Bipolar Disorder   Talk Privately with a Therapist Live Online

The heart that is soonest awake to the flowers
is always the first to be touched by the thorns.  

Thomas Moore, 1779–1852

Basic Terminology

Bipolar disorder is the medical name for manic depression. The terms may be used interchangeably. Bipolar disorder is a mental illness, but it is more appropriately described as a neurobiological brain disorder involving extremes in mood. It is one of the three major affective (mood) disorders. The other two affective disorders are unipolar disorder (depression only) and schizoaffective disorder. Most medical researchers believe that bipolar disorder is genetic.

Click here to read the criteria for bipolar disorder from the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV).

Click here to read the ICD-10 Classifications for Bipolar Disorder, from the World Health Organization.

The DSM or ICD criteria are merely guidelines, sort of like a check-off list of symptoms. Newly-diagnosed people will sometimes go to the library or bookstore to learn about bipolar disorder. They are likely to get very confused by what they read, and wonder if the psychiatrist made a mistake! This is because bipolar disorder may be quite complex in its variations, a fact that the popular literature doesn't always address. Each individual has her or his own unique form of the illness.

Some people have mild manias, called hypomanias, and others have wild manias. Some people have depressions which are deep, awful, and long-lasting. Others may have brief depressions. Still others have a sort of a "physical" depression or physical pain, with flattened or non-existent emotions. And sometimes (not always) a person with bipolar disorder may have accompanying psychotic features such as delusions and/or hallucinations.

People without bipolar disorder seem to think that hypomania and mania sound like fun. After all, most of the definitions in books say that mania is a euphoric or "high" state. It is true that mild hypomania may be fun, because it is so energizing and may lead to a period of highly productive activity. But in actuality, both mania and hypomania may also be dysphoric. Dysphoria implies agitation, anxiety, uncontrollable rage, or self-destructive feelings. Sometimes mania and depression happen at the same time. These are called mixed states.

Finally, a person with bipolar disorder doesn't generally have an episode of depression, then an episode of mania, in equal amounts. Although it is true that "what goes up, must come down," the cycles are often unpredictable and of varying length.

Most people with bipolar disorder have extreme cycles only once every few years. Rapid cyclers go through four or more episodes of mania and depression per year. Ultra-rapid cyclers have episodes shorter than a week. Ultradian cyclers have distinct and dramatic moods shifts within a 24-hour period.

And, believe it or not, some people with bipolar disorder may have weeks, months, or years with absolutely no extreme ups and downs at all. Instead, they have normal moods like everyone else. Psychiatrists actually classify this, too! It is called euthymia. Talk Privately with a Therapist Live Online

My Own Experience

I was diagnosed with bipolar disorder in 1992, after a lifetime of struggling with depression and mania. According to the DSM-IV, I am Bipolar 1, Rapid Cycling. I also have a seasonal aspect to my illness. Every summer I cycle into mixed states from about mid-June through the end of August.

I have tried many medications, in varying dosages and combinations. Fortunately, I have an exceptional psychiatrist, who works with me and is there for me. There is nothing quite like a good partnership with your doctor, especially when it comes to mental illness.

The best description I have seen of what it is like for me to live with manic depression comes from Dr. Kay Redfield Jamison's book, Touched With Fire: Manic-Depressive Illness and the Artistic Temperament (The Free Press, Macmillan, New York, 1993). Dr. Jamison has bipolar disorder, and knows what she's talking about.

"The clinical reality of manic-depressive illness is far more lethal and infinitely more complex than the current psychiatric nomenclature, bipolar disorder, would suggest. Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. The illness encompasses the extremes of human experience. Thinking can range from florid psychosis, or "madness," to patterns of unusually clear, fast and creative associations, to retardation so profound that no meaningful mental activity can occur. Behavior can be frenzied, expansive, bizarre, and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swing erratically between euphoria and despair or irritability and desperation. The rapid oscillations and combinations of such extremes result in an intricately textured clinical picture. Manic patients, for example, are depressed and irritable as often as they are euphoric; the highs associated with mania are generally only pleasant and productive during the earlier, milder stages." (Jamison, Touched With Fire, pages 47-48.)

Available Treatments

There is no cure for bipolar disorder, but it may be managed with medication, psychotherapy, and life-adjustment skills. Usually a combination of all three is required to avoid hospitalization and/or the eventual lure of suicide.

