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Thu 6 Dec 2007 11:12 AM

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Bipolar disorder

The manic highs and depressive lows of bipolar disorder can be devastating, but treatment may even them out.

Normally, how happy or sad we feel is connected to events in our lives - achievements and rejections, love found and loved ones lost. But in people with mood disorders, these emotions take on a life of their own often unrelated to circumstance. Mood has been described as our emotional temperature. With mood disorders, we lose the ability to regulate that temperature.

Bipolar disorder, once known as manic-depressive illness, is a mood disorder. People with the condition cycle through changes in mood that are - just as the name suggests - at opposite ends of a spectrum. The "up" part of the cycle is called mania. Untreated, mania can last months, even years. In its milder form, it can be pleasant. People feel wonderful - exuberant, energetic, optimistic. They're charming, outgoing, and talkative. They believe their thinking is sharper and more creative - and sometimes it is.

Bipolar disorder, once known as manic-depressive illness, is a mood disorder.

But manic episodes tend to crescendo. Self-confidence changes into grandiosity as people imagine they have special talents and can achieve unrealistic fame and fortune. The nimble thinking accelerates into racing, jumbled thoughts. Some people lose touch with reality and hallucinate or have delusions.

Mania is sometimes depicted as a happy state of mind, but full-fledged episodes can be miserable. People often become tense, irritable, and angry as mania takes hold.

Mania also unleashes reckless behavior; a shopping spree is the classic example. In An Unquiet Mind, psychologist Kay Redfield Jamison's memoir of her struggles with bipolar disorder, Jamison writes about purchasing 12 snakebite kits in a mania-fueled moment of safety-consciousness.

Such sprees may seem harmlessly odd, but they can land people disastrously in debt if they spin out of control. Mania can also lead to sexual indiscretions and hasty, ill-advised marriages as well as the breakup of established ones.

Depressive side of the coin

Because mania is the hallmark of bipolar disorder, the depressive episodes sometimes get overlooked. But in reality, people with bipolar disorder spend much more time depressed than manic. Years of depression may go by between manic episodes.

The depression experienced by people with bipolar disorder is similar in many ways to any other significant depression. People struggle with poor self-esteem, concentration, and making decisions. But some research suggests that the depression of bipolar disorder is distinctive. Bipolar depression may lead to excessive sleep and overeating, whereas in regular depression, insomnia tends to be the problem. Bipolar depression may come on more abruptly than normal depression, and a study published in 2006 found that fears were more common.
Although the manic phase of bipolar disorder is more likely to result in emergency hospitalization, the depressive phase may be more dangerous. Bipolar disorder increases suicide risk, and it's estimated that more than 70% of the suicides stemming from the disease occur during a depressive episode.

The mania that people like

Instead of mania, a person with bipolar disorder may experience a milder form called hypomania (hypo is Greek for under). People sometimes enjoy - indeed, cherish - these episodes. They're like the beginning stages of mania, a "high" of quick and inventive thinking, bursts of energy, lots of ambition. And, by definition, hypomania doesn't include hallucinations or delusions, or require hospitalization. Hypomania may, though, have negative consequences if the confidence leads to excess spending or promiscuity.

Distinguishing bipolar disorder from attention deficit hyperactivity disorder (ADHD) in children is difficult.

It's speculative, of course, but a number of famous people (Vincent van Gogh, Isaac Newton, Florence Nightingale, Virginia Woolf) may have had bipolar disorder, judging by their periods of great productivity and crushing depression. A biography of Beethoven argues that he was bipolar: suicidal at times but writing several symphonies simultaneously at others. If these people did have bipolar disorder, they might have had a milder form, called bipolar II, in which depression alternates with productive hypomania instead of the depression-mania pattern of bipolar.

Worst of both

The depressive and manic aspects of bipolar disorder sometimes overlap so people are tense, restless, and despondent at the same time. This combination goes by several names: mixed state, mixed affective state, dysphoric mania. Although she doesn't use the term mixed state, Jamison recounts periods of total despair with terrible agitation that seem to describe the condition. She says her mind would race from one gory image to the next, rather than be filled with exhilarating ideas.

