Bipolar Affective disorder
VINAY sang in a high pitched voice. He felt elated and “on top of the world”. He believed that he had invented a new “supercomputer”, while in reality, he was a marketing executive and his computer knowledge was limited to user level. He started talking to strangers about his invention and if they were not receptive, he became irritable. He became more religious, performing elaborate rituals both at home and the office. He went on a buying spree, getting things that he did not need. He took a personal loan and made a down payment for two expensive cars. Within a week, he had caused immense problems for his company by making extravagant offers to clients.
His family could not fathom what was happening. Two weeks ago, Vinay was severally depressed. He was sad and tearful most of the time, wanting to resign his job as he felt he was worthless. He harboured suicidal ideas but did not act on them. He had no interest in work or leisure time activities, as he could not enjoy them like he had used to. The picture now was exactly the opposite of what it was two weeks ago. He had not only improved from depression, but had also switched to the other side of the mood spectrum.
Mood swings are an integral part of Bipolar Affective Disorder (earlier known as manic depressive psychosis). The illness has two faces, rather two phases — the manic phase and the depressive phase.
Features of manic phase:
- Elated mood that is not in synchrony with the circumstance.
- Increased energy, that which leads to overactivity, increased speech and a decreased need for sleep.
- Marked distractibility and an inability to sustain attention on a task for longer.
- Inflated self-esteem, overconfidence and over-optimism. Grandiose ideas that he is capable of doing anything.
- Racing thoughts. Thoughts keep coming rapidly and as a result the person jumps from one topic to another rapidly, the link being a pun, rhyme or a metaphor.
- Behaviour changes such as spending money recklessly (a shopping spree or donating money) increased religiosity, making reckless business decisions, embarking on impractical, extravagant ventures.
- Normal social inhibitions will be absent (instead makes inappropriate gestures or sexual advances).
- When mania becomes severe, there could be grandiose delusions and hallucinations. The person would believe that he is an important person (“I am the king”. “I am the prime minister”) and/or that he is capable of anything (“I can win all the gold medals at the Olympics”). Hallucinations would also be in keeping with the mood (Hearing god’s voice — auditory hallucination; Being able to see god — visual hallucination).Hypomania is a milder form of mania. Most of the features of mania are present but to a lesser degree. Delusion and hallucination will be absent.Features of depressive phase:A depressed mood most of the time
- Loss of interest in all activities.
- Inability to appreciate things (A song which he would have enjoyed so much in the past, might now sound lifeless and boring).
- Reduced energy. Becoming tired without much effort.
- Difficulty in concentrating.
- Poor self confidence and self esteem.
- Ideas of helplessness and worthlessness.
- Pessimistic views about self, environment and future.
- Ideas of guilt.
- Suicidal ideas.
- Disturbed sleep and appetite.
- If depression is severe, there could be delusions and hallucinations. (The person might firmly believe that he was responsible for an earthquake). Hallucinations could be in the form of voices berating him or accusing him (“You are bad. You deserve this”).Why was the name changed from the better known manic-depressive psychosis? Not everyone who has a depressive episode goes on to have a manic episode. Only some of them do. A number of people have a single depressive episode or recurrent depressive episodes, without any manic episodes. In addition, the course and treatment of their illness is different from those who get both manic and depressive episodes. Hence the need for segregation.Earlier they were all clubbed together as manic-depressive psychosis. Now they are grouped separately. Those with only recurrent depressive episodes are diagnosed as having recurrent depressive disorder. Bipolar disorder occurs equally in both genders whereas depressive disorder is more common in women. Bipolar disorder runs in families.“Bipolar” affective disorder implies that they could go to both the poles of the affective (mood) spectrum. The frequency and duration of the episodes vary from person to person. Manic episodes usually begin abruptly and could last for two weeks to six months (median duration is about four months).Depressive episodes tend to last longer (median length is about six months). The first episode occurs commonly between 15 to 30 years of age but also at any age from childhood to old age. In between episodes, the person would be completely normal.
The aim of the treatment is to reduce the duration of an episode and also prevent future episodes. Manic episodes respond to medication known as neuroleptics while depressive episodes respond to anti-depressant medication. To prevent further episodes, medication from a group called “Mood stabilisers” is used.
Lithium was the earliest medication used as a mood stabiliser. Since this decade, many more options are available, like Sodium Valproate and Oxcarbamazepine, which have a better side-effect profile. In addition, associated psychological and social problems need to be addressed by counselling and psychotherapy.
This article was first published in The Hindu on 23 Feb 2003