issue 104 (our 9th year)
issue 104 (our 9th year)
At age 23 Joseph noticed she was having trouble concentrating at work – that is, when she actually made it into the office. Many days, she couldn’t get out of bed. She spent hours staring at the wall, crying at the drop of a hat. And although she’d only worked for nine months as a certified public accountant for a large accounting firm, she was already in danger of losing her job.
Joseph checked into a psychiatric hospital for several weeks, where she was diagnosed with what she and physicians then thought was major depressive disorder. The diagnosis made sense at the time; after all, Joseph had experienced mood dips throughout her teens. She was prescribed an antidepressant, found a psychiatrist and started talk therapy.
It took 13 years and several doctors for Joseph, now 51, to realize she’d received the wrong diagnosis. After describing her agitated mood swings to a psychiatrist – episodes filled with anxiety, rage and impulsive shopping sprees, interspersed with prolonged periods of extreme sadness – she learned she had bipolar disorder, a psychiatric condition that affects an estimated 2.6 percent of the country’s adult population. More specifically, she had a subtype of the illness called bipolar II.
Like major depression, bipolar disorder is characterized by sadness, fatigue, a loss of enjoyment in everyday activities and disruptions in appetite and sleep patterns. But individuals with bipolar disorder differ from patients with major depressive disorder in that they experience what’s called mania or hypomania – emotional highs, bursts of extreme energy and severe irritability that ranges in intensity and duration.
As Joseph’s case indicates, bipolar disorder is complex in presentation, and often extremely difficult to diagnose. Studies suggest it can take patients an average of 3.3 physician visits to get an accurate assessment of their condition, and 73 percent initially receive an incorrect diagnosis. Due to the illness’ broad nature, the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders, DSM-V, divides bipolar disorder into several subtypes, but its symptoms often run on a spectrum, meaning there’s no one-size-fits-all diagnosis or treatment. And often, people who are initially diagnosed with depression develop bipolar symptoms later in life.
According to the National Institute of Mental Health, bipolar disorder can result in a 9.2-year reduction in expected life span, and approximately 1 in 5 sufferers commit suicide. Clearly, it’s a serious diagnosis. But experts say patients who receive the right treatment and support can lead full, productive lives.
What Causes Bipolar Disorder?
The underlying causes of bipolar disorder are convoluted, experts say. Although the exact biological mechanisms are unknown, “it’s probably an interaction of genetic vulnerability with whatever happens in one’s life – so it’s a combination of nature vs. nurture,” says Terence Ketter, chief of the Bipolar Disorders Clinic at Stanford School of Medicine.
Research suggests bipolar disorder is 60 percent hereditary. Other factors that likely contribute include biological differences in the brain and an imbalance of chemicals called neurotransmitters and hormones. Life stressors such as emotional or physical trauma, a stressful relationship or a taxing career can also trigger the onset. While bipolar disorder typically rears its head in adolescence – at least half of cases occur before age 25 – it can also lie dormant and emerge later in a person’s life.
Bipolar disorder is equally prevalent in men and women, although studies indicate it might affect each both genders differently. For example, women tend to have more depressive features, while men experience more manic features.
Receiving a Bipolar Diagnosis
Francis Mondimore, director of the Mood Disorders Clinic at the Johns Hopkins Bayview Medical Center, says the main symptom of bipolar disorder is severe depression, which can last for weeks to months. There are physical signs – loss of energy, sleep and appetite changes – as well as a lower mood and a lack of interest in life. Though there may be periods of another abnormal mood state, such as extreme euphoria or irritability, it’s often the lows that both patients and doctors first notice.
“Many people with bipolar disorder will present at treatment the very first time with depression symptoms,” Mondimore says. “The way we make a diagnosis of bipolar disorder in those people is to look at things like whether there’s a family history of bipolar disorder and a number of other indicators that suggest a period of depression might represent bipolar depression.”
These indicators, Mondimore says, vary. They include a young age of onset, since bipolar disorder often first presents in adolescence; having family members with the condition; or experiencing a first episode of depression after giving birth – a significant percentage of women who develop postpartum depression turn out to have bipolar disorder.
Additional red flags can include having tried antidepressants to no avail, or experiencing agitation or rushed, disorganized thoughts while on antidepressants. People who’ve undergone severe depressive episodes with psychotic symptoms, such as delusions or hallucinations, might also be at higher risk for bipolar disorder.
Diagnosis can further be complicated by having other chronic conditions. Sixty percent of patients with bipolar disorder also have substance abuse problems, Ketter says, making it difficult to determine if someone’s fluctuating moods are due to drugs or alcohol or something else. Attention deficit hyperactivity disorder is also common in patients with bipolar disorder, as as are anxiety and personality disorders, further exacerbating ease of diagnosis.
