the features of the disorder itself. For instance, the finding that the depressive phase of bipolar disorder is improved by medication, which increases the brain chemical serotonin, does not necessarily mean that reduced levels of the same chemical caused the original depression.

If brain differences are finally established, they will have to be consistent with the fluctuating patterns of bipolar disorder and take account of both extremes of mood evident in this illness. It is likely that any brain abnormalities (if present at all) will be found in the interactions between structures involved in integrating and organising different brain functions.

Environmental

If genes or biology were the only factors that influenced bipolar disorder, then the experiences a person has in life should not affect whether he or she develops the disorder or becomes ill again subsequently (relapses). However, there is clear evidence that in the period leading up to first becoming ill people will often have experienced significant changes or problems in their lives. The level of these problems will usually be higher than those experienced by people who do not become ill. Once a person has received the initial diagnosis of bipolar disorder, further periods of ill health will again often be preceded by difficulties in the period leading up to ill health recurring. In the past, there had been suggestions that this apparent relationship between people's experiences and their subsequent mood problems was misleading. It had been argued that this association just reflected the fact that people were beginning to become unwell and their behaviour was then responsible for causing difficulties in every day life. Researchers, working first in the area of depression and later looking at bipolar disorder, have therefore distinguished between events that could be described as dependent (caused by the person) and those that are independent (not under the control of the individual). An example might serve to illustrate this distinction:

If a person lost his or her job in the weeks leading up to an episode of illness, then this would be a dependent event if it were the result of the person's increasingly erratic behaviour. However, it would be an independent event if it followed satisfactory job performance and the firm the person worked for was in the process of reducing its workforce for economic reasons.

When this distinction is made and researchers have looked at how many independent life events occur prior to a period of illness, they do seem to be more frequent than in periods of good health for an individual, or for comparison groups who do not become ill. Therefore, the experiences people have do appear to have a potential impact on their mental health and this cannot be solely explained by a person's own behaviour being affected by the early stages of illness.

Personality

There is no single type of person who develops bipolar disorder. However, there are certainly a number of people with high levels of motivation towards achievement and significant levels of perfectionism who suffer from bipolar disorder. Of course, there are also many people with the same characteristics who remain psychologically well. People with a history of fluctuating mood, variable enthusiasms and periods of despondency are said to have a cyclothymic personality. There is evidence that people with this type of personality are at increased risk of going on to develop bipolar disorder. However, it should again be made clear that many people who go on to develop this disorder will not have had such a personality prior to its onset.

Course of illness

Age of onset

Bipolar disorder seems usually to be first diagnosed when the person affected is in the later teenage or early adult years. One major review of age of onset suggested that the highest risk period is in people between fifteen and twenty-four years. This is an illness that often begins in early adulthood, although it can occur at any stage of adult life.

What can cause episodes of illness?

There are numerous possible causes for episodes of illness. As noted above, the experiences a person has can be associated with periods of either depression or mania. These can be positive or negative experiences, but are characterised by having a significant level of impact on the person's functioning. Thus, the birth of a child might generally be regarded as a positive event, but sometimes the associated strain of changing roles, lack of sleep and possible additional financial burdens could be associated with increasing levels of stress. This could in due course be associated with illness in someone with a sensitivity to bipolar disorder.

It seems that people with bipolar disorder can if anything become more sensitive to such experiences as they get older. Poor sleep, alcohol and drug use, and erratic work and social routines are all possible factors in the occurrence and reappearance of bipolar symptoms. Our research and clinical experience indicates that individuals with a diagnosis of bipolar disorder can identify experiences that might cause them health problems and can develop skills to avoid such situations. When avoidance is either not possible or not appropriate, then people can learn to take steps to protect themselves at an early stage from the consequences of such situations.

Social and personal costs of bipolar disorder

In the past, there was a tendency to describe bipolar disorder in relatively benign terms. There was an assumption that although specific episodes of depression or mania could be severe, they were also time-limited. Furthermore, and in contrast to views about schizophrenia for instance, it was assumed that people were actually quite well in between the episodes that brought them to the attention of psychiatric services.

More recent work has, however, indicated that although some people do indeed cope very well with their lives for the vast majority of the time, there are a lot of people who have to cope with significant levels of symptoms even when they are 'well'. That is, many people do not have sufficient symptoms to be said to be clinically depressed or manic but may at the same time have combinations of symptoms that serve to make day-to-day life very difficult. Indeed, an American survey suggested that on average a person with bipolar disorder could expect to lose nine years of life, fourteen years of effective activity and twelve years of normal health. These figures are quoted to emphasise the seriousness of the problem that people with this diagnosis have to deal with. It also shows that there are likely to be important gains to be made for clients who are offered appropriate support and treatment in between episodes as well as when they are clinically depressed or manic.

Possible outcomes

Outcomes can vary widely for people with bipolar disorder. For some people, there will be a small number of episodes at a particular period in their lives and then little impact subsequently. For others, there will be some periods when the illness dominates and other periods when it recedes.

Creativity and bipolar disorder

One of the problems that some people with bipolar disorder describe is that clinicians seem to focus their concern on their highs or manic periods but apparently put less therapeutic effort into helping them with their lows. Whether or not this is always an accurate perception, it highlights an important point. For many people with bipolar disorder, the periods of being manic can be relatively infrequent, or at least short lived, whereas the periods of depression can be more sustained and are often reported as being more painful to the individual.

In between these two extremes is the experience of elevated mood, which is associated with increased levels of mental and physical activity, greater confidence and sociability but which has not developed into mania. People with bipolar disorder often regard this intermediate state of hypomania very positively. During these phases, people will often recall having periods of great creativity either at work or at home and of finding life in general thoroughly enjoyable. Although there is often an awareness that these periods will commonly tip over into a clinical state, it is not uncommon for an individual to aspire to a position in which he or she is able to 'handle' these periods in such a way as to be sustained without becoming ill. Unfortunately, the life histories of many people who have striven to maintain these hypomanic periods at a manageable level show that this is very difficult to achieve.

There is good evidence that many creative people throughout history have had experience of bipolar disorder, including eminent academics, artists, writers, poets and actors. Indeed, the author and psychologist Kay Redfield Jamison, who has written openly about her own experience of bipolar disorder, wrote thatshe could recall having produced substantial portions of herearly work in hypomanic periods. Although she -acknowledged the positive side of this, she also identified that the costs increased in terms of further psychiatric episodes and that she has subsequently employed a combination of psychology and drug treatments to maintain mood stability to avoid these costs.

Points Covered In This Chapter

1. Bipolar disorder is found in around one in a hundred people at any one time.

2. Symptoms of bipolar disorder include symptoms of both depression (low mood) and mania (elevated mood)..

3. Genes can have a role in bipolar disorder, but even people with exactly the same genes do not necessarily all develop the illness..

4. No single specific brain abnormality has been clearly identified in bipolar disorder..

5. Environment and life events (in effect, the experiences that a person has) seem to be important in the development of bipolar disorder..

6. Social and personal costs of bipolar disorder can be severe, but appropriate treatment can improve these outcomes..

7. Periods of increased creativity can occur for some people in hypomania. The costs of trying to maintain this state can be high as, for many people, mania soon develops, often followed by painful periods of depression.

About the Author

Steven Jones is Senior Lecturer in Clinical Psychology at the University of Manchester in England.

Peter Hayward works at the Institute of Psychiatry in London.

Dominic Lam is a Senior Lecturer in Clinical Psychology at the Institute of Psychiatry.