What is Bipolar Disorder and how is it treated?

What is Bipolar Disorder and how is it treated? May 2, 2013

Last week I spoke about what psychiatrists call “Major Depressive Disorder.”  Today I want to speak about Bipolar Disorder, the condition formally known as Manic Depression.  This post should be read in conjunction with a few others in this series in particular.  Here are the key ones that are important for understanding this article:

A patient with Bipolar Disorder may initially have exactly the same symptoms as a patient with depression. There appears to be a clear biological difference between these two conditions, however.

Bipolar Disorder is characterized by experiencing “highs,” as well as “lows.”  Doctor’s call “highs” mania or hypomania depending on the severity. During a “high” some of the symptoms will be present which I described in a previous post. It is important to understand that such symptoms can initially be quite subtle. In fact during the early stages of hypomania patients may simply seem more enthusiastic than normal, happy, invigorating, full of good ideas, energetic, and might be more interested than usual in religious matters.

There is a particular danger in church contexts that a mildly hypomanic individual might not be recognized as ill, especially because we do believe that the Christian faith can give rise to “joy unspeakable and full of glory.”  A tired Pastor who is drained by the chore of constantly having to find sometimes unwilling volunteers may be thrilled that one of his members suddenly seems to want to do everything.  Beware of thinking that this person who suddenly has such unbridled energy really can do as much as it seems without any problems.  Such increased activity levels can sometimes contribute towards the person experiencing a fully fledged illness episode.

Many people with Bipolar Disorder are high achievers, and intelligent. They may not fit the mold of what people imagine a psychiatric patient would be like. Some are very creative, able to process information quickly and make connections other’s can’t. They may challenge the status quo, and in some cases may start companies, invent things, and be very successful. Some of the most influential members of Society have suffered from this condition. Interestingly there is evidence that some  relatives of people with Bipolar Disorder exhibit some of these positive traits without having the illness.

Even hypomania can actually be very destructive, however. Projects enthusiastically begun but never completed may pile up. Elevated mood can distort into aggressive mood. Relationships will suffer from the intensity, and impulsiveness. A reduced need for sleep, together with excessive activities carried on in the night hours, possibly loudly, can be disruptive for other members of the family who do need their sleep.  Conversations with a person who is manic or hypomanic can be very difficult for friends and family.  Ideas and plans are eagerly described, with less and less of a handle on what is achievable or realistic. Spending sprees and other reckless behaviors can result. People can suddenly lose their inhibition and behave in a very provocative way, perhaps carrying out sexual activity that is out of character and that they will later regret.

Sometimes it is hard to distinguish between illness-inspired behavior and what is simply ordinary misbehavior.  Family members may alternate between feeling incredibly frustrated and angry at the person, and deeply concerned for their welfare.  Trying to contain a person who is becoming increasingly manic is more and more difficult.  People will sometimes abscond and behave in ways that are totally out of the ordinary.

Patients with Bipolar Disorder may also experience psychotic symptoms.

It is not at all uncommon for people with mania to end up being found in a terrible state in a public place, and be placed at times against their will in a psychiatric hospital.  The mood instability often responds very well to medication.  The resulting damage to relationships, careers, families, and finances may be harder to repair.  As a form of self-medication some people with Bipolar Disorder will also consume excessive alcohol or illicit substances.  Suicidal thoughts, acts, and completed suicide are also common.

One of the challenges with Bipolar Disorder is that it really is not just the patient that suffers from this condition. Everybody around them has to deal with both the consequences of the patients words and actions, and the strong emotions they are likely to feel themselves.

Bipolar Disorder falls into two main types: Type I and Type II.  There is some confusion about this, but Type 2 Bipolar Disorder is diagnosed when the high mood never reaches the threshold for “mania,” but only “hypomania”.  Type I will be diagnosed when the patient has had a single episode of mania, even if after that episode any subsequent episodes are less severe.  Sometimes people are reluctant to call an episode “mania,” and out of what can only be assumed to be politeness will call it “hypomania.”

Type I is more severe than Type II, but is less common.  It is believed with a reasonable degree of confidence that approximately 1% of people suffer with Bipolar I Disorder during their lifetime. If your church has more than one hundred people in it and represents the community demographically, you will more than likely have a member with this condition. Even if your church is smaller there is a very good chance you will have someone with a friend or family member who suffers from the condition. This figure is fairly constant in different countries and cultures.  It is harder to be certain what the true incidence of Bipolar Disorder Type 2 is, as estimates vary widely, with some believing it may be as high as 10%.

Treatment of Bipolar Disorder is somewhat different to Major Depression.

Biological  Mania appears to improve in many cases when taking mood stabilizers (e.g. Lithium or Valproate) and / or atypical antipsychotics (e.g. quetiapine, olanzapine, risperidone).  These medications can have significant side effects, and will generally only be initiated by a psychiatrist.  At times a bit of trial and error may be required to get the right combination for the patient, and this might be affected by all kinds of things, such as whether the person plans to become pregnant, or if they are particularly sensitive to certain of the medications.

Treating Bipolar Disorder with the right combination of medications can have some of the most dramatic effects that a psychiatrist will ever observe.  A patient who just a few days before appeared so agitated and even in some cases psychotic, may now superficially appear to be entirely well.  Obviously full recovery usually takes longer than that, but when the right combination of medication is found, many patients with Bipolar Disorder will be able to return to the same level of functioning they had before the illness.  In fact, sometimes if they had been quietly suffering with less severe forms of the illness, in the aftermath of an episode they may even