One in five Americans has a mental health condition. Fact: The highs and lows of bipolar disorder are very different from common mood swings. People with bipolar disorder experience extreme changes in energy, activity, and sleep that are not typical for them. The psychiatry research manager at one U. Even a diagnosis of rapid-cycling bipolar disorder requires several days in a row of hypo manic symptoms, not just several hours.
Clinicians look for groups of symptoms more than just emotions. Fact: There are four basic types of bipolar disorder, and the experience is different per individual. Fact: Bipolar disorder is a lifelong illness and there currently is no cure.
However, it can be well-managed with medication and talk therapy, by avoiding stress, and maintaining regular patterns of sleeping, eating, and exercise. Fact: In some instances, a manic person may feel good at first, but without treatment things can become detrimental and even terrifying. They may go on a big shopping spree, spending beyond their means. Some people become overly anxious or highly irritable, getting upset over small things and snapping at loved ones.
A manic person may lose control of their thoughts and actions and even lose touch with reality. Fact: Treatment often allows you to think more clearly, which will likely improve your work. Pulitzer Prize-nominated author Marya Hornbacher discovered this firsthand. And the book itself, the book that was ultimately published, I wrote in 10 months or so.
Once I got treated for my bipolar disorder, I was able to channel the creativity effectively and focus. You can work with it. Fact: People with bipolar disorder can experience long periods of even, balanced mood called euthymia.
Fact: It might take some trial and error to find the medication that works for you. Something that works for one person might not work for another. One in five people is diagnosed with a mental illness, including bipolar disorder.
I, like so many others, have responded extremely well to treatment. Appetite changes can also occur if the person develops depression.
As with mania, depression can also cause irritability and restlessness. You might notice symptoms from both phases. Composed of both the brain and the spine, your central nervous system is made up of a series of nerves that are in control of different body activities. You may even talk faster than usual. A depressive episode can also cause concentration difficulties, but your mind may feel a lot slower than normal. You might feel restless and have a hard time making decisions. Your memory may also be low.
Manic phases often mean that you need very little sleep, and depressive episodes can result in sleeping more or less than normal. Insomnia can become especially dangerous in bipolar disorder, as you may be more tempted to take sleeping pills. Such risks are more associated with mania than depression. When you have anxiety in addition to bipolar disorder , this can affect your cardiovascular system, too. Your endocrine system consists of hormones that rely heavily on messaging signals from the brain.
When these signals are disrupted, you can experience hormone fluctuations. Bipolar disorder can cause changes to your libido. Mania may put your sex drive on overload, while depression can significantly decrease it.
Some people experience poor judgment with this disorder, which can also increase the risk for poor decision-making in terms of sexual health.
Bipolar disorder may also affect your weight, especially during depressive phases. With depression, you might experience a decrease in your appetite, resulting in weight loss. In addition there are increases in oxidative stress with every episode, and that can damage the brain. So there's more potential for hurting brain cells and hurting brain function with every episode because there are increases in these toxic factors, and there's a loss of these brain-protective factors like BDNF.
So that's why we think the illness can progress and get more severe over time because the pathways for getting ill are actually getting grooved, if you will.
They're getting more automatic. And that's where treatment comes in, because most of our treatments actually counter all those things I talked about. They can prevent stress from decreasing BDNF. They can increase this brain-protective factor, BDNF, all by themselves. And if they prevent episodes, they're really going to be protecting the brain.
So it's a whole new way of looking at this illness. We used to think that the treatments just had side effects, but now we know they have brain-protective effects as well.
In some people it does, yeah. The folks with recurrent depression and with bipolar illness are at much higher risk for suicide than the general population. Yeah, it's a huge risk.
And there's also a huge medical risk of being depressed and not having it treated, because people with depression are more likely to get all kinds of medical problems like heart attacks and strokes and die earlier of medical complications even if there's not a suicide problem there. So it's sort of a double whammy and something that's very important to really go after and try to prevent as best one can.
And with the good treatments we have now, in most individuals you can really get after the illness and prevent these episodes.