First-line treatments in the United States include lithium and Depakote. These are called mood stabilizers. Lithium is a naturally occurring substance (an element), and is usually the first drug tried because of its overall success rate. But despite its good press, lithium doesn't always work, and the side effects are sometimes too hard to live with.

In 1995, the U.S. FDA approved Depakote, an anti-convulsant, for use in treating bipolar disorder. Depakote, Depacine, Depakene, Epival, Epilim, and Valproate are derivatives of a substance called valproic acid. Other anti-convulsants which are being used (but have not been FDA-approved for bipolar disorder) include carbamazepine (Tegretol), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax), tiagabine (Gabatril), and clonazepam (Klonopin). In addition, verapamil (Calan), a calcium-channel blocker, has been used experimentally in the treatment of manic-depressive illness. 

Antidepressants may be added to mood stabilizers, especially if the individual has particular trouble with depression. However, unopposed antidepressants (use of antidepressants without also using a mood stabilizing drug) may be dangerous for a bipolar patient. It is dangerous because the person may go into a manic state very quickly, or begin rapid cycling, or their illness may worsen. Even patients who are on an antidepressant plus a mood stabilizer must carefully monitor themselves for these altered patterns. 

It is often very frustrating to treat manic depression. What works for one person may not work for another. Sometimes a combination of medications is effective, including use of anti-psychotics, benzodiazepines, thyroid supplements, and sleeping aids. (If a person has other medical problems which require medications, these must be balanced very carefully with those taken for manic depression.) 

These varying mixtures are often referred to by patients as med cocktails or meds. And even with the best of med cocktails, the side effects of the drugs may be nearly unbearable, or there may be breakthrough episodes of mania or depression. 

Suicide and Bipolar Disorder

About 1% of the world's population is thought to have some form of bipolar disorder, from mild to severe. Statistically, men and women are equally represented. Approximately 1 in 5 people with bipolar disorder eventually commit suicide (Goodwin and Jamison, Manic Depressive Illness, p. 228). This is 30 times higher than the general population! And 20-50% of people with bipolar disorder attempt suicide at least once (p. 231). 

"Patients with depressive and manic-depressive illnesses are far more likely to commit suicide than individuals in any other psychiatric or medical risk group. The mortality rate is higher than it is for most types of heart disease and many types of cancer. Yet this lethality often is underemphasized, a tendency that may be traceable to the erroneous but widespread belief that suicide is volitional." (Goodwin and Jamison, Manic Depressive Illness, p. 227)

Imagine thinking about suicide daily. Imagine feeling like there is no way out of the madness of your thoughts, your bizarre emotional swings, or your life situation except to kill yourself. For a person with bipolar disorder, suicidal ideation (i.e., suicidal thoughts, plans, obsessing on death) may occur during depression, dysphoric mania, and/or mixed states. 

If you feel suicidal right now, please go to this site immediately.  

 Learning About Your Diagnosis

People with bipolar disorder are sometimes told by family and friends to "just snap out of it" or "just cheer up" or "pray to God and you will be healed." This sort of well-meaning advice can be lethal to someone who is experiencing the disturbing states of mania or depression. The implication is that if we tried harder, we would not be having all these problems. What nonsense! 

Remember, mental illnesses have a biological basis, just like other illnesses. There are plenty of scientific studies which prove this. This is not a justification of the unusual behavior which happens during mania or depression, but rather an explanation of its origin. 

Perhaps you have been to a doctor, and now have a prescription in your hand. The doctor says, "Take as directed. In two weeks you will feel much better." Is this true? What if you get side effects? What if nothing happens? How can you possibly survive the wait? 

As difficult as this sounds, you must be your own health care advocate. Don't expect your doctor to do it for you, or your significant other, or your parents, or your friends. Take charge of your diagnosis. Speak to your doctor about your concerns. In the beginning, you may need daily or weekly contact with the doctor. Ask questions. Find answers.

You may wish to keep a journal or a mood chart. Learn to identify those things that make your episodes worse. Identify things which seem to help. Make adjustments to your daily life. Find support to help you through the rough times.

If you have been diagnosed with a mental illness such as bipolar disorder it is time to learn as much as you can, as fast as you can. There are books to read, organizations you can contact, real-world support groups, Internet mail lists and newsgroups, and Web-based chat areas. Plus, there are some excellent Web sites which you can visit on your journey of discovery.