Understanding Bipolar Disorder
What Is (and Isn’t) Bipolar Disorder?
Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.
I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do.
—Kay Redfield Jamison, PhD
Kay Redfield Jamison, who writes eloquently about her experience with bipolar disorder, credits others with helping sustain her. She knows very well that bipolar disorder doesn’t affect only one person and is best managed by two or more people working together. Let’s listen to the voices of people who are living with people with bipolar disorder:
My husband, Ryan, is manic-depressive, although I didn’t know that when we got married. I thought he was just moody, and—I can’t believe this—I thought it was kind of attractive; he was unpredictable and mysterious, like a romantic poet. But the poetry became work. And that’s not even his depression phase—that’s his manic mood! A lot of people think the manic side is happy. But his shrink told me that mania doesn’t always look “happy, happy, happy.” More often than not, it’s irritability that explodes into rage. Great, right?
—Jane Pastalouchi, Des Moines
When my ex-girlfriend told me she was manic, I said, “No, you’re totally out of control.” And she was! In the summer especially, she could never sleep. So she’d spend hours rollerblading—in the dark! Then I couldn’t sleep because I was worried she’d fall and break something, or be attacked by someone less innocently out at night.
—Harold Goldstein, New York City
Jeff was hilarious—a really great guy to be around. He was so funny and so handsome—when we got dressed for a party, he was almost shiny, like a celebrity. He was kind of famous, actually—a pretty well-known photographer, and his output was phenomenal. But then, over the course of a week or so, he’d spiral down. The bottom would just drop out. He’d get so low he was unrecognizable, almost. He stopped working, shaving, bathing, even talking . . . he wouldn’t change his clothes. He looked like a homeless person. Our kids thought it was like having two dads, and pretended it was funny, but it wasn’t. Now, when my teenage grandson goes radio silent and shuts himself in his room, I wonder if it’s happening all over again . . .
—Helen Watchover, Los Angeles
My wife seemed fine. She was great with our kids—lunches, school, homework. And I really depended on her to do that. Didn’t think twice about it. When she was stressed, she’d cry a lot, but then she’d snap out of it, and she seemed really happy again—baking cookies, cleaning the house from top to bottom, cutting out a million coupons—the whole Mom thing. She went to therapy, sure, but who doesn’t? Then one night before dinner she told me she wanted to die. She had it all planned out. I got really scared and called her therapist, he had her come in, and the next thing I knew she was hospitalized. Now she’s on some kind of medication, and she seems pretty even, but sometimes I get scared that she’ll stop taking it and want to kill herself again.
—Michael Jetter, St. Louis
Does any of this sound familiar?
If your partner or loved one is bipolar, you have your own stories to tell. You may be lucky enough to have found someone who’ll listen, or you may feel too embarrassed and just hope the problem will go away. This suppression can make you feel isolated and alone. But although you may often feel isolated, you—and your partner—are far from alone.
Bipolar disorder—or more accurately disorders, as there are multiple types—is an often misunderstood and misdiagnosed group of illnesses believed, conservatively, to affect more than five million American adults. The National Alliance on Mental Illness, considering all of the bipolar and related disorders, puts the figure closer to ten million.
To give you some perspective on this number, approximately 2.2 million people over eighteen in the United States are thought to suffer from obsessive-compulsive disorder; 2.4 million from schizophrenia, 4.5 million from Alzheimer’s disease; and about 18 million from diabetes. So yes, by any standard, there are a lot of people living with bipolar illness, and many more who are living with these folks.
What is bipolar disorder? Well, first, its name comes from its most obvious characteristic: people with bipolar disorder tend to experience extreme, polar opposite states of mood. They can be exceptionally high, or “manic,” at one time, then exceptionally low, or “depressed,” at other times. Although there is much more to BD, as you will see, the extreme moods are what people note most often.
As to cause, bipolar disorder is not your partner’s “fault”: it is a brain condition. It does not happen because of upbringing, although it can be triggered or worsened by physical or emotional trauma or extreme stress. (The same is true of many medical conditions, such as high blood pressure.) It does not happen because your partner wants it to, either.
Although it may not be chronic (meaning symptoms never go away), it is usually recurrent (that is, symptoms keep returning), and some symptoms can linger, even when someone with bipolar is not having a full episode of illness. To varying degrees, these symptoms and episodes can be managed. The most common treatments are medication, neuro-therapies (physical treatments, other than drugs, to change brain activity), and supportive therapies (such as psychotherapy). We’ll discuss all of these in greater detail later in this book.
In this chapter, however, we’ll address the basic question: What does bipolar disorder look and feel like?
Bipolar disorder is characterized by its episodes of extremes in mood, and that’s what people with BD actually experience. Understanding the nature of these moods makes it easier to understand the differences between the types of bipolar disorders.
A manic episode is typified by elevated mood, increased energy, and perhaps paradoxically, irritability. Often there is a sense of power or importance, rapid thinking, talkativeness, a flurry of activity, and decreased need for sleep. There may be impaired thinking and psychotic symptoms (delusions and hallucinations). In a manic episode, symptoms are severe enough to cause substantial disruption to daily life and obligations. Sometimes hospitalization is required.