What about the mania part of bipolar disorder? How can the mania change if it's left untreated? The mania can go from mild to more severe, but it can also start quite severe and somebody can have a psychotic, delusional mania where they think they can fly or do all sorts of bizarre things. They think they're God. They think they can do almost anything. And those folks tend to have a recurrence of the same sort of episode if it isn't treated. And there's also a component of mania where we used to think it's only somebody who would be euphoric and have mood elevation and think they can do all sorts of great things and that they're the President of the United States and that sort of stuff.
But now we also know that lots of manic patients can also be very uncomfortable, anxious, and overdriven. They don't like it. It's what we call dysphoric mania, and two thirds of women actually have this uncomfortable or dysphoric mania. It can actually become more dysphoric over time. People who use substances of abuse are more likely to move into dysphoric mania as well.
It depends on the person, and it also depends on whether somebody has this hypomanic form of bipolar illness, or the full blown manic illness, where they tend to be totally out of control. Those two tend to recur with a fair bit of similarity with each episode. And the same thing for the depressions, although occasionally someone can move from a very slowed down depression or a very anxious one or the other way around, but typically the kind of episode one has tends to repeat itself over time.
Can a person's symptoms ever get better or go away completely if they don't have treatment? That's sort of a hooker of a question. It's an easy answer with treatment: Yes, with treatment, definitely yes. Without treatment, we think it's extraordinarily rare, almost never. There are a couple of people that I've heard about where that's supposed to have happened, but it usually is more like diabetes or high blood pressure — it really needs treatment to be under control. Post, what about the progression of bipolar disorder and the changes in the brain?
You talked a little bit about some of this stuff, but how do they know this? Do they see it on imaging technology or irreversible behavior patterns?
How do they know this? A couple of different ways: In people with recurrent unipolar depression, just depressions and no manias for example, they see that the more time depressed, the smaller is one's hippocampus, this area of the brain that's necessary for memory.
You can measure this directly on an MRI scan, and they see that the volume of the hippocampus decreases with aging and more time depressed. However, if you're treated with anti-depressants, that prevents the hippocampal atrophy and that keeps the hippocampus normal sized. And we know that there are the same kinds of things going on in bipolar illness.
There are deficits in brain function in some of the cortical areas, and there's hyperactivity in some of the deeper areas of the brain that mediate emotions.
So it's like the higher cortical centers can't tell the lower ones to kind of shut up, be quiet, be appropriate, and there's a loss of normal control of mood, and there are over-swings in terms of the manic and depressive directions. Now we know with treatment that some of those losses can be prevented. There are three studies now indicating that lithium can actually increase the amount of gray matter in brain, the part of the brain that relates to neurons.
And that happens in patients with bipolar illness but not controls. So there looks like there can be progression that you can see on various brain imaging techniques, but that this can be stopped with our good medicines. It can in kind of funny ways. You can have a lot of other illnesses that go with it, like what we call comorbidities, or other disorders. Like, it is very common to have a full blown anxiety disorder with bipolar illness.
That makes it a little bit more complicated and difficult to treat. Another big problem is that people with bipolar illness are more likely to pick up alcohol problems or substance abuse problems than folks in the general population. We think that this is in part to try to self-medicate and get after their depressions.
Also they have lot of misjudgment of what's safe or not when they're hypomanic or manic. So these illnesses can accumulate.
Then as I mentioned before, you can also begin to have more medical illnesses that come with untreated depression. So things can subtly evolve and get worse in that way. The other thing we know is that in some youngsters who have both bipolar illness and substance abuse that one place they show up, which is tragic, is in jail.
They can have such poor judgment that they do things off-the-wall and get involved in the legal system, and there are a lot of folks with bipolar illness and substance abuse that are actually in jail now.
So with episodes that sort of progress and get out of control and are not adequately treated, there can be a lot of havoc in one's life either from the depressions or the manias. How about other mental illnesses? Can bipolar progress into schizophrenia or some other type of mental illness?
It doesn't look like it happens that often, no. It tends to have this recurrence of the fairly similar kind of episode. But if somebody has too many depressions, they can actually progress to having cognitive difficulties and trouble with thinking and remembering, and that looks like that's a function of the number of episodes one has.
So that's a real problem — that it can progress into cognitive problems and learning and memory difficulties. We've been talking about how bipolar disorder can progress if it goes untreated. Bipolar is often misdiagnosed, so what about progression with the wrong treatment? For example, if somebody is being treated for depression when they actually have bipolar disorder, can that change the way those symptoms progress, Doctor?
