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BREAKING THE SILENCE: BIPOLAR DISORDER

Written by  Susan Dubuque

 

This series explores diseases that can be devastating to the individuals and families they affect—yet no one is talking about them. That is, until now. In each edition of Our Health, we bring these medical issues into the light—and dedicate these stories to the courageous patients and families living with them and the providers and researchers who commit their lives to treating and seeking cures for these silent killers.

Claire’s Story

“Hi, how many for dinner? Please come this way.” With a bright smile and sunny disposition, Claire Wenzel greets her guests in her role as hostess for a local chain restaurant—a job that she greatly enjoys and is very good at performing. But such confidence and competency weren’t always the case.

“Claire was evaluated for the first time when she was just six years old,” shares her mother, Donna Wenzel. “She would cry over the smallest thing, and her temper tantrums were way out of proportion to whatever was happening at that time.” Most frightening of all, even at that young age, Claire had suicidal thoughts.

Matters went from bad to worse. As an adolescent, Claire exhibited extreme mood swings, impulsivity and poor judgment. She repeated got in trouble in school and home—fighting with classmates and her siblings. By 10th grade her behavior was so out of control that she had to be hospitalized. It was during this inpatient stay at the VCU Virginia Treatment Center for Children that Bela Sood, MD, child psychiatrist, confirmed Claire’s diagnosis as bipolar disorder. “What looked like defiant behavior,” recalls Donna, “was actually the result of maniac episodes and psychosis.” While Claire’s behavior seemed outrageous, she simply couldn’t help it.

The family can now look back with humor at some of Claire’s antics when she was in a maniac state. One summer, Claire went on Craig’s List and started adopting pets. Seven or eight cats and a dog were delivered to the family’s home before Claire’s parents realized what was going on. And then there was the home-buying spree. At age 10, Claire filled out a loan application online for the purchase of a luxury home. “The real estate agent was sorely disappointed when he called the house asking for Ms. Claire Wenzel, only to be told she was outside playing,” says Donna.

Humor and loving support have been ongoing survival strategies for Wenzel family. “When you have 11 children—now ranging in age from 13 to 30—you better have a sense of humor,” remarks Donna. Along the way the family has had to cope with its share of tragedy. In 2012, Claire’s 21-year old brother, Luke, died unexpectedly and one month later Neil Wenzel, the children’s father, passed away. According to Donna, “Claire comes by her bipolar disorder honestly.”  Donna suspects that Claire’s father, although undiagnosed, experienced similar issues, and three of Claire’s brothers have also been diagnosed with bipolar disorder.

Despite the challenges and heartaches, today Claire is thriving. She attributes her stability and healthy outlook to finally achieving the right combination of medications and sticking with it—even when annoying side effects occur.

Claire has graduated from high school and is now working full time. She is looking forward to a bright future, full of promise. With a wink of one of her huge blue eyes, Claire declares that if not veterinary medicine, maybe she’ll go into real estate after all.

–It’s time to bring bipolar disorder into the light—and learn what this disorder is, the signs and symptoms, how it is diagnosed and treated and advances that may provide support and relief for those coping with this insidious disorder.

What is bipolar disorder?

Bipolar disorder—also known as manic-depressive illness—is a brain disorder that causes unusual shifts in mood, energy and activity levels that occur in distinct periods called “mood episodes.” An individual may go from an overly joyful or excited state, called a manic episode, to an extremely sad or hopeless state, called a depressive episode. Sometimes symptoms of both mania and depression occur during the same episode, which is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

“Everyone experiences highs and lows, but when ups and downs become times of life-altering and regrettable decision making and horrible moments of self-loathing and loss, bipolar disorder may need to be considered,” notes Karen Rice, licensed clinical social worker with the Virginia Home for Boys and Girls. If left untreated, bipolar disorder can result in damaged relationships, poor job or school performance and even suicide.

Bipolar disorder is not only a serious medical condition, but it is also one that affects many people. According to the World Health Organization, bipolar disorder is the sixth leading cause of disability in the world, affecting approximately 5.7 million adult Americans. To put that in perspective, more people lose productive time due to bipolar disorder than all forms of cancer combined.

According to Ananda Pandurangi, MD, psychiatrist with VCU Medical Center, “Bipolar is an equal opportunity illness. Roughly the same number of men and women develop the disorder and it occurs in all ages, races, ethnic groups and social classes.” The disorder typically emerges in late teens or early adult years, with at least half of all cases starting before age 25. Some people have their first symptoms during childhood, while others may develop symptoms late in life.

While there is no single gene identified with bipolar disorder, the family ties are definitely apparent. More than two-thirds of people with bipolar disorder have at least one close relative with the illness or with major depression, and if one identical twin has the illness, there is a 40 percent chance that the other twin will too.

Signs and Symptoms

So what does bipolar disorder look like? Well, it all depends. The signs and symptoms will vary depending upon the type of episode an individual is experiencing at that time.

