| Bipolar Disorder

NIH Publication No. 95-3679September 1995
What is Bipolar Disorder?AwarenessRecognitionTreatmentGetting HelpFor further information contact:Message from the Director of the NIMH
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**WHAT IS BIPOLAR DISORDER?**
Bipolar disorder--which is also known as manic-depressive illnessand will be called by both names throughout this publication--is amental illness involving episodes of serious mania and depression.  Theperson's mood usually swings from overly "high" and irritable to sadand hopeless, and then back again, with periods of normal mood inbetween.
Bipolar disorder typically begins in adolescence or early adulthoodand continues throughout life.  It is often not recognized as anillness, and people who have it may suffer needlessly for years oreven decades.
Effective treatments are available that greatly alleviate thesuffering caused by bipolar disorder and can usually prevent itsdevastating complications.  These include marital break-ups, job loss,alcohol and drug abuse, and suicide.
**Here are some facts about bipolar disorder.**
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**AWARENESS**
**Manic-depressive illness has a devastating impact on many people.**
- At least 2 million Americans suffer from manic-depressiveillness.  For those afflicted with the illness, it is extremelydistressing and disruptive. Like other serious illnesses, bipolar disorder is also hard onspouses, family members, friends, and employers.
Family members of people with bipolar disorder often have tocope with serious behavioral problems (such as wild spending sprees)and the lasting consequences of these behaviors.
Bipolar disorder tends to run in families and is believed to beinherited in many cases.  Despite vigorous research efforts, a specific genetic defect associated with the disease has not yet been detected.
Bipolar illness has been diagnosed in children under age 12, althoughit is not common in this age bracket. It can be confused with attention deficit/hyperactivity disorder, so careful diagnosis is necessary.
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**RECOGNITION**
**Bipolar disorder involves cycles of mania and depression.**
***Signs and symptoms of mania include discrete periods of:***
- Increased energy, activity, restlessness, racing thoughts, andrapid talking Excessive "high" or euphoric feelings
Extreme irritability and distractibility
Decreased need for sleep
Unrealistic beliefs in one's abilities and powers
Uncharacteristically poor judgment
A sustained period of behavior that is different from usual
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
Provocative, intrusive, or aggressive behavior
Denial that anything is wrong
***Signs and symptoms of depression include discrete periods of:***
- Persistent sad, anxious, or empty mood Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in ordinary activities, including sex
Decreased energy, a feeling of fatigue or of being "slowed down"
Difficulty concentrating, remembering, making decisions
Restlessness or irritability
Sleep disturbances
Loss of appetite and weight, or weight gain
Chronic pain or other persistent bodily symptoms that are notcaused by physical disease
Thoughts of death or suicide; suicide attempts
It may be helpful to think of the various mood states in manic-depressive illness as a spectrum or continuous range.  At one end is severe depression, which shades into moderate depression; then come mild and brief mood disturbances that many people call "the blues," then normal mood, then hypomania (a mild form of mania),and then mania.
Some people with untreated bipolar disorder have repeated depressionsand only an occasional episode of hypomania (bipolar II).  In theother extreme, mania may be the main problem and depression may occuronly infrequently.  In fact, symptoms of mania and depression may bemixed together in a single "mixed" bipolar state.
Descriptions provided by patients themselves offer valuable insightsinto the various mood states associated with bipolar disorder:
**Depression:***I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point ofbeing virtually useless....[I am] haunt[ed]...with the total, the desperate hopelessness of it all... Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do.  If I can't feel, move, think, or care, then what on earth is the point?*
**Hypomania:***At first when I'm high, it's tremendous...ideas arefast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible.  Your marrow is infused with unbelievable feelingsof ease, power, well-being, omnipotence, euphoria...you can do anything...but, somewhere this changes.*
**Mania:***The fast ideas become too fast and there are far toomany...overwhelming confusion replaces clarity...you stop keeping up with it--memory goes.  Infectious humor ceases to amuse.  Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped.*
Recognition of the various mood states is essential so that the person who has manic-depressive illness can obtain effective treatment and avoid the harmful consequences of the disease, which include destruction of personal relationships, loss of employment, and suicide.
**Manic-depressive illness is often not recognized by the patient, relatives, friends, or even physicians.**
- An early sign of manic-depressive illness may be hypomania--a state in which the person shows a high level of energy, excessive moodiness or irritability, and impulsive or reckless behavior. Hypomania may feel good to the person who experiences it.  Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong.
In its early stages, bipolar disorder may masquerade as a problem other than mental illness.  For example, it may first appear as alcohol or drug abuse, or poor school or work performance.
If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression.
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**TREATMENT**
**Most people with manic-depressive illness can be helped with treatment.**
- Almost all people with bipolar disorder--even those with the most severe forms--can obtain substantial stabilization of their mood swings. One medication, lithium, is usually very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.
Most recently, the mood stabilizing anticonvulsants carbamazepine andvalproate have also been found useful, especially in more refractory bipolar episodes.Often these medications are combined with lithium for maximum effect.
Some scientists have theorized that the anticonvulsant medications work becausethey have an effect on 
kindling
, a process in which the brain becomes increasinglysensitive to stress and eventually begins to show episodes of abnormal activity evenin the absence of a stressor.  It is thought that lithium acts to block the earlystages of this kindling process and that carbamazepine and valproate act later.
