Bipolar Affective Disorders


What is Bipolar Affective Disorder ?

“Bipolar Affective Disorder” is sometimes called “Manic Depression” or “Bipolar illness”. In this condition one has periods (several weeks or months), where one’s mood (affect) is in one extreme or another.
  • One extreme is called Depression where one feels 'low' and have other symptoms.
  • The other extreme is called Mania (or hypomania if symptoms are less severe) where one feel 'high' or elated along with other symptoms.
The length of time one spends in each extreme can vary. It is usually for several weeks or months at a time. Bipolar Affective Disorder is very different from the mood swings that moody people have which last minutes or hours.

One can have any number of episodes of highs and lows throughout one’s life. In between episodes of highs or lows there may be gaps of weeks, months or years when one’s mood is normal. However, some people swing from highs to lows quite quickly without a period of normal mood in between. This is called 'rapid cycling'. (If one has the rapid cycling form of the illness one has at least four mood swings per year.)

Who gets Bipolar Affective Disorder ?

About 1 in 100 people develop this condition at some stage in life. It can occur at any age, but most commonly first develops between the ages of 18 and 24. It occurs in the same number of men as women. The rapid cycling form of the illness occurs in about 1 in 6 cases.

(Note: mania or hypomania occur in only a small number of people who develop depression. It is much more common to just have depression without episodes of mania or hypomania.)

What causes Bipolar Affective Disorder ?

The cause is not known. One’s genetic makeup seems to play a part as one’s chance of developing this condition is higher than average if other members of one’s family are affected. Stressful situations may trigger an episode of mania or depression in people prone to this condition. However, stress is not the underlying cause.

What are the symptoms of Mania and Hypomania ?

Mania causes an abnormally 'high' or irritable mood which lasts at least one week - but usually lasts much longer than this. It can develop quite quickly - over a few days or so.

When one is 'high' one will usually have at least 3 or 4 of the following:
  • Grand ideas about oneself and one’s own self importance.
  • Increased energy. One also tends to move quickly and need less sleep than usual.
  • Be more talkative than usual. One tends to talk quickly.
  • 'Flight of ideas'. One tends to quickly change from one idea to another. One may feel as if one’s thoughts are racing.
  • Easily distracted. One’s attention is easily drawn to unimportant or irrelevant things.
  • Full of new ideas and plans. Often the plans are grandiose and unrealistic.
  • Irritation or agitation, particularly with people who do not seem to understand one’s 'great' ideas and plans.
  • Wanting to do lots of pleasurable things (but these can often lead to painful consequences). For example, one may:
    • Spend a lot of money (which one often cannot afford).
    • Be less inhibited about one’s sexual behavior.
    • Make rash decisions, often on the spur of the moment. These can be about jobs, relationships, money, health, etc, and are often disastrous.
    • Take part in risky 'exciting' adventures.
    • Drink a lot of alcohol, or take illegal drugs.

Severe mania may also cause 'psychotic' symptoms where one loses touch with reality. For example, one may hear voices which are not real (hallucinations), or have false beliefs (delusions). These tend to be delusions of importance (such as believing that one is a famous celebrity).

Usually, one does not realize that one has a problem when one is high. But, as the illness develops, to others the patient’s behavior can be bizarre. Family and friends tend to be the ones who realize that there is a problem. But, if someone tries to point out that the patient is behaving oddly, he/she tends to become irritated.

If mania is not treated, the bizarre and uninhibited behavior may cause great damage to one’s relationships, job, career, and finances. When one recovers from an episode of mania, one often regrets many of the things that one did when one was high.

Hypomania is the term used when one is high, but the symptoms are less severe or extreme as in true mania. One may function quite well if one has hypomania. For example, one may just appear to be full of energy, the 'life and soul' of the party, work too much, but find it difficult to 'switch off' and relax. However, one is still at risk of making rash and dangerous decisions. Family and friends will recognize that the patient is not his/her normal self.

What are the symptoms of Depression ?

The word depressed is a common everyday word. People may say "I'm depressed" when in fact they mean "I'm fed up because I've had a row, or failed an exam, or lost my job" etc. These ups and downs of life are common and normal.

