Fife Bipolar Group

Bipolar Disorder is basically a mood disorder involving extreme swings of mood from depression to mania, (lows and highs). We can think of 'mood' as how we are feeling at any given point (happy, sad, frustrated, optimistic, etc ). It has been described as our 'emotional temperature'. Generally, we feel a particular way because of what is happening in our lives at that time. With mood disorders, however, mood becomes disconnected from our environment and appears to be outside of our direct control. With bipolar there is a problem around the regulation of mood.

The brain mechanisms that normally regulate mood do not always function as they should. Of course, there can also be long periods of stability when we feel as we did prior to the onset of bipolar. During these times our emotions are within the usual range of experiences that anyone could identify with. Similarly, our behaviour also returns to that which friends recognize as reflecting our 'usual self'. Having said that, however, it is important to recognize that everyone's experience of bipolar is different.

Some people have more depressive episodes, others more manic, some have long periods of stability between episodes, while others experience them more frequently. The duration of an episode of mania or depression also differs from one person to the next, as does the severity of an episode.

You are likely to come across diagnoses such as bipolar 1, bipolar 11 or bipolar 111. (Bipolar disorder is simply another name for manic depression.) The categories reflect differences in the severity and duration of episodes of mania or depression. People with less severe mood swings are described as experiencing cyclothymic disorder. You may also hear the term, 'rapid cycling' which is used to describe a situation where a person experiences four or more 'highs' or 'lows' in a year. Swings can be even more frequent; everyone with a diagnosis of bipolar will have their own unique pattern.

Perhaps the most important, if obvious, thing to be said is that no one causes him or herself to have Bipolar and that bipolar cannot be overcome with willpower alone. In fact, bipolar appears to have no simple cause. There is strong evidence that it is associated with changes in various transmitter substances in the brain, but the precise mechanisms are not yet known. The illness can also be influenced by the stresses and strains of everyday life, or a traumatic event, but it is likely that one was predisposed to developing it. There is no test that can be given to determine if someone has manic depression and this can mean a long delay in getting an accurate diagnosis. However there is research being carried out at Edinburgh University

During a manic episode you may witness any or all of the following behaviours:-

Expansiveness, grandiosity, overconfidence, increased sexual preoccupations, increased interest in religion, inappropriate spending, intolerance, increased smoking, increased telephone use or letter writing, reduced need for sleep, irritability and much more rapid speech. It is not possible to be prescriptive because everyone's behaviour will differ, but this gives you an idea of the most common behaviours. Do not assume that they will all necessarily apply to you, your friend or family member.

Sometimes a severe manic episode can also involve a mixture of depressive features (this is known as a mixed episode). During a mixed episode, both manic and depressive symptoms are experienced daily for at least 1 week. The person usually feels very anxious and disorganized and commonly will develop insomnia, psychosis, and loss of appetite. (A layperson's definition of psychosis might be those times when an individual appears 'out of touch with reality')

A mixed episode can last from a week to several months and is usually followed by a depressive episode. They occur more often in people (especially men) under 25 and over 60 years of age. Mixed episodes are seen most frequently in teenagers who have experienced major depression.

During a depressive episode the person may complain of physical symptoms such as pains (for example stomach ache or headaches), they may appear to move more slowly, to lack concentration and to feel that even the simplest of tasks require monumental effort. Their thinking can be dominated by thoughts of sadness, guilt, pointlessness and loss. Anxiety and panic can also be a feature of a depressive episode for some people. (n.b. It is also important for the health care provider to ensure that any physical symptoms are properly investigated and not dismissed as manifestations of Bipolar Disorder without sound evidence)

This is very difficult area, both in terms of the concerns it may raise for family members, and because our understanding of the genetic component is very limited. We can talk about the family incidence of bipolar disorder in only a very general way. Whilst we know that children of people who have bipolar disorder have an increased risk of developing the condition themselves, this needs to be put in context. Overall, the risk that a child with a parent who has the diagnosis will develop it him or herself is put at about 10-15%. The risk is somewhat higher where both parents have the diagnosis, but risks differ depending on different circumstances and, once again, it is difficult to generalize. The risk that siblings of the person with the diagnosis will themselves have children with the condition is very small indeed. Your G.P. can refer you to a genetic counsellor if you wish to discuss your concerns.