Symptoms of mania or manic episodes include:

  • A long period of feeling “high,” or an overly happy or outgoing mood
    • Extreme irritability
    • Talking very fast, jumping from one idea to another, having racing thoughts
    • Being easily distracted
    • Increasing activities, such as taking on new projects
    • Being restless
    • Sleeping little or not feeling tired
    • Having an unrealistic belief in one’s abilities
    • Behaving impulsively and engaging in pleasurable, high-risk behaviors

Signs of hypomania—or a less severe form of mania—include:

  • Feeling euphoric, energetic and productive. (To others this may simply looks like the individual is unusually happy.)
  • Able to carry out day-to-day activities and never lose touch with reality
  • May lead to  bad decisions that harm relationships, careers and reputations
  • Often escalates to full-blown mania or is followed by a major depressive episode

And depression or depressive episode symptoms include:

  • A long period (two weeks or longer) of feeling worried or empty
  • Loss of interest in activities once enjoyed, including sex
  • Feeling tired or “slowed down”
  • Having problems concentrating, remembering and making decisions
  • Being restless or irritable
  • Changing eating, sleeping or other habits
  • Thinking of death or suicide, or attempting suicide

Diagnosing Bipolar Disorder

“Bipolar disorder may not be recognized as an illness, and people may suffer for as long as 10 years from the first onset until an accurate diagnosis is made,” says Martin Buxton, MD, psychiatrist at Chippenham and Johnston-Willis Hospitals. Perhaps the most important diagnostic tool is talking openly with a healthcare provider about mood swings and changes in behavior and lifestyle habits such as in diet, sleep and use of drugs and alcohol.

“A useful screening tool for bipolar disorder is the Mood Disorder Questionnaire,” notes Dr. Buxton.  “Individuals can complete this brief instrument online and share the results with their healthcare providers for further evaluation.”

 

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania. Therefore, a careful medical history is needed to ensure that bipolar disorder is not mistakenly diagnosed as major depression. Unlike people with bipolar disorder, people who have depression only (also called unipolar depression) do not experience mania. “A significant number of patients are discovered to have bipolar disorder when they present with symptoms of depression, are prescribed an antidepressant and flip into a manic state,” indicates Dr. Buxton.

The healthcare provider will also conduct a physical exam and take a complete family history. Although bipolar disorder cannot be identified through a blood test or a brain scan, these tests may help rule out other medical issues that may contribute to mood problems, like a stroke, brain tumor or thyroid condition.

There are challenges to diagnosing bipolar disorder. “We’re not dealing with a single disease,” explains Dr. Pandurangi. “Bipolar syndrome occurs across a spectrum.” Three forms of the disorder along this continuum are:

Bipolar I Disorder. A severe form of the illness that is characterized by episodes of both mania and depression. During the manic phase a patient may become psychotic—that is, have a break with reality. This may involve delusions (false beliefs) and hallucinations (seeing or hearing things that aren’t there).

Bipolar II Disorder. The individual experiences hypomania—milder than full-blown mania—and episodes of severe depression. This form of the illness is more common than bipolar I disorder, but it may be misdiagnosed as major depression.

Cyclothymia.  Characterized by mood swings that cycle between hypomania and mild depression. You might think of cyclothymia as “low grade” bipolar disorder. The cycles between moods tend to happen more quickly and be of shorter duration, and overall this form of the illness is less debilitating.

Some researchers suggest that there are more varieties, such as manic temperament, which is a personality type with behaviors that appear like a continuous mild mania.

Bipolar disorder can co-occur with other medical and mental health conditions. “The co-occurrence of bipolar disorder and drug or alcohol abuse may be as high as 60 percent and appears to be genetically linked,” indicates Dr. Gardner. Substance abuse may trigger or prolong bipolar symptoms, and the lack of judgement and problems with behavioral control that are associated with mania can in excessive drinking.

Anxiety disorders—like post-traumatic stress disorder (PTSD) and social phobia—often appear with bipolar disorder. And attention deficit hyperactivity disorder (ADHD) has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity and other physical illnesses. These illnesses may cause symptoms of mania or depression, and they may also result from treatment for bipolar disorder.

Treatment Options

There is no cure for bipolar disorder, however there are a number of treatments available to help people gain better control of their mood swings and manage their symptoms.

 

“There are three general types of medication used to treat bipolar disorder--mood stabilizers, antipsychotics and antidepressants,” says Dr. Pandurangi. “Not everyone responds to medication the same way. So patients may have to try several different drugs or combinations of drugs before finding what works the best.”

 

 

The initial choice for medication is usually a mood stabilizer. Lithium was the first mood stabilizer approved by the FDA, in the 1970s, for treating both manic and depressive episodes. Individuals who take lithium must have regular blood tests to monitor thyroid and kidney function. Anticonvulsant medications, originally developed to treat seizures, are also beneficial in controlling moods.

 

Antipsychotic medications, often taken in combination with an antidepressant, can treat manic or mixed episodes or psychosis. These medications can cause major weight gain and changes in metabolism, which may increase the risk of getting diabetes and high cholesterol. Patients taking this type of medication must have their weight, glucose levels and lipid levels monitored regularly.

