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Bipolar Disorder


There are, broadly speaking, two types of depressive disorders, informally known as unipolar and bipolar disorders. In unipolar disorder, formerly known as Major Depressive Disorder, one usually experiences only two mood states, euthymia (or “normal” mood) and depressed.

In Bipolar Disorder there is a third and often a fourth mood state, known respectively as “mania” and “mixed state”. Mania consists of times of abnormally elevated mood that may include reduced sleep, increased energy as reflected by increased activity, speech and racing thoughts. These times may be remarkable for particular feelings of well being or even euphoria. Note that “elevated” and “increased” implies that these symptoms may occur in intensity from mild to severe. When these symptoms are severe there is little difficulty in identifying them, but when they are mild they are often difficult to identify for a number of reasons, including failure of the person experiencing them to recall them as “abnormal” and thus significant for diagnostic purposes. Sometimes a reluctance to associate oneself with an ill parent also leads to reluctance to acknowledge and report symptoms as mania (“I’m not like my mother”…”I won’t be drugged up like my mother was”, etc).

The fourth, or mixed state, is thought of as the co-occurrence of the high energy of mania and the negative emotions of depression. This high-energy unhappy state manifests as irritability, anger, or anxiety, or a combination of all three. The increased energy of the manic portion of mixed states often leads to reduced and broken sleep, physical agitation or even aggression, racing thoughts and highly distractible attention. These mixed states contrast sharply with the usual depressions of bipolar disorder that include increased sleep, lethargy, and cognitive dulling. In bipolar depression, one often feels one cannot get enough sleep, in mixed mania, one cannot sleep well. In bipolar depression one’s mind is dull and slow, in mixed states one’s mind often feels like a popcorn popper, with thoughts exploding into consciousness only to be replaced by other, often unrelated thoughts, the thoughts usually, however, all running along markedly negative lines. In bipolar depression, one has too little energy (lethargy, fatigue, poor motivation being common descriptors), in mixed states one has too much energy, but the energy is unproductive, nervous, agitated or angry.

Mixed mania is the “great impersonator”, during which virtually each of the six common anxiety disorders can occur, eating disorders become active, impulses emerge to self destructive behaviors like self mutilation, and psychoses intrude. Untangling these symptoms and identifying the primary from the secondary diagnoses is often difficult, even for skilled and experienced diagnosticians. Parsing the symptoms that are due to mixed states that do not represent independent disorders (i.e. “secondary” conditions) can lead to years of ineffective and even harmful treatment with inappropriate medications. There are several very important observations about Bipolar Disorder to be made here: the proportion of depressions to manias is not relevant to the diagnosis: one may have experienced 30 or more depressions for each (brief) mania, but the diagnosis is still Bipolar Disorder (studies have shown that in Bipolar II this is precisely what happens). Many, if not most people with Bipolar Disorder do not experience the classic “euphoric” (or happy) mania, but rather mixed states. The anxiety of mixed mania may be overwhelmingly the most distressing part of a patient’s experience, but it is still primarily due to a mood disorder and will not improve until treated as such (As such, an anxiety disorder may be an incorrect diagnosis as the primary problem is still Bipolar Disorder). As many as 1% of bipolar patients will never have experienced a true depression and some of these patients may only have experienced mixed states and euthymic (“normal”) moods, confounding the “two mood states is unipolar depression” rule noted above and presenting particular diagnostic challenges.

Historical points suggesting the presence of bipolar disorder include any family history of Bipolar Disorder, multigenerational mood disorders (“my grandmother was like this and my mother had problems too.”

Bipolar Disorder is more heritable than unipolar depression, family members who abuse drugs or have alcohol or a personal history of substance abuse (up to 60% of people with bipolar disorder have a significant history of such abuse, much higher than the general population or people suffering from unipolar depression) early (childhood or adolescent) onset of a mood disorder, feeling “great” within days of starting an antidepressant (referred to as “switching”; “too good too soon is not good”), failure of many (more than two) trials of antidepressants consistently to improve a depression; becoming manic or markedly agitated or anxious while taking an antidepressant; and others.

Bipolar Depression is distinguished from Major Depressive Disorder because the treatment of Bipolar Disorder is different from the treatment of Major Depression. The use of antidepressants alone is appropriate in Major Depression, but can make Bipolar Disorder worse, leading to the rapid switching between moods noted above and increasing the rate of cycling. This leads to the paradoxical, but very important principle that antidepressants are not appropriate for all depressions. In fact, there are certain kinds of depression that should not be treated with antidepressants. This in turn leads to the axiom that no depression should be treated with medications before a thorough and complete assessment of lifetime symptoms has been accomplished by a qualified and experienced mental health clinician.

The treatment plan for Bipolar Disorder should recognize that Bipolar Disorder consists of two components, the mood fluctuations as the moods move from depressed to normal to manic or mixed mania, and the mood itself. This is to say that one cannot really identify what the mood of a person may be when it will be different tomorrow from what it is today from what it was last week. Only when the mood fluctuation has been stabilized into a more consistent state can the question of mood be addressed. Medications that stabilize mood can reduce these mood fluctuations by holding the mood in a more constant state, but that state may be a normal mood or it may be depression (manic states are unstable by nature). Once stabilized, in other words, the mood itself may be depressed. This is progress. Once the mood is stable, then one can address the remaining depression while maintaining the stability previously achieved. Stabilize the mood first and then address the depression, if still present.