With true depression (clinical depression), one has low mood and other symptoms each day for at least two weeks. Symptoms also become severe enough to interfere with day-to-day functions. The following is a list of common symptoms of depression. One may not have them all, but one usually develops several if one has depression.

  • Low mood for most of the day, nearly every day. Things always seem 'black'.
  • Loss of enjoyment and interest in life, even for activities that one normally enjoys.
  • Abnormal sadness, often with crying.
  • Feeling guilty, worthless, or useless.
  • Poor motivation. Even simple tasks seem difficult.
  • Poor concentration. It may be difficult to read, work, etc.
  • Sleeping problems.
    • Sometimes difficulty in getting off to sleep.
    • Sometimes waking early and unable to get back to sleep.
    • Sleeping too much sometimes occurs.
  • Lacking in energy, always tired.
  • Difficulty with affection, including going off sex.
  • Poor appetite and weight loss. Sometimes the reverse happens with comfort eating and weight gain.
  • Being irritable, agitated, or restless.
  • Symptoms often seem worse first thing each day, and gets gradually better later in the day or in the evening.
  • Physical symptoms such as headaches, palpitations, chest pains, and 'aches and pains'.
  • Recurrent thoughts of death. This is not usually a fear of death, more a preoccupation with death and dying. Some people get suicidal ideas - "life's not worth living".

Some people do not realize when they develop depression. They may know that they are not right and are not functioning well, but don't know why. Some people think that they have a physical illness, for example, if they lose weight.

What is the usual pattern and outcome of the condition ?

Bipolar Affective Disorder is a lifelong condition. There is no usual pattern. Every case is different. Some general points include the following.

Without treatment :-

  • The average length for an episode of mania is four months. But for some people it can last much longer.
  • The average length for an episode of depression is 6-9 months. But again, it can be longer.
  • One cannot predict how often episodes of mania and depression will occur.
    • After recovering from an episode of mania, a further episode of mania or depression occurs within 1 year in about half of cases; and within 5 years in about 7 out of 10 cases.
    • Some people only ever have one episode of mania for a few weeks or months.
    • The rapid cycling form of the illness occurs in about 1 in 6 cases.
  • Some people have 'mixed states' where symptoms of both mania and depression occur at the same time. For example, a low mood, but with racing thoughts.

So, some people have more frequent and severe episodes than others. Because of the nature of the condition, one’s chance of holding down a job is less than average. Relationships can be strained. Also, one has an increased risk of suicide if depression becomes severe and an increased risk of death from risky adventures during an episode of mania. The outlook is worse if one takes street drugs or drinks a lot of alcohol.

With treatment:

The course, pattern and outlook of the condition can be improved. However, there is no once and for all 'cure'.

What is the treatment for Bipolar Affective Disorder ?

Treatments include:

  • Medicines that aim to prevent episodes of mania, hypomania and depression. These are called 'mood stabilizers'. You take these every day, long-term.
  • Treating episodes of mania, hypomania and depression when they occur.
  • A. Lithium
    Lithium is the most commonly used medication for Bipolar Affective Disorder. It comes as a tablet and has been used for many years. However, it is not clear how it works. It is used to treat episodes of mania, hypomania and depression. It is also taken by many people long-term as a 'mood stabilizer' to prevent episodes. Lithium often works well, but does not work in all cases. It tends to prevent episode of mania better than episodes of depression.

    One problem with lithium is that the dose for an individual has to be 'just right'. Too low a dose has little effect. Too high a dose and side-effects can be a problem. So, if one take lithium, one need to have blood tests from time to time to check the dose is just right for you.

  • B. Anticonvulsant medicines
    Sodium Valproate, Carbamazepine, and Lamotrigine are also used to treat episodes of mania. They are also used long-term as 'mood stabilizers'. (Anticonvulsant medicines are commonly used to treat epilepsy but have been found to be working in Bipolar Affective Disorder too. However, it is not clear how they work in this condition.) Sometimes one of these medicines is used alone. Some people take an anticonvulsant in addition to lithium if lithium alone does not work so well.

