What is Bipolar Disorder?

Bipolar disorder is a type of mood disorder we see pretty often. What do I mean by “mood”? We often say things like “You’re in a good mood today.” Or maybe you’re deciding on dinner: “What are you in the mood for tonight.” But in psychiatry, what we call mood is the level at which you’re experiencing things like well being, motivation, Basically, your mood is how you experience a sense of well being, a kind of overall level of energy, motivation, and joy. Or not. Bipolar disorder has to do with significant mood shifts or mood swings.

Now, everybody goes through fluctuations in moods. That’s part of our normal experience of life. But psychiatry is more a matter of degree than of kind. Some people experience more profound highs and lows, and for longer periods of time. When otherwise ordinary feelings go too extreme they begin to interfere with our enjoyment of life or our ability to function. At this point we can characterize this situation as a disorder. There are typical patterns we can spot, identify, and give a name to.

Bipolar means having two poles. Picture planet earth which has a north pole and a south pole. You might say “my mood has gone south,” meaning your sense of well being has taken a hit. You may feel drained of energy, not motivated. Maybe you can hardly drag yourself out of bed in the morning. What’s the use? What’s the point? Maybe you feel sad, maybe just blah. But you’ve been robbed of your joy. Nothing is fun anymore. You may feel worthless. Maybe even guilty. Molehills turn into mountains. It becomes harder and harder to imagine a positive future. Somebody may, God forbid, just feel like dying. Stop the world, I want to get off. Someone might even resort to self harm.

Maybe you feel sad, maybe just blah. But you’ve been robbed of your joy. Nothing is fun anymore. You may feel worthless. Maybe even guilty. Molehills turn into mountains. It becomes harder and harder to imagine a positive future. Somebody may, God forbid, just feel like dying. Stop the world, I want to get off. Someone might even resort to self harm.

That’s depression: the south pole of Bipolar disorder. A phase or episode like that can last for weeks or months. Now take everything I’ve described and go to their polar opposite: the north pole of Bipolar disorder is a state we call mania. You’re not down in the dumps. You’re walking on water. You’ve got buckets of motivation, high energy. Maybe you’re bouncing off the walls. Your brain is a Ferrari on the Autobahn. And your mouth tries its best to get the words out: talking ninety miles a minute, jumping from subject to subject. Not always making the best sense, frankly.

But you’re having a good time. Well maybe. Some people swing from sad to glad. Others from sad to made. But typically, you’re like, having more fun than the law allows. Sometimes literally. You get a kick out of the strangest things, and you don’t know when to quit. Shopping sprees. Calling up your BFF at three am. I mean, you’re not sleeping, and your body says you don’t need to. Far from feeling hopeless or worthless, you’re a superstar. With special powers. Taking crazy risks. That Danger Will Robinson thing gets switched off.

In some extreme cases people start to lose contact with reality, believe bizarre things, maybe even hear voices. But as I said before, some folks get more mad than glad. Angry, irritable, maybe even violent. So those are the two poles, mania and depression. This explains the old name for it, “manic depression,” which means exactly the same thing as Bipolar disorder.

Now what I’ve been describing are the extremes. Not everybody experiences every symptom. And you may not go all the way to the North Pole, and visit Santa Claus. Some people just let’s say hang out in the Yukon. Surf the wave of creativity, but they can more or less make life work. We call that hypo-mania, rather than full bore mania. But people can rotate through any of these phases, again for weeks or months at a time. But there can also be long phases of “normal” (whatever that means), at the equator, or in the tropics. But you never know. It’s the instability that makes life difficult.

Now nobody wants the label “Bipolar.” Nobody wants to have that diagnosis. But if you do experience Bipolar Disorder, you want to know it so we can do something about it. And we have lots of good ways to treat it. Sometimes I see someone in their forties or fifties. And they’ve never been able to figure out why everyone else’s life seems to work but theirs doesn’t. Something has always wreaked havoc with relationships, with jobs, even the law. When we can give that something a name, like Bipolar Disorder, identifying the enemy is half the battle. So, when we know what it is, we can do something about it. And I’ve seen over and over, set up a good treatment regimen and people can do really, really well.