That’s why it often takes time for doctors to diagnose bipolar disorder, Mondimore says. “Sometimes people do walk in the clinic, show extremely classic symptoms and you can make a diagnosis in 15 to 20 minutes. But there are a lot more for whom there needs to be an assessment over a period of time.”
Forms of Bipolar Disorder
Igor Galynker, director of the division of biological psychiatry at Beth Israel Medical Center in New York, explains that there are several main subtypes of bipolar disorder. Patients who have bipolar I experience mania – an uncharacteristically elevated mood, accompanied by insomnia, over-activity and a tremendous sense of well-being. Patients often don’t need sleep, and they might become more talkative than usual. Manic episodes may be preceded – or followed – by a hypomanic or depressive episode.
In extreme cases, people with mania become impulsive and lose their inhibitions, leading to risky behaviors such as drugs, gambling and extravagant shopping sprees. Occasionally, they experience delusions and become psychotic. “They start believing they’re a prophet, or going to cure cancer or become a movie star or rock star,” Mondimore says.
A milder form of the disorder, bipolar II – the subtype Joseph was diagnosed with – is characterized by hypomania, or a very mild form of mania. While hypomania still causes elevated energy and over-activity, it’s not disabling. But that doesn’t mean it’s not serious. Often, those with hypomania make poor decisions; because their symptoms are subtler, however, they can be difficult to identify, increasing the likelihood that people could miss potentially destructive actions.
The illness’ third most common subtype, Galynker says, is mixed bipolar disorder – defined by symptoms of both mania and depression. Patients can feel agitated and energetic, but also extremely depressed. Mixed bipolar disorder often occurs later in life, and can be more difficult to treat.
While the DSM-V includes additional forms of bipolar disorder, including a mild type called cyclothymia, those listed above are seen most often.
Treating Bipolar Disorder
Ketter says bipolar disorder is typically treated with a mood stabilizer, such as lithium or Lamictal. These medicines help temper both mania and depression, and are occasionally used in conjunction with an antidepressant. However, doctors warn that antidepressants can nudge patients into full-blown manic episodes or cause rapid cycling, which describes fluctuations between mania, hypomania, depression and mixed states. Bipolar patients taking antidepressants should be carefully monitored.
Occasionally, patients are also prescribed second-generation antipsychotic medications, which help temper mania and depression. Many of these medications have side effects, so it’s important to discuss long-term risks with doctors.
Therapy is also helpful, experts say. Being diagnosed with bipolar is a life-changing event, and it’s helpful for patients to have support while dealing with a highly stigmatized mental illness. It can also help patients learn to cope with chronic psychological stressors that exacerbate symptoms.
Different patients might need different types of therapy. For example, patients with families might benefit from family-focused therapy, which aims to reduce stress and negative interactions within the family unit, support the patient and educate the family about the illness and how to work on encouraging medication compliance, Galynker says.
“What’s really important is what we call a psychoeducational component,” Mondimore says. “This is when we educate the patient about the disorder and what I call mood hygiene, or the lifestyle changes that are going to decrease the chances of relapse – avoiding sleep deprivation, avoiding intoxicating substances and adopting various lifestyle interventions.”
Sometimes, medication and therapy aren’t enough, however. A drastic life change, like a career switch, might be necessary to prevent triggers that worsen the illness. Support groups may also benefit patients, allowing them to meet others with the same diagnosis and develop a peer network.
Patients can achieve remission from symptoms, experts say – or at least enjoy stable lives. As for Joseph, after years of hardships, including multiple medication changes, filing for bankruptcy due to shopping spree-induced credit card debt and a suicide attempt, she has found that her illness can indeed be treated. Mood stabilizers and antidepressants, therapy and a structured daily routine have helped her immensely.
“I wouldn’t say it’s panacea,” she cautions. “I still have to be vigilant. I still have people in my life, like my therapist, who will let me know when they think I’m off. But you can live a full life with mental illness, especially the mental illness that I have. I just have to stay in therapy, and stay on medication. It’s in my brain. It’s not a character defect.”
Kirstin Fawcett, Contributor
Our new Bipolar Carers Support Group meetings are held at South Yarra on the first Tuesday of each month commencing at 7:00pm (except January) – see http://bipolarlife.org.au/south-yarra-bp/
Close family and friends (bipolar carers or caregivers) can be a primary source of support for a person with bipolar disorder. Discussions include ways caregivers can take care of themselves, deal with the bipolar disorder and the personal impact it has on them.
Enquiries to firstname.lastname@example.org
If you are over 18 and have bipolar disorder you may be eligible to help us trial new, online self-guided interventions designed to improve quality of life in people who experience bipolar. We are comparing two types of interventions that have been created by international experts which both include videos, exercises, tools, forums and an online coach.
To find out if these interventions are helpful, you would also be asked to complete 4 assessments (which include a telephone and online component) over a 6 month period. You will be reimbursed for participation in these assessments.