Difficult, controversial diagnosis

Bipolar disorder is difficult to diagnose. Alcoholism and drug abuse may cover up the symptoms. Mania is sometimes mistaken for schizophrenia and the mixed state for a personality disorder. The depressive phase often starts years before any mania, so bipolar disorder is often diagnosed as major depression until a manic episode occurs - perhaps an unavoidable problem until we know more about the disease. And for those with longstanding depression, hypomania may be welcomed as a reprieve from the blues rather than an abnormal mood shift worth bringing to the attention of a doctor.

Experts used to think the bipolar child was rare. Now many believe that symptoms often begin to surface early in life and, therefore, as many as one in every 200 children is affected by the disease. In 1997, the prevalence was estimated to be one in every 20,000.

But there's also some real worry that doctors are diagnosing and treating moodiness and related behavioral problems as bipolar disorder when children and adolescents actually have other problems (abuse, family conflict) or are simply going through the ups and downs of growing up. A study published in the Archives of General Psychiatry in September 2007 lent some credence to concerns about overdiagnosis. The study found that the number of American children diagnosed with bipolar disorder increased 40-fold between 1993 and 2003. The number of adults diagnosed doubled during the same period.
Distinguishing bipolar disorder from attention deficit hyperactivity disorder (ADHD) in children is difficult. ADHD has symptoms - impulsiveness, lack of concentration - that are similar to some aspects of mania. About a third of children diagnosed with ADHD are eventually identified as having bipolar disorder.

A menu of treatments

Medications don't cure bipolar disorder but can control the symptoms. Drugs are often taken in combination, and more than 80% of patients take two or more.

Lithium. This drug has been used for about half a century and in some ways is still the most effective medication for bipolar disorder, particularly for calming mania and reducing suicide risk. Doctors sometimes have difficulty finding a dose that balances safety and comfort with effectiveness. Many people tolerate lithium well, but others are bothered by side effects that include nausea and diarrhea, weight gain, concentration and memory problems, and low thyroid levels.

Anticonvulsants. These medications were developed to treat seizures, but doctors noticed they had mood-stabilizing effects. This group includes valproate (Depakene, Depakote), carbamazepine (Epitol, Equetro, Tegretol) and lamotrigine (Lamictal). Whether they're as effective as lithium is debatable, but they're seen as an attractive alternative to lithium because for some people they have fewer side effects. Antipsychotics. Once limited to treatment of psychotic symptoms, the antipsychotics are now prescribed for treatment of both the manic and depressive phases of bipolar disorder. Psychiatrists tend to prescribe the newer "atypical" antipsychotics, but many antipsychotics can control symptoms.

Antidepressants. Antidepressants have been a vexing issue in the treatment of bipolar disorder. They haven't been adequately tested as treatment for bipolar depression. They've also been known to trigger mania and send some patients into rapid cycling between mania and depression. A Harvard study published in 2007 in the New England Journal of Medicine tested two antidepressants - paroxetine (Paxil) and bupropion (Wellbutrin) - in combination with drugs that stabilize mood (lithium, valproate, and so on). The good news was that the antidepressants didn't trigger mania. But the results also showed that adding an antidepressant to the mood stabilizer was no better than adding a placebo pill.

Beyond drugs

As with almost every disease, most bipolar patients will do better if they're educated about their illness, understand the importance of taking medication, and recognize the signs of relapse early on. Support groups and various kinds of psychosocial treatment (such as interpersonal therapy and cognitive behavioral therapy) can also help bipolar patients.

But finding an effective therapeutic regimen can take time. Patients respond differently to given medications - and in some cases, they don't respond to any. People with bipolar disorder often stop taking their medications or seeing their therapists. The active involvement of family and friends can help keep them on track, although the shifts from dark depression to reckless mania - and then back again - tend to erode the very support that bipolar patients need.

Still, there are reasons to be optimistic. People with bipolar disorder can lead extraordinarily productive and creative (if trying) lives. Many patients respond to medication. By reining in their errant moods, treatment can help ensure that those who possess "unquiet" bipolar minds aren't quite so troubled.

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