This section covers diagnosis and treatments:
Bipolar disorder operates on a spectrum that includes four types. To be diagnosed with any form of Bipolar disorder, one must meet the criteria set out in the Diagnostic and Statistical Manual of Mental Disorder (the DSM).
- Bipolar I Disorder ~ defined by manic or mixed episodes that last for more than a week, or by manic symptoms so severe hospitalization is required. There is usually a depressive episode lasting longer than 2 weeks. This is the “classic” form of the illness
- Bipolar II Disorder ~ characterized by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic or mixed episodes.
- Bipolar Disorder Not Otherwise Specified (BP-NOS) ~ used when symptoms of Type I or Type II are not present, but the behavior is clearly not within the normal range for that person.
- Cyclothymic Disorder, or Cyclothymia ~ a mild form of Bipolar Disorder (there has been some talk as to whether to include this in the Bipolar Spectrum). It is used when the person has episodes of hypomania as well as mild depression for at least 2 years. The symptoms do not meet the criteria for Bipolar Disorder as laid out in the DSM.
Since people are more likely to seek out treatment when depressed, the diagnosing clinician should take a very specific medical history to avoid a misdiagnosis of Major Depressive Disorder. People who what they refer to as Unipolar Depression do not have manic or hypomanic episodes.
Bipolar Disorder can get worse with time if left untreated. Episodes may be more frequent or more intense. In addition, delays in getting the correct diagnosis can lead to significant personal, social and work-related problems (oh, how well I know that having been fired from 2 jobs before being correctly diagnosed with Type I Bipolar). Proper treatment of the illness can help reduce the frequency and intensity of the episodes making it possible for a person with manic-depresseive illness able to lead a full and productive life.
Substance abuse is high among Bipolars although the reasons for the connection are not clear. The working hypothesis is that people are self-medicating. Taking CNS inhibitors like alcohol or certain groups of pills to bring themselves down, and using stimulants when feeling depressed.
Anxiety Disorders such as PTSD, social phobia and generalized anxiety often co-occur in people with Bipolar Disorder. Bipolar Disorder is also co-morbid with ADHD/ADD which both mimic some of the symptoms of Bipolar like restlessness or an inability to focus. I am one such lucky individual to have the PTSD, Social Phobias, and ADD. Makes for an interesting ride sometimes.
Now we get into the fun stuff: medication, or the “med-go-round” as I have named it. Bipolar Disorder cannot be cured but it can be effectively managed. Proper treatment can help many people ~even those with the most severe forms ~ manage their mood swings and the resulting behavior. As it is a lifelong illness, treatment is an ongoing long-term process and even those who have most successfully recovered may have continued albeit not as intense mood swing and changes in behavior. The NIMH funded “Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)” is the largest study ever conducted on Bipolar Disorder. It found that almost half of those who had recovered still had lingering symptoms, and having additional mental disorders increased the chance of relapse (no wonder I cannot hold down a job).
Treatment is most effective when the patient works closely with his or her doctor and there is open and honest communication about medication and how the patient feels they are doing on it. The most effective treatment plan usually includes medication and psychotherapy.
This is where the patient gets turned into a guinea pig. I am really not kidding. Finding the right medications to stabilize a person’s mood and therefore their behavior is a really un-fun (yes, I know that’s not a word) proposition. There are many different types of medication used for the treatment of Bipolar Disorder. One suggestion for the early phases of medicating a person is to have the patient log their moods, sleep patterns, and “life events”/stress/anxiety and tell the psychiatrist about side effects, especially if they become intolerable, or if your moods change for the worst. That will give the clinician an idea of what’s working and what’s not working. Although, my experience with the first go at medication had me on 6 different medications. How could they tell what worked and what didn’t? I eventually found a psychiatrist who thinks the way I do about medication. The fewer to accomplish the goal, the better.
There are a few basic types of medication used to treat Bipolar Disorder. They include mood stabilizers like Lithium, atypical antipsychotics like Abilify, and anti-depressants although one has to be careful with that class of medication as it can provoke a manic episode and/or increase mood cycling.
Lithium is the mood stabilizer of choice when a person first steps on the med-go-round. Lithium is a trace element that everyone needs to live, but in much higher doses, it is an effective mood stabilizer. Unless you are allergic to it as I am. Then, it does nothing for your mood because you are feeling like you have the flu all the time. Essentially, you are being poisoned. But, it does work for a lot of people. It was the first of the mood stabilizers to be approved for use by the FDA in the 1970’s for treating both mania and depression.
Anti-convulsants are also used as mood stabilizers although their primary purpose is to treat seizures associated with Epilepsy or other seizure disorders. The ones most commonly used are Depakote, which was approved in 1995 although there are special risk factors for younger women, Lamictal which can be effective in treating depression but comes with a “black box” warning that it may have serious side effects such as Steven-Johnson Disease which can be fatal. The anti-convulsant category comes with the FDA warning that use may increase suicidal ideation and behavior. Tried both of the above and side effects were intolerable, and didn’t need to be more suicidal than I already was. Doctors and patients need to closely monitor the effects of the anti-convulsants for any mood changes for the worse, and suicidal thoughts and/or behavior.
All of the medications in the category “mood stabilizer” have lengthy lists of side effects including dry mouth, bloating, restlessness, joint or muscle pain, and others. Other common side effects include drowsiness, dizziness, headaches, mood swings and cold-like symptoms. Medication is fun!
Atypical anti-psychotics (the new breed of Thorazine without the drooling) are sometimes used to stabilize mood and behavior. The most prominent are Zyprexa usually used with an antidepressant to control mania and psychosis, Abilify used for manic or mixed episodes, and Seroquel, Resperidal, and Geodon also used to treat mania.
I currently take 30 mg of Abilify each morning, with Welbutrin and Klonopin (for anxiety), and 500 mg of Seroquel at night as it knocks me out cold for a good 9 hours (see post on Waking up On Seroquel). Geodon is worse. Won’t take it, don’t even try.
The side effects of atypical antipsychotics are not nearly as bad as their predecessors. First of all, don’t drive until you know how they affect you (I once had the world tilt 90 degrees while at the grocery store, and I had driven my car there. That was not cool). The list of side effects for the atypicals is fairly short: drowsiness, dizziness upon standing, blurred vision, rapid heartbeat, sun sensitivity, and a couple of others.
I am going to skip the anti-depressant category because most people have either taken one of them personally or know someone who does. The only problem with using them for Bipolar depression is mood switching and rapid cycling of moods.