Yeah, sometimes it can, because the treatment with just regular anti-depressants isn't very good for bipolar illness. It isn't even very good for bipolar depressions per se. There was just a recent study from the NIMH National Institute of Mental Health that was published in the New England Journal of Medicine that indicated that if you added an anti-depressant to a mood stabilizer, something like lithium or valproate for bipolar depression, that addition of the anti-depressant was not successful in improving the depression compared to placebo.
So we have really good anti-depressants for unipolar illness, but we have to treat bipolar illness with other than anti-depressants. And that's why it's so important to make the distinction between just regular recurrent depression and bipolar depression.
How does a person know if they're on the wrong treatment? What symptoms should they look for? If they're having episodes that are breaking through of some severity, and they're having lots of problems with dysfunction because of that, either because of depression or mania, they should presume that they're not yet on the right treatment because the goal is to really get rid of these episodes and prevent them from recurring. So if somebody has recurrent episodes of moderate to severe depression or periods of hypomania or mania where their friends and family members are telling them they're totally out of control or their boss tells them don't come to work because they're so outrageous, they're not on the right treatments yet.
A lot of people stick with the wrong treatment and try to make it work. What should they be doing instead? That's a really good question. They should be trying to educate themselves more and get opinions from their doctor. If the doctor says that he's stumped, they should ask for a consultation with another doctor who might have some ideas about other things that are more effective.
I was at the National Institutes of Mental Health for 36 years. When I first started doing research there, we only had, really, lithium and a few other treatments. Now we have lithium, a whole bunch of drugs that are used for seizures, these anti-convulsants that have mood stabilizing properties, a whole bunch of new major tranquilizers, what we call atypical anti-psychotics. There are lots and lots of different kinds of options for treating people. So if they're having difficult symptoms, they should explore other options.
And the same with side effects — some of these drugs have very different side-effect profiles than others. The goal is no more episodes and very few, if any, side effects. And that can often be achieved, but sometimes it takes years and years of trying to figure it out and make little adjustments for it to occur. So I think the thing to do is to push the treating doctors for keeping after their illness.
Another thing they can do is to bring a record or a mood chart in every time they see the doctor so that they can rate their mood on a daily basis and see what kind of patterns of mood fluctuations there are that are breaking through treatment and try to specifically go after those. Obviously we talked about how bipolar disorder can get worse without treatment, but how does it progress if the patient has the right treatment? If your symptoms are under control, does that mean that the disease has stopped progressing in any way?
We think that's pretty much the case, that if you stop having episodes, that really stops the main mechanism that we think is driving illness progression. We think the episodes themselves are making things worse, because every time you have an episode, these brain-protective factors are dropping, and you have increases in toxic factors that hurt the brain.
So if you're having good treatment and not having these episodes, that, we think, is the best case scenario. Can symptoms return after being successfully treated for many years, or are you always at risk of having an episode even when your treatment is working? Actually both of those things. If somebody is doing well for three, four, five years, the longer they stay well, the more likely it is that they're on the right treatment, and they're going to stay well.
But even then there's a small subgroup of people who begin to have breakthrough episodes, and they need to change the treatment and get revisions in the treatment.
We call that a tolerance pattern where the episodes can begin to break through previously successful treatment. That doesn't happen very often, but it does sometimes, and it requires new treatment approaches. But the other thing I think that you were asking about is that if you're well for 20 years, say on lithium, and then you go off your medicine, your risk of relapse is very high. So the illness doesn't go away in terms of your vulnerability to recurrence no matter how long you've been well.
If your symptoms do return, does that mean the disease is progressing despite the treatment, and should you change you course of treatment? Well, no, if you go off the treatment and they return, that's one thing.
That means the treatments were holding it, and going off has let it go again. It's just like my blood pressure or my cholesterol.
I have high levels of both, and I had a heart attack in And I take two meds to keep my cholesterol normal and two medications to keep my blood pressure normal. And everybody listening on this phone line knows what happens if I stop taking those drugs. My blood pressure and cholesterol are going to get right back up, and I may not have an immediate heart attack, but I'm at risk for it. So it's the same kind of thing. When the meds are working in this illness, they should get left alone.
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