“A vivid imagination is awesome.  A manic imagination is a curse.”  ― Stanley Victor Paskavich

Bipolar disorder, also known as bipolar affective disorder or manic-depressive disorder, is a condition in which people experience mood swings ranging from the low and sense of hopelessness of depression to the euphoria and energized feeling of mania or hypomania.  These shifts in mood can occur rather infrequently, only a few times a year, or as rapidly as a few times a day.  In some cases individuals can experience both the mania and depression at the same time.  The symptoms of bipolar disorder are often quite severe and are very different from the normal ups and downs that we all experience from time to time.  Manic-depressive illness tends to worsen if left untreated.  Over time those with bipolar disorder will experience more frequent and severe episodes, and as a result are much more likely to suffer the social, personal and work/school related problems associated with it.  Although far too many people suffer for years before being accurately diagnosed, bipolar disorder can be very effectively treated, thereby dramatically reducing the frequency and severity of episodes, and allowing those suffering from it to lead wonderfully full and productive lives.  In the first part of this two-part series the reader will be presented with an overview of bipolar disorder, its various subtypes and occurrence, and its wide-ranging patterns and symptoms.

Bipolar disorder affects men and women equally, is more common in relatives of people with bipolar disorder, and typically first demonstrates itself between the ages of 15-25.  In fact, at least half of all cases of bipolar disorder are diagnosed in individuals under the age of 25.  Some may first show symptoms in childhood, while others may not develop the disorder until much later in life.

As bipolar disorder usually lasts a lifetime, if not adequately and consistently treated episodes of mania and depression can recur over time.  The actual signs and symptoms vary from person to person.  For some, depression is the primary concern, while others are mainly challenged by the symptoms of mania.  Yet for others, it is the occurrence of both…known as a mixed episode.   In between episodes many individuals can remain symptom free.  Bipolar disorder is divided into different subtypes, each having various patterns of symptoms.

• Bipolar I disorder is mainly characterized by manic or mixed episodes lasting for at least several days and of such severity as to cause significant problems at work, school, and/or with personal relationships.  The symptoms can often be so severe and potentially dangerous as to require hospitalization.  Often the person will also have had recent symptoms of depression having lasted more than a couple of weeks.
• Bipolar II disorder is less severe than bipolar I and is defined primarily by a presentation of periods of depression alternating with episodes of hypomania (a much less severe form of mania) but without true manic or mixed occurrences.   In bipolar II disorder people experience irritability and elevated mood, but changes in functioning are usually such as to not dramatically interfere with normal routines of daily life.  In this subtype the periods of depression often last longer than the episodes of hypomania.
• Cyclothymic disorder, also known as cyclothymia, is a milder form of bipolar disorder.  In cyclothymia periods of hypomania shift back and forth with episodes of mild depression, and have to been occurring for a minimum of two years.  Although disruptive, the lows and highs of cyclothymic disorder are not nearly as severe as with other forms of bipolar disorder.
• Rapid-cycling bipolar disorder is diagnosed when an individual experiences four or more episodes of mania (or hypomania), depression, or combined (mixed) symptoms within a 12-month period.  Some will actually experience more than one “switch” in a week, or even within the same day.  Studies have shown that this form of bipolar disorder may be more common in those with a severe form of the illness, in those who experience their first episode at a younger age (mid to late teens), and appears to affect women more than men.

The manic phase of bipolar disorder is associated with an extended period of feeling overly happy and outgoing (a feeling of being “high”) as well as extreme irritability of mood, agitation and feeling “wired”.  While mania at first feels good, feeling all-powerful, invincible, and destined for greatness, it will inevitably spiral out of control leading to an ever-increasing level of reckless behaviors, anger, and irritability.  Some will even become psychotic, experiencing delusions and possibly hallucinating.  These symptoms can last from days, to even months, and can include:

• Inflated self-esteem (unrealistic beliefs about their abilities)
• Increased energy with increased physical activity
• Racing thoughts, jumping from one topic to another
• Pressured and racing speech
• Marked impulsivity
• Restlessness
• A sense of euphoria
• Irritation or agitation
• Easily distractible
• Poor judgment
• Little need for sleep
• Reckless behavior and diminished self-control
• Aggressive behavior
• Increased sex drive
• Binge eating, drinking and/or illegal drug use
• Spending sprees
• Poor work/school performance
• Numerous absences from work/school

Delusions/psychosisDuring a hypomanic episode a person may have many of these same symptoms, but they are not as severe as typical mania.  A person having a hypomanic episode may actually feel quite good, being energetic, productive and functional.  In fact, the hypomanic individual may not feel that there is anything at all wrong, and is at a loss to explain why family and friends are concerned.   However, without proper treatment people with hypomania are prone to harming relationships, reputations and careers, and can often go on to develop severe mania or depression.

At the other end of the “mood scale” is the depression.  Up until recently, bipolar depression was grouped together with regular depression.  However, we are now aware of significant differences between the two, most importantly when it comes to effectively treating them.  The majority of patients with bipolar depression are not meaningfully helped by the administration of antidepressant medications.  In fact, there is some risk that antidepressant medication can actually make bipolar disorder worse by triggering mania or hypomania, causing a rapid cycling between mood states, and possibly interfere with the more effective mood stabilizing medications.  The depression in bipolar disorder can range from severe to mild.  In the severe range there is a high risk of suicide.  Many will abuse alcohol or drugs making both the symptoms, and the suicide risk, even worse.  A chronic longstanding mild low mood is referred to as dysthymia.  Symptoms of depression can also last from days to months, and can include:

• Sadness
• Hopelessness
• Helplessness
• Low self-esteem
• Difficulties concentrating
• Loss of interest in previously enjoyable activities
• Sleep difficulties
• Anxiety
• Isolation
• Diminished appetite
• Loss of energy
• Irritability
• Guilt
• Thoughts of death and suicide
• Poor performance and frequent absences from work/school

Instead of the more clearly defined mania/hypomania and depressed phases seen in adults, children and adolescents suffering from bipolar disorder more typically demonstrate problems with rapid mood shifts, explosive out of control temper tantrums, reckless behavior and aggression.  Oftentimes their rapid and extreme mood shifts can occur within a matter of hours.

A mixed episode of bipolar disorder tends to include symptoms of both depression and mania/hypomania.  More commonly seen is the depression along with anxiety, irritability, agitation, distractibility and racing thoughts.  It is this combination of elevated energy and discomfort along with a low mood state that makes mixed episode bipolar disorder patients a particularly high suicide risk.

In Part 2 of this two-part series I will discuss the causes and complications of bipolar disorder, co-morbid conditions typically associated with it, and the various treatment interventions available.