Bipolar Disorder
Manic Depressive
Dual-Diagnosis
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National Services Directory
Bipolar Disorder / Manic Depressive
Bipolar disorder symptoms are characterized by an alternating pattern of emotional highs (mania) and lows (depression). The intensity of signs and symptoms can vary from mild to severe. There may even be periods when your life doesn't seem affected at all..
Here is an example of how bipolar disorder diagnosis is played out
over and over again in Psychiatrists offices all over the world. This
is about a mom named "Nora" and her daughter "Chloe"
that have come to see a Psychiatrist about Chloe's behavioral problems.
Nora asked to speak with me while her daughter filled out the stack
of new patient forms. She did not take my lead to step into the hallway
leading to my office and instead announced to anyone within ear shot,
“My daughter is Bipolar.” This seemed to be Nora’s
explanation for her daughter’s embarrassing ppearance. The unspoken
message was loud and clear, Chloe’s look was due to an unfortunate
genetic quirk and not Nora’s inability to influence her child
to be more presentable. Chloe wanted her mother to stay in the waiting
room while she came in for her visit. She barely sat down when she echoed
her mother’s words proclaiming, “I’m Bipolar.”
I smiled and said, “I’d rather call you Chloe.”
Chloe seemed resigned to her diagnosis but added, “None of the
meds ever worked for me and I don’t want to take them. They just
make me want to eat and I get real fat.”
At twenty-two years old Chloe had seen a total of five psychiatrists
since the age of fifteen when she started using drugs. Her first psychiatrist
diagnosed her with
depression. At that time Chloe appeared depressed and had been sleeping
excessively. However, the psychiatrist did not know that Chloe was just
coming off cocaine at that time. The symptoms of a post cocaine crash
look like clinical depression as it is defined in the Diagnostic and
Statistical Manual. She was seen by another psychiatrist while using
methamphetamine, so her next psychiatrist had assessed her as manic
and gave her a diagnosis of Bipolar Disorder. At the age of sixteen,
when her drug use was discovered and she was sent to rehab, she was
then categorized as having both the diagnoses of drug abuse and Bipolar
Disorder. From that point Chloe’s diagnoses followed her from
treatment center to treatment center and from doctor to doctor.
Her well-meaning psychiatrists all provided the “standard of care”
for Chloe. They prescribed the customary medications given for Bipolar
Disorder. However, Chloe found the side effects of the medication unacceptable.
In particular she hated gaining twenty pounds each time she was put
on these medications. Even when she was not coming off “coke”
or “speed”, if she was put back on her “Bipolar meds”,
she gained weight. In truth, Chloe’s weight gain often triggered
a relapse.
A complete history and a focused physical exam revealed physical evidence
that Chloe had a hormone imbalance. The knuckles of her hands and toes
were dark. She also had brown pigmented creases in her palms and a few
darkened scars on her legs. Her knees and elbows were also dark. She
gave a humorless laugh and said that when she was a kid her mother had
tried to scrub “the dirt” off her knees. She scrubbed Chloe’s
knees with a pumice stone, even Ajax but all of Nora’s efforts
only created pain from scraped knees and elbows. Chloe said that
when her first grade teacher asked her what happened, she was too embarrassed
to tell the truth about her permanently “dirty” knees and
elbows and lied that she
fell.
Chloe jumped when I hit my hand on the table demonstrating a high startle
response even though she could anticipate the sound. She admitted that
she was
pretty jumpy most of the time.
Her blood pressure was very low and she added that if she stood up too
quickly she felt like she was going to faint. Often she had to sit back
down and get up more slowly. At times she would remain standing and
waits a few seconds for the darkness to clear to be able to see again.
She said that she passed out a couple of times but would “come
to” after a few seconds on the floor.
Chloe looked surprised when I asked her if she had some odd food preferences
or cravings. In addition to salty foods, especially olives, she liked
her food doused with lemon, vinegar or drenched in hot sauce. She admitted
to a special affinity for pickles. When I asked her if she sometimes
drank pickle juice, her astonished response was, “How did you
know?” Chloe also confessed to a daily diet of sweets, bread and
pasta.