A hypomanic episode has the same basic features as a manic episode, only milder. By definition, hypomanic symptoms do not cause severe disability or hospitalization and are not associated with psychosis.
A depressive episode is characterized by sadness or low mood; diminished energy, interest, and pleasure; greater or lesser appetite for food; excessive or poor-quality sleep; and feelings of worthlessness or guilt, and even despair.
Mood swing means that the episodes of mania and depression shift from one pole to the other. This can happen over and over again. If the shifts occur at least four times a year, the illness is called rapid cycling.
A mixed episode is when mania and depression fluctuate so quickly that they seem to occur at the same time, or when symptoms that meet the criteria for a manic and a depressive episode actually do occur at the same time. Indeed, the “poles” of bipolar disorder are not entirely opposites; if you read about the symptoms, you will see they overlap.
Sometimes the term mixed mania is used when manic features predominate but there are also substantial symptoms of depression. Similarly, there are states of energetic or agitated depression—in which depression dominates but features of mania exist at the same time.
The most commonly used official diagnostic criteria for bipolar disorders are given in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition, called by its initials: DSM-IV-TR—the principal guidebook for psychiatrists. (You’ll find excerpts from the complete clinical criteria at the end of this book.) Although at first glance these criteria may seem clear, in practice a diagnosis of BD is not a simple one to make, primarily because BD is often confused with other disorders with similar features. In fact, it has been estimated that the average bipolar patient suffers through ten years of symptoms before receiving a correct diagnosis.
The DSM-IV-TR and most other official criteria recognize multiple forms of bipolar disorder. The primary forms are bipolar 1 and bipolar 2.
Bipolar 1 Disorder
According to the DSM-IV-TR,
The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of at least one, and usually more, so-called Manic Episodes or Mixed Episodes. Often individuals have already had one or more Major Depressive Episodes. Sometimes, the individual is experiencing a first episode of illness (i.e., Single Manic Episode). More commonly, the disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode, from manic to depressed or vice versa, or by an interval between episodes of at least two months without symptoms of illness.
The illness is said to be chronic if an episode never fully ends, and significant symptoms remain; it is recurrent if there are new episodes of illness separated from previous episodes by at least a few months.
Bipolar 1 patients do not just have extremes of mood. They may also experience hallucinations and, more commonly, delusions. For this reason, BD is considered a psychosis.
Hallucinations are false sensory perceptions. In BD, these are usually auditory (such as hearing voices) or visual (seeing things that are not there). Often these voices or visions are related to the episode of illness. They are often consistent with the high mood and grandiosity of mania (the victim might believe she hears voices of angels or God), or with despondency in depression (the voices might tell him he is worthless or disgusting).
Delusions are false and odd beliefs. As with hallucinations, in BD they are often consistent with the prevailing mood. A person who is manic may believe he has exceptional, even superhuman, strength or prowess. An individual who is depressed might believe she is rotting or beset by demons. Delusions of grandeur or persecution are the most common delusions in people with bipolar 1 disorder. (We’ll look at these in a little more detail later in this chapter.)
In lay terms, bipolar 1 is the classic form. It is what most people think of when they hear the terms bipolar or manic-depressive: the recurring experience of big highs (mania) and big lows (depression). But it is not the only type of bipolar disorder.
Bipolar 2 Disorder
According to the DSM-IV-TR, “The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode.”
Hypomania can be characterized by abundant energy, confidence, and other seemingly “good” emotions and states—or, like mania, it can be associated with disconcerting irritability. In people suffering from bipolar 2, this mood state often precedes an episode of serious depression.
A person suffering from bipolar 2 disorder may not appear to be as “clearly manic-depressive” to the observer, especially when the person just seems to be in a particularly good mood. But it can be just as serious a disorder as bipolar 1, because the depressions can be just as deep.
Is There a “Bipolar 3”?
Some people seem to experience episodes of bipolar disorder only in the context of a general medical illness, such as multiple sclerosis or thyroid disease, or only after exposure to a drug, such as a steroid medication or a stimulant. The term bipolar 3 is often used to describe bipolar disorder apparently induced by prescription or nonprescription drugs.
Of particular importance, medication prescribed for a diagnosed depression will sometimes give rise to mania or hypomania instead of just restoring normal mood. This may be the first evidence that someone suffering a depression has a form of illness related to bipolar disorder. The relationship between these forms of the disorder and bipolar 1 and 2 is not clear; but, in addition to symptoms, all probably share some underlying physical characteristics, including inherited factors that determine the risks of becoming ill.
Human conditions are rarely fully described by neat lists of symptoms and specific criteria, and so it is with bipolar disorder. Many people have symptoms of BD, but don’t quite fit the criteria in the textbooks. The DSM-IV-TR classifies such people as Bipolar Disorder Not Otherwise Specified, or BD-NOS, another term you may have heard. People who have BD-NOS can experience some or most of the elements of mania and depression, but not enough to meet the specific criteria for Bipolar 1 or 2 Disorder in the DSM-IV-TR. Cyclothymia is frequently found in relatives of people who have bipolar disorder. This much milder version of BD includes both depressions and hypomanias, and mood may shift much more rapidly than in other forms of bipolar disorder. Although less severe than bipolar 1 and 2, it can cause problems in daily life and relationships. Over time, it may evol...