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The Complex Interaction of Brain Chemicals

Your ability to adaptively control strong emotions relies on a very complex interaction of brain chemicals operating to regulate the millions of nerve cells in a part of the brain called the limbic system (also commonly referred to as the emotional brain). The limbic system and a closely related brain structure, the hypothalamus, are responsible for igniting appropriate emotional reactions (for example, the fight-or-flight response); for maintaining some degree of control, which is necessary for clear and adaptive thinking; and for getting the brain and body back into a state of homeostasis once the stressful circumstances have subsided. In addition, these brain structures also influence a number of biological functions such as sleep, appetite, sex drive, physical and mental energy, and activity levels.

To carry out these necessary functions, the brain must maintain a delicate balance of neurochemicals - most notably serotonin, norepinephrine, glutamate, GABA, and dopamine. A good analogy is that the brain is like a thermostat in your home. There is a comfort range set on most thermostats. The built-in thermometer in the thermostat is constantly monitoring the temperature in the room. If the temperature rises above a certain point, the air conditioner automatically turns on. If it falls below a particular temperature, the furnace comes on. Such automatic monitoring and fine-tuned adjustments also are constantly at work within the brain, to maintain a relative emotional comfort zone.

Your Thermostat Is Broken

The problem for people with bipolar disorder is that the thermostat in the brain doesn't always do its job correctly. Medical research has clearly documented that bipolar disorder involves a biologically based impaired ability to effectively regulate intense emotions - just like a broken thermostat that can't monitor the temperature correctly. There is nothing wrong with you psychologically; instead, there is something wrong with your brain's neurochemistry.

Your Brain Is Very Sensitive

Because your brain doesn't function as a normal brain should, outside events and your own behaviors can lead to serious mood swings. Sleep deprivation or disruption is a notorious trigger for bipolar mood swings, as are other factors that can significantly alter hormonal functioning and brain chemistry. Stressful life events can provoke shifts into overwhelming states of mania or depression. And even in the absence of specific stressors, abnormal neurochemical functioning in the limbic system can, at times, spontaneously provoke the emergence of intense mood swings, like a thermostat that for no apparent reason turns on the furnace, even though the house is already warm. This explains why you can't by willpower alone just get a handle on your emotions.

Medications are designed to regulate your emotions and get your brain back on track so that it can respond correctly to life events. It's not the goal of medications to take away your creativity, numb you to the reality of life, or change your personality. They are simply meant to regulate your brain thermostat so that it can work correctly. Understanding and appreciating the biological basis of bipolar disorder is critical for those with the illness and for family members and close friends. As you will read in this book, a number of very effective strategies can help to stabilize and normalize brain chemistry for people suffering from bipolar disorder, and certain psychiatric medications are the most direct and powerful way to accomplish this.

Cortisol: The Stress Hormone Unless bipolar disorder is well controlled, most people suffering from this illness will spend many, many months in episodes of depression. One very significant health consequence of untreated depression is an extreme elevation of the stress hormone cortisol. Cortisol is normally not at all dangerous to the body, but the exposure to prolonged elevations seen in severe depression is considered to be toxic and to influence general health. High, sustained levels of cortisol damage the interior walls of blood vessels. This eventually can lead to artery disease and a very significant increased risk of strokes and heart disease. Death rates from heart attacks among people with poorly controlled depression are twice those seen in age-matched adults without bipolar disorder. High cortisol also has a significant impact on the immune system, resulting in a weakened ability to fight diseases. Rates of death due to infectious diseases are two to three times higher in people experiencing prolonged periods of depression. Finally, high cortisol levels also reduce the release of growth hormone. This greatly contributes to an increased risk of developing osteoporosis. Effective medication treatments for bipolar disorder not only target devastating mood swings, but also can contribute significantly to lowering risks for these serious medical disorders.

Knowing Your Current Medication Options

The choice of medications used to treat bipolar disorder depends on the mood state you're currently experiencing - mania, depression, or another major symptom such as psychosis or anxiety. In addition, medication choices always must take into consideration the ultimate goal of preventing recurrences.

Currently, there are eleven medications approved by the Food and Drug Administration (FDA) for the treatment of bipolar disorder: lithium, Thorazine, Risperdal, Seroquel, Geodon, Abilify, Equetro, Symbyax, Depakote, Lamictal, and Zyprexa. However, a number of other highly effective drugs are in common use. The use of medications not approved by the FDA for the treatment of certain conditions is referred to as off-label use; it must be emphasized that off-label use of medications is very common in every branch of medicine.

Why So Many Pills for One Illness?

Recent surveys reveal that in the United States, only 11 percent of people being treated for bipolar disorder take just a single drug (called monotherapy). On average, most people being treated for bipolar disorder take three or four medications simultaneously. The reason for this is simple: Medication combinations are often necessary to adequately treat the wide array of symptoms seen in this illness.

What to Expect from Medication Treatment

Bipolar disorder is like a number of other chronic medical conditions, such as diabetes, asthma, or arthritis. It's not a condition that can be cured by currently available medications. However, the medications discussed later in this chapter are effective in relieving many of the more serious symptoms of bipolar disorder and often can reduce the frequency of mood episodes for most people, if they receive appropriate treatment.

With aggressive, appropriate, and ongoing medication treatment, which is started during the first or second mood episode, about 30 percent of people do not experience severe recurrences.1 Thus, in about one out of five people, the medications are highly successful in preventing significant relapses (as long as people continue to take them). This of course leads to the question: What about the other 80 percent of people with bipolar disorder, especially those who go through many episodes before being adequately diagnosed and treated? The facts are that when people do not receive effective medication treatment during the first several episodes of bipolar disorder or are given the wrong medications because they have been misdiagnosed, medication outcomes are not as positive as they are for those who receive the correct treatment during the first episode. Certainly in the case of people who are diagnosed later than the first or second episode, many people do respond to medication treatments, but delays in getting treatment can make it more challenging to successfully control the disorder. Still, people can find significant relief. Even after starting medication treatment after the first or second mood swing, the recurrence rates for severe episodes can be reduced by about 75 percent, and hospitalizations can often be avoided when the correct medications are used. Subsequent episodes that do occur tend to be milder (as opposed to severe) depressions and hypomanias.2 These statistics show that medications work in preventing serious bipolar disorder relapses, but they are far from perfect. And, as mentioned in this chapter, it may take quite awhile to find the right combination.

Hazel's Story Age 46 I've never seen anything like the difference in my daughter since she started medications. She was manic from the time she was sixteen. In fact she was out of control and living on the streets for a while. She got in trouble with drugs and when the police found her purse on the roof of a drug house, they found her and took her to the station for questioning. It was the best thing that ever happened to her. She was clearly manic and they put her in seventy-two-hour observation where she received medications and took them for the first time in her life. About the third week she was there, I walked in and she said, "Hi, Mom." And I could tell I had my daughter back. It was like someone was in her body for all of those years. I know it's an illness and it was never her fault, but I get so angry for the lost years. Then I remind myself that she's back. I think she was just finally old enough to see where her life would be without medications. She works now and has a family. She still gets mood swings, but they are nothing like they were before medications - we can deal with them as a family now that we have a treatment plan for the tough times.

Copyright © 2006 by Julie A. Fast and John Preston, PsyD.

About the Author

Julie A. Fast is the founder of Bipolar Happens, a popular online resource, and lives in Portland, Oregon.

John Preston, Psy.D., is a board certified neuropsychologist and lives in Shingle Springs, California.