Children and adolescents with bipolar disorder are generally treated with lithium,but carbamazepine and valproate are also used.
Valproate has recently been approved by the Food and Drug Administration for treatment of acute mania.
The high potency benzodiazepines clonazepam and lorazepam may be helpful adjuncts for insomnia.
Thyroid augmentation may also be of value.
For depression, several types of antidepressants can be useful when combined with lithium, carbamazepine, or valproate.
Electroconvulsive therapy (ECT) is often helpful in the  treatment of severe depression and/or mixed mania that does not respond to medications.
As an adjunct to medications, psychotherapy is often helpful in providing support, education, and guidance to the patient and his or her family.
Constructing a life chart of mood symptoms, medications, and life events mayhelp the health care professional to treat the illness optimally.
Because manic-depressive illness is recurrent, long-term preventive (prophylactic)treatment is highly recommended and almost always indicated.
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**Getting Help**
Anyone with bipolar disorder should be under the care of apsychiatrist skilled in the diagnosis and treatment of thisdisease.
Other mental health professionals, such as psychologists andpsychiatric social workers, can assist in providing the patient andhis or her family with additional approaches to treatment.
***Help can be found at:***
- University- or medical school-affiliated programs Hospital departments of psychiatry
Private psychiatric offices and clinics
Health maintenance organizations
Offices of family physicians, internists, and pediatricians
**People with manic-depressive illness often need help to get help.**
- Often people with bipolar disorder do not recognize how impaired they are or blame their problems on some cause other than mental illness. People with bipolar disorder need strong encouragement from family and friends to seek treatment.  Family physicians can play an important role for such referral.
If this does not work, loved ones must take the patient for proper mental health evaluation and treatment.
If the person is in the midst of a severe episode, he or she may have to be committed to a hospital for his or her own protection and for much needed treatment.
Anyone who is considering suicide needs immediate attention, preferably from a mental health professional or a physician; school counselors and members of the clergy can also assist in detecting suicidal tendencies and/or making a referral for more definitive assessment or treatment.  With appropriate help and treatment, it is possible to overcome suicidal tendencies.
It is important for patients to understand that bipolar disorder will not go away, and that continued compliance with treatment is needed to keep the disease under control.
Ongoing encouragement and support are needed after the person obtains treatment, because it may take a while to discover what therapeutic regimen is best for that particular patient.
Many people receiving treatment also benefit from joining mutual support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association.
Families and friends of people with bipolar disorder can also benefit from mutual support groups such as those sponsored by NDMDA and NAMI.
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**FOR FURTHER INFORMATION CONTACT:**
- National Institute of Mental Health Information Resources and Inquiries Branch6001 Executive Boulevard
- Room 8184, MSC 9663 Bethesda, MD  20892-9663Telephone: 301-443-4513
- FAX: 301-443-4279 TTY: 301-443-8431FAX4U: 301-443-5158
- Website:  http://www.nimh.nih.gov  E-mail: [email protected]
National Depressive and Manic Depressive Association
- 730 Franklin Street, Suite 501 Chicago, IL  60610Telephone: 312-642-0049;  1-800-826-3632
- FAX: 312-642-7243   Website: http://www.ndmda.org
National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
Telephone: 703-524-7600;  1-800-950-NAMI (6264)
- FAX: 703-524-9094 Website: http://www.nami.org
National Foundation for Depressive Illness, Inc.
- P.O. Box 2257 New York, NY  10116Telephone: 212-268-4260;  1-800-239-1265
- FAX: 212-268-4434 Website: http://www.depression.org
National Mental Health Association
- 1021 Prince Street Alexandria, VA  22314-2971Telephone: 703-684-7722;  1-800-969-NMHA (6642)
- FAX: 703-684-5968 TTY: 1-800-433-5959Website: http://www.nmha.org
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***MESSAGE FROM THE NATIONAL INSTITUTE OF MENTAL HEALTH**
The year 1996 marks the fiftieth anniversary of the National Institute of Mental Health(NIMH).  Throughout the past 50 years, the results of research supported by the Institutehave brought new hope to millions of people who suffer from mental illness and to their families and friends.  In work with animals as well as human participants, researchers haveadvanced our understanding of the brain and vastly expanded the capability of mental healthprofessionals to diagnose, treat, and prevent mental and brain disorders.
During this last decade of the twentieth century--designated "The Decade of the Brain"by the U.S. Congress--knowledge of brain function has exploded.  Research is yielding information about the causes of mental disorders such as depression, bipolar disorder,schizophrenia, panic disorder, and obsessive-compulsive disorder.  With this knowledge,scientists are developing new therapies to help more people overcome mental illness.
The National Institute of Mental Health is part of the National Institutes of Health (NIH),the Federal Government's primary agency for biomedical and behavioral research.  NIH isa component of the U.S. Department of Health and Human Services.

Acknowledgments
This publication was written by Mary Lynn Hendrix of the Office of Scientific Information, National Institute of Mental Health.  Expert assistance was provided by Frederick K. Goodwin, M.D., Robert M. Post, M.D., Hagop S. Akiskal, M.D., andWilliam Z. Potter, M.D.
All material in this pamphlet is free of copyright restrictions and may be copied,reproduced, or duplicated without permission from the Institute; citation of the sourceis appreciated.
U.S. Department of Health and Human ServicesNational Institutes of Health
NIH Publication No. 95-3679September 1995* |
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