The behaviours exhibited by people with the diagnosis can have a profound effect on those closest to them, who can suffer the consequences of the disorder as well. It is not always easy to offer sympathetic support to someone who may have been behaving erratically, angrily, recklessly or thoughtlessly. It is difficult not to take such behaviour personally and to react to it, particularly when it creates disruption or has negative repercussions. Family and friends often express the opinion that they feel they have been rejected by the individual concerned, and are unsure how to respond. The more you understand about the illness the more you will be able to empathise and to offer useful support.

One of the best ways of acquiring this insight is to read about the experiences of those who have the diagnosis. One of books, is written by a psychiatrist who has the diagnosis herself. "An Unquiet Mind" by Kay Redfield Jamison is extremely well written and enlightening. In her book "Touched with Fire: Manic Depression and the Artistic Temperament" she vividly describes the experiences of many well-known and accomplished people who have the diagnosis. She drives home the point that even the most strong-willed, popular and gifted individuals can be brought to the point of despair by this illness.

There is no clear answer here, certainly there is no one cure. There are some people who will never experience another episode of mania or depression again even without further treatment, but this is rare. Usually there will be periods when the individual remains well for a given period of time, only to find the symptoms reappear. Having said that, much can be done to reduce the severity or duration of an episode, or even the number of episodes experienced. Once the diagnosis is made steps can be taken to minimize the extent of the mood swings and thereby reduce the disruption that they can have on our lives and the lives of those around us The best treatment is usually a combination of medication, counselling and self-management, but obtaining counselling via the NHS can mean a lengthy wait, depending upon where you live. The importance of early diagnosis and treatment cannot be overstated.

Self management is built on the principle that people with manic depression can become experts on their own mental health. Research shows that if we are able to recognize the early triggers and early warning signs of an impending episode, and implement appropriate 'coping strategies', then we can gain greater control over our mood swings. Examples of coping strategies would be; reducing stressful activities, relaxation exercises, maintaining a regular sleeping pattern (for mania) or exercise and cognitive therapy techniques (for depression).

We know that circadian rhythms, especially the sleep/wake cycle are very important in manic depression. Lifestyle regularity is important in controlling the symptoms of both mania and depression. Another useful tool is keeping a mood diary, which can provide an early warning of a mood swing and can also help to identify any patterns to the episodes. People who self manage often write an 'action plan' which lists coping strategies which we can put into effect if the triggers and warning signs should appear. I have listed some examples of coping strategies above, but it is not possible to be prescriptive, different strategies work for different people.

You can do a great deal to support this process. Have you noticed early warning signs? Are there any particular triggers, which seem to make a mood swing more likely? Working together, you can often identify emotions, behaviours and events, which could be early indications of a mood swing. Common early warning signs of mania, for example, are increased energy, a need for less sleep, spending more money than usual. Each person's symptoms are unique and by learning to distinguish between characteristic behaviours and non-characteristic behaviours associated with episodes of mania or depression, you may be able to alert them to early warning signs. Identifying an episode right at the start means that one has a far greater chance of preventing it or reducing its impact. You may also be able to offer support in drawing up the action plan, helping in the identification of coping strategies and agreeing what help you could give if the early warning signs of an episode should appear.

This can be the cause of a great deal of tension. It is important to recognise how difficult it can be to manage the situation sensitively. You will want to take early action to prevent a mood swing, but no-one wants to feel that they are being continually observed for signs of an impending episode, nor lectured about how best they should live their life. On the other hand, it can be a mistake to procrastinate for too long. Finding the right balance requires ongoing communication and acceptance of each other's feelings.