  • C. Antipsychotic medicines
    One of these may be used to treat an episode of mania or hypomania. Another name for these is 'Major Tranquillisers'. They include Chlorpromazine, Haloperidol, Risperidone and Olanzepine, but there are others. Some are more 'sedating' than others. Once one of these medicines is started, the symptoms of mania often settle within a week or so. These medicines are usually stopped once the symptoms have gone. They are not usually used as long-term 'mood stabilizers'.

Treating episodes of depression :-

The treatment of depression in people with Bipolar Affective Disorder is similar to that for people who develop depression without episodes of mania.
  • A. Antidepressant medicines are commonly prescribed for all types of depression.
    • Antidepressants work well to relieve symptoms in about 7 out of 10 cases.
    • They do not usually work straight away. It takes 2-4 weeks before their effect builds up fully. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. So, one has to persevere if one is prescribed an antidepressant medicine.
    • A normal course of antidepressants is for 6 months or more after the symptoms of depression have eased. If you stop them too soon the depression may quickly return.
    • There are several types of antidepressants, each with various 'pros and cons'. For example, they differ in their possible side-effects. (The leaflet that comes in the medicine packet provides a full list of possible side-effects.)
    • One uncommon problem with antidepressants is that they can 'trigger' an episode of hypomania in some people.
  • B. Lithium :- is used to treat depression as well as being a mood stabilizer. A combination of lithium and an antidepressant may be used to treat episodes of depression.

  • C. Cognitive therapy :- (if available in one’s area) is another option which can work well to treat depression. It is a type of psychotherapy ('talking' treatment).

  • D. Regular exercise may also help to ease symptoms of depression.

Compulsory treatment :-

When one has an episode of mania or hypomania, usually one does not realized that one is ill. It is sometimes necessary to give treatment against one’s will if one has symptoms which are putting him/her or other people, at risk of harm. A short admission to hospital is sometimes needed.

Other treatments and new developments :-

Research continues to try and find better 'mood stabilizer' medicines. New non-drug treatments such as Trans-cranial Magnetic Stimulation (TMS) and Vagal Nerve Stimulation (VNS) are being studied.

What can one do to help ?

  • One should try to avoid stressful situations which may trigger an episode of mania or depression. This is often easier said than done. But, a change in lifestyle may be appropriate for some people.
  • One should try not to drink much alcohol or take any street drugs. These may trigger an episode of mania.
  • If one is prescribed a mood stabilizer medicine, one should take it regularly. Sometimes, suddenly stopping a mood stabilizer can trigger an episode of mania. So, if one gets any side-effects, he/she should consult his/her doctor. The dose of type of medication can often be changed, but this should be done with the advice of a doctor.
  • One should consider being quite open to family and friends about one’s illness. If they understand the condition, they may be able to tell if one is becoming ill, even if the patient does not realize it himself/herself. Particularly if one is developing an episode of mania. Rather than thinking of you as 'bizarre' they may think of you as ill and may encourage you to get help.
  • One should learn about one’s illness. It has been shown that if a patient has been taught to recognize the early stages of mania, he/she is more likely to seek help and treatment which may prevent a major episode developing. One’s doctor or psychiatrist may help to teach about recognizing when to seek help.
  • One should consider joining a self-help or patient group.
  • When one is well, he/she should consider putting some safeguards on his/her money so that he/she cannot overspend if he/she becomes high. For example, if one is married, one should consider putting one’s bank account solely in the name of the spouse.
  • If one are the main or only carer of children (for example, if one is a single parent), it is important that someone else who knows the patient well is aware that he/she may become ill quite quickly and not be able to care for his/her children properly.

Family and friends

Episodes of mania or depression can be distressing for family and friends, particularly the first episode of mania. Bizarre and odd behavior in a close relative or friend, which is out of character, can cause a lot of upset.

It may help once they know the diagnosis. They may then understand that the odd behavior of their friend or loved one is due to a mental illness. People with mania usually do not realize they are ill. So, family and friends are often of great help in alerting a doctor or other health worker if symptoms of a new episode of illness develop.Family and friends should try to encourage the affected person in the 'self help' measures listed above.
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