 

 

Antidepressants are sometimes prescribed to treat symptoms of depression in bipolar disorder. However, taking an antidepressant alone can increase the risk of switching into mania or hypomania. To prevent this mood swing, it is recommended that doctors also prescribe a mood stabilizer, even if depression is the predominant mood state.

“Treating bipolar disorder requires patience and tenacity,” advises Dr. Pandurangi. “It takes time for medications to produce results. And once a patient is feeling better, there is a tendency for them to think that treatment is no longer needed. Some patients, especially high achievers, don’t like the slowdown in energy level or flatness in mood that medications can cause. Patient education is needed to help patients understand the risks of not treating mania or hypomania. Different medications used to treat bipolar disorder may have a variety of side effects—ranging from dry mouth, dizziness and drowsiness to blurred vision and rapid heartbeat. It is important that patients talk with their physicians if they are experiencing any annoying or worrisome side effects—and not just stop taking their medications."

 

Talk therapy, when used in combination with medication, can provide education and support to people with bipolar disorder and their families. “Cognitive behavioral therapy helps patients explore their thoughts and perceptions of their illnesses,” comments Bela Sood, MD, pediatric psychiatrist with the Virginia Treatment Center for Children at VCU Medical Center, “and change negative thought patterns and behaviors.”

 

“Family members are significant resources to an individual being treated for bipolar disorder,” says Ms. Rice. “They often can assist the patient with tracking and predicting mood and behavior changes, and are usually extremely aware of the patterns exhibited and potential triggers to mood shifts. Including supportive family members in a comprehensive treatment plan is essential for the patient and for the continued healthy involvement of the family.”

 

When medication and therapy are not sufficient to manage the symptoms of bipolar disorder, electroconvulsive therapy (ECT) may be tried. Formerly known as “shock therapy,” ECT had a negative, frightening reputation in the past. But the treatment has improved dramatically in recent years and is performed under brief general anesthesia, making it very tolerable. ECT is effective in providing relief for patients suffering from severe depressive, manic or mixed episodes who have not responded to medications.

What does the future hold?

“When we look to the future, there are two areas of exciting development in our effort to conquer bipolar disorder,” predicts Dr. Pandurangi. “New neuroimaging techniques mean we will eventually be able to see what is happening in the brain. This may be particularly beneficial in distinguishing bipolar disorder from major depression. It may also help doctors predict who will respond to which type of medications and brain stimulation therapies.”

Genetic testing offers the promise of earlier identification for individuals at risk for bipolar illness. And starting treatment earlier means a better chance for a better outcome. “Bipolar is a ‘neurodegenerative’ disease,” explains Dr. Sood. “Without proper treatment, a patient’s episodes may become more frequent or more severe over time. That means it is important to get a patient into treatment early and maintain symptom control. But bipolar is a chronic condition, just like diabetes—and treatment is a life-long journey.”

Medical Experts

Martin Buxton, MD, Chief of Psychiatry, Chippenham and Johnston-Willis Hospitals and Medical Director of Tucker Pavilion

Ananda Pandurangi, MD, Vice Chair, Department of Psychiatry, VCU Medical Center

Karen Rice, LCSW, Supervisor, Outpatient Services, Virginia Home for Boys and Girls

Aradhana Bela Sood,  MD, MSHA, Senior Professor of Child Mental Health Policy, Pediatric Psychiatrist, Virginia Treatment Center for Children at VCU Medical Center

Resources

Centers for Disease Control and Prevention (CDC) – cdc.gov

Depression and Bipolar Support Alliance - dbsalliance.org

National Alliance on Mental Illness - NAMI.org

Mental Health America - nmha.org

National Institute of Mental Health - nimh.nih.gov

Mood Disorder Questionnaire - www.healthyplace.com/psychological-tests/mood-disorder-questionnaire-mdq/

Bipolar Disorder Facts and Figures

  • Bipolar disorder affects approximately 5.7 million adult Americans every year or about 2.6% of the U.S. population age 18 and older.
  • The median age of onset for bipolar disorder is 25 years, although the illness can start in early childhood or as late as the 40's and 50's.
  • An equal number of men and women develop bipolar illness and it is found in all ages, races, ethnic groups and social classes.
  • More than two-thirds of people with bipolar disorder have at least one close relative with the illness or with unipolar major depression, indicating that the disease has a heritable component.

Children and Adolescents

  • Bipolar disorder is more likely to affect the children of parents who have the disorder. When one parent has bipolar disorder, the risk to each child is l5 to 30%. When both parents have bipolar disorder, the risk increases to 50 to 75%.
  • Bipolar Disorder may be at least as common among youth as among adults. In a recent National Institute of Mental Health (NIMH) study, 1% of adolescents ages 14 to 18 were found to have met criteria for bipolar disorder or cyclothymia in their lifetime.
  • Some 20% of adolescents with major depression develop bipolar disorder within five years of the onset of depression.
  • Up to one-third of the 3.4 million children and adolescents with depression in the United States may actually be experiencing the early onset of bipolar disorder.
  • When manic, children and adolescents, in contrast to adults, are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. When depressed, there may be many physical complaints such as headaches, and stomachaches or tiredness; poor performance in school, irritability, social isolation, and extreme sensitivity to rejection or failure.