It is not uncommon for people with the diagnosis to experience over controlling and critical behaviour from family and friends who believe they are acting in that person's best interest. Negotiation is required during periods of wellness, to ensure that any actions you take have been agreed ahead of time and address both of your needs. Open communication and joint problem solving are required, but this takes practice and trust; family therapy may well be an option you wish to consider.

There are a number of medications, which can help in reducing mood swings. These fall into three broad categories

• mood stabilizers (e.g. lithium, carbamazepine, sodium valproate, lamotrigine) can be described as maintenance treatments. They are taken long-term to prevent manic and depressive episodes.
• anti-depressants (e.g. Prozac, Efexor, Imipramine) are used to treat and control depressive episodes
• major tranquillizers (sometimes called 'anti-psychotics'), which are used to treat and control manic episodes. (Examples of the older drugs are chlorpromazine and Haloperidol; the newer 'atypicals' generally have less unpleasant side effects (e.g. Olanzapine and Risperidone)

Different medications, and combinations of medications, suit different people and the side effects experienced also differ. It is a question of balancing the benefits against the side effects experienced in determining if a particular medication is suitable. If side effects outweigh the benefits then alternative medications should be sought. Do not assume that the doctor will have prescribed the correct tablets and the correct dosage; there is often a great deal of trial and error involved before an acceptable medication regime is identified. Be an active gatherer of knowledge about bipolar so that you may be empowered to engage in discussions with health professionals from an informed position.

The first and often the most difficult milestone in gaining control of lives affected by bipolar is to have the courage to accept the diagnosis. Particularly difficult is accepting one's vulnerability to another episode. Once an individual's mood has stabilised it is tempting to believe that the illness has disappeared rather than in remission. A person may then decide to discontinue medication. It may also be the case that experiencing a high has led the person to believe that the medication is unnecessary.

Whatever the circumstances, it is important that the decision to stop is made in conjunction with the doctor. If a person is well at the time, then this poses fewer problems. If they are aware of the possible risks, and can make an informed decision, then, of course, it is everyone's right to decide what medication they will, or will not, take.

During a manic or depressive episode, however, it may be necessary for you to alert their healthcare provider on their behalf. Again, it is best to agree ahead of time what action you will take, and to have a shared, clear and reliable record of current medications. This will prevent a possible deterioration in your relationship if your actions are misinterpreted as controlling or interfering.

You should contact their healthcare provider. Be very clear about your concerns, and ask for a home visit. If the person is attending an outpatient department, the best procedure is to contact their psychiatrist by phone. The Community Psychiatric Nurse can also be a good contact if he or she visits sufficiently frequently. Many of the Primary Care Trusts (PCTs) have 'crisis cards' that list telephone numbers where mental health services can be reached at all times. Get this information ahead of time. Not everyone will experience episodes, which require this type of intervention, but it is best to prepare ahead of time. 'Planning Ahead' is another valuable MDF booklet, written to give strategies for coping when unwell. You will find it has a centre-fold blank 'Advance Statement' and some notes on how to complete it. The Advance Statement expresses in writing what the person's wishes are in the event of an episode of mania or depression: who to inform, which medications are preferred, which medications to avoid, looking after the home, looking after the family, looking after money, where medical records can be located and so on. The Advance Statement can give considerable peace of mind. You will know that you are taking account of all eventualities and that you are behaving in a way that has the prior agreement of the person for whom you are caring. It is not always possible to prevent a mood swing, it does not mean that there has been a failure on anyone's part.

Do not neglect your own needs. Having your own interests and leading your own life, can prevent you from being perceived as too intrusive and will enable you to deal with difficulties more calmly and with tolerance. Consider what social support you need for yourself, and what practical and/or emotional support you have available. Do not feel guilty about putting your own needs first. It is important that you remain well if you are to offer support to others.