I explained to Chloe that her signs and symptoms, including her food
preferences, might indicate that she had an insufficient amount of cortisol.
Her mood changes may be in part due to an imbalance of stress hormones.
The drugs she used, cocaine and methamphetamine, may have made a problem
with low cortisol even worse.
“Does low cortisol cause Bipolar Disorder?” she asked.
“We don’t know what causes Bipolar Disorder” I answered.
“In fact, all psychiatric diagnoses don’t have a cause.
They’re defined by symptoms and there are many things that can
cause mood fluctuations.” I explained.
Chloe seemed a bit confused by this revelation.
“So, am I Bipolar?”
“It’s unlikely, because the diagnosis was made when you
were either using drugs or crashing when you went off them.”
Chloe seemed confused about how to feel, but then brightened, “I
don’t think my mother will agree with you.” Somehow this
did not surprise me. For Nora, Chloe’s Bipolar Diagnosis was an
explanation for her daughter’s lack of propriety.
Chloe and other patients have heightened my awareness of the medical
causes of psychiatric symptoms and in particular hormone imbalances
that manifest as
alterations of mood and behavior. Hormones are the body’s chemical
messengers and affect every organ in the body, including the brain.
The brain then may respond by altering its balance of neurotransmitters,
such as serotonin and dopamine. This change in neurotransmitters would
quite likely trigger an emotional change.
Interestingly enough, the reverse may also be true. Making a choice
to change your thoughts, changes your mind and that changes your brain’s
eurotransmitters.
The power to choose is the most important gift we are endowed with as
humans. It is truly what separates us from the animal kingdom. However,
it feels that we lack control over our thoughts and feelings because
they seem to just materialize. Because we did not consciously choose
feelings and thoughts that seem to hijack our very essence, we lose
site of our ability to make a decision to change our thoughts and feelings.
Believing in a mechanistic perspective based on the workings of a few
neurotransmitters we abdicate any hope for choice. In order to empower
our gift of choice it is helpful to know the mechanisms in place that
help run our brains and bodies. Understanding them can help us realize
how much power we have given over to our biochemical workings. Even
though it is true that our ability to function is due to the myriad
of biochemical complexities that comprise our physical beings, it is
not our only answer.
Form is not function. It is as if we have relegated all learning to
be within the buildings we erect as our schools and do not recognize
that the building is not the source.
Treatment of Bipolar Disorders
The usual treatment for Bipolar I Disorder is lifelong therapy with a mood-stabilizer (either lithium, carbamazepine, or divalproex / valproic acid) often in combination with an antipsychotic medication. Usually treatment results in a dramatic decrease in suffering, and causes an 8-fold reduction in suicide risk. In mania, an antipsychotic medication and/or a benzodiazepine medication is often added to the mood-stabilizer. In depression, quetiapine, olanzapine, or lamotrigine is often added to the mood-stabilizer. Alternatively, in depression, the mood-stabilizer can be switched to another mood-stabilizer, or two mood-stabilizers can be used together. Sometimes, in depression, antidepressant medication is used. Since antidepressant medication can trigger mania, antidepressant medication should always be combined with a mood-stablizer or antipsychotic medication to prevent mania.
Treatment for bipolar disorder falls into three categories:
Acute treatment suppresses current symptoms and continues until remission, which occurs when the symptoms are diminished for a period of time.
Continuation treatment prevents a return of symptoms from the same episode.
Maintenance treatment prevents a recurrence of symptoms. The risks of long-term medication use must be weighed against the risk of getting sick again (relapse).
Prognosis
With treatment, the outlook for bipolar disorder is favorable. Most people respond to a medication and or combination of medications. Approximately 50 percent of people will respond to lithium alone. An additional 20 to 30 percent will respond to another medication or combination of medications. Ten to 20 percent will have chronic (unresolved) mood symptoms despite treatment. Approximately 10 percent of bipolar patients will be very difficult to treat and have frequent episodes with little response to treatment. On average, a person is free of symptoms for about five years between the first and second episodes. As time goes on, the interval between episodes may shorten, especially in cases in which treatment is discontinued too soon. It is estimated that a person with bipolar disorder will have an average of eight to nine mood episodes during his or her lifetime.