If you would like more information about the research or would like to participate go to: www.orbitonline.org
Every day we are encouraged to help brave cancer survivors overcome the loss of dignity and beauty they face as part of chemotherapy. We proudly donate money, hair and hairpieces to these survivors. But we rarely show the same support or recognition to patients with bipolar disorder who must also tolerate medications with significant side effects that can affect their appearance.
Just like patients with other medical illnesses, people with bipolar disorder face tough choices about their treatment. Medications are available which can be lifesaving. The medications can help regulate emotions and perceptions, they can make it possible to develop relationships, they can help to restore judgment and insight, and they can prevent suicide.
But many of these medications can affect the way you look. Some can cause significant weight gain, hair loss or acne. It takes great personal strength to take these medications.
Instead of providing support for people willing and able to take these medications, some people with bipolar disorder get criticized for taking these lifesaving drugs.
And relatives and friends can make unkind comments about the effects of drugs on appearance: “Why don’t you lose weight. You would look so pretty if you just lost weight.” Even when these friends and relatives don’t say anything out loud, sometimes they cast suspicious glances when it’s time for dessert.
We respect and understand the difficulties faced by individuals with medical disorders like cancer or diabetes. Why don’t we show the same respect to individuals with bipolar disorder? Maybe we just need more information.
Many different medications commonly used for psychiatric illness have weight gain as a side effect. These can include many tricyclic antidepressants and some SSRIs, as well as mood stabilizing agents such as Lithium and the anticonvulsant agents. Many antipsychotic medications (including the first and second generation medications) are also associated with weight gain.
Not everyone gains weight, but more than half of individuals on these medications will be affected by weight gain. The weight gain can be rapid and intense. The effects are worse for people who are taking these medications for the first time. A second trial of medication is less likely to result in as significant a weight gain.
The weight gain is not a problem of character. You may be the one picking up the fork, but the decision to eat too much is not really about a lack of mental discipline. Instead, researchers think the medications may drive changes in the way you respond to the cues your body gives you about hunger, pleasure, and feeling full.
How do these cues affect you? Let’s think about the big picture. Weight gain is a function of energy intake and energy expenditure (i.e., how many calories you take in and how many you burn). If you take in more than you use, you will gain weight. The medications and the condition itself can influence both how much you take in and your participation in activities that burn up calories.
Some medications can influence how many calories you consume. For example, some of the medications may change your response to leptin – a hormone that communicates the sense of fullness. These medications may make you less sensitive to this hormone, so you don’t get a clear sense of fullness after eating. As a consequence, you may keep eating long after your biological needs are satisfied.
Some medications can increase your appetite, because they may change the way you experience the pleasure of food or the motivation to eat. As one patient put it, “It’s like having a neon sign in your head that is flashing all the time – EAT EAT EAT! CAKE CAKE CAKE!” It is pretty hard to exert self control when your brain and body are sending you such loud signals.
The effects of the medications on these and other biological systems mean that you can’t use your internal cues to regulate eating. On some of these medications, the internal messages you get about hunger or fullness are just not as reliable. You will need other strategies and support to help regulate when and how much to eat.
So I wonder – where is the help to support these strategies? Where are the donations of healthy foods or pre-packaged meals? Or discounts for the local farmer’s market? Where are the donations to support gym memberships or co-payments for medications that can help with some of the weight gain side effects?
And most important, where is the care and respect? Where is the recognition that taking medications is hard, but often necessary and brave. And that health makes us beautiful.
Initially I was diagnosed with Post Natal Depression 19 years ago, shortly after I had my first daughter. The diagnosis changed later to Clinical Depression and about 6 years ago my psychiatrist of 15 years diagnosed me with Bipolat 2.
At first it was a shocked and I did not want to accept my diagnosis of bipolar.
I just could not see how I possibly could have this condition. But I had to accept the diagnosis, which was the first step to learn to live with this illness. I learned I have to take my medication to stay well enough, so I can look after my family and function.
Another important factor was to learn my triggers, which meant to really look after myself and take care of myself when I could see I might spiral out of control, either with mania or depression.
It’s not an easy road we’re on, that’s why acceptance of this chronic condition and knowledge about it is so critical in order to be able to live a fulfilled life.
It’s very important not to be defined by Bipolar, but to learn to live with the strengths this illness gives you, for example in my case it’s creativity.
It’s a big journey but it’s good to know you’re not alone and you can find support out there, it’s just a matter of reaching out.
If you are between 18 and 60 years of age you may be eligible to take part in important new brain research.
This study is investigating thinking skills and emotion in people with bipolar disorder. It will involve a brain scan and participation in a range of thinking skills. The tests will take place over two 4 hour sessions at the Advanced Technology Centre at Swinburne University, Hawthorn. You will be reimbursed for your time and travel costs.