So let’s talk about medications. I don’t mean to suggest for a minute that medications are the be all and end all. Healthy life choices, working with a good therapist, becoming more self aware are all vital aspects or managing this disorder. But medications is where I come in. That’s how I contribute. So when we are thinking of medication for Bipolar disorder, we are looking at two broad categories.

First, because of the depression component–and often Bipolar depression is a particularly deep depression–we may prescribe an antidepressant. Medicines like Prozac, Lexapro, Effexor work as mood elevators. That is they lift you up out to the basement and up to the sunshine and fresh air. But… we have to be careful, because it is possible, with Bipolar Disorder, our elevator turns into a Willy Wonka elevator, you know, and just shoots right through the roof and into the sky. What I mean is, sometimes an antidepressant can overshoot the goal and drive a person up into the mania. Now we don’t want that, and whenever a person comes in manic, the first thing we do is stop the antidepressants, if they’re on these. So it’s a two-edged sword at times, but still we do frequently use antidepressant medication for Bipolar disorder.

What we really want, however, is stability, and so the mainstay of medication treatment will be one or more mood stabilizers. As the name suggests, what these are for is to rein in the wild swings so the range of ups and downs is pretty much, you know, “normal.” But if you were to think of mood stabilizers as those medications which bring the mania down, and hold it down, and antidepressants as those which bring you up from depression and hold it there–well, that might be a useful way of looking at things.

Now there’s more than one type of mood stabilizer. In fact there are three types I’m going to talk about. As I said, in some cases we use a combination of a couple of these types. First we have Lithium. This is the classic mood stabilizer, our first ever, and this type of medication dates back to the 1800s. We are actually talking about a compound of the element Lithium, a salt called Lithium Carbonate. So as medications go, it’s a really simple molecule. And very effective. It works really well. But there are downsides. You knew there would be. Some people may find it difficult to tolerate. A metallic taste: Lithium is a metal after all. And you get thirsty and have to drink more water: it is a salt, after all. Also, we have to carefully watch the level of the medication in the blood. There’s a narrow safety range, and an accidental overdose can be quite dangerous. So we have to draw blood regularly and keep an eye on things. So, some people love it for its helpful effects. Others go with one of the other options, which they might be able to handle more easily.

Next, we have the anticonvusants, that is medications otherwise used to prevent seizures, as in epilepsy. People sometimes look at me funny when I suggest a seizure medicine for their mood disorder. But when you think about it, a seizure is the nervous system acting up, firing erratic impulses which need to calm down. If you look at Bipolar mania as another kind of erratic impulse in the nervous system, it kind of makes sense these medications work for both problems. Some big names in this category are Divalproex (AKA Depakote), Carbamazepine (or Tegretol), and Lamotrigine (that is, Lamictal). (In case you haven’t noticed medications have a generic name and one or more trade names, just to make it confusing,) These have side effects too–there are always side effects–things such as drowsiness. Typically, this gets easier after a while. Some of these we also keep an eye on with regular blood tests.

That brings us to the third category of mood stabilizers, and these are the antipsychotics. Kind of an unfortunate name, though we do use them to treat psychotic symptoms, such as hearing voices or believing you are Superman. So, I may tell you I think you need an antipsychotic, but I mean that in the nicest possible way. Psychiatrists are mulling over revising all these category names. Antipsychotics do more than fight psychosis. They can be very effective mood stabilizers. And some even work as antidepressants. Aripiprazole (or Abilify) is a good example of this. Others include Quetiapine or Seroquel, Risperidone or Risperdal, and Olanzapine or Zyprexa. Some of these can also make you sleepy, or lead to weight gain. More concerning are possible involuntary movements, such as shaking and rocking. Most people seem to sail through without undue difficulty and anyway find the benefits to their quality of life outweighs the possible downsides of these medications.

So I hope this brief overview of Bipolar disorder has been of some interest and help. I’ve tried to remain reasonably accurate while still using regular English and not just the secret language of medical insiders. It’s not a perfect situation, and psychiatry is far from an exact science, but modern psychiatry is definitely one of the best reasons to be glad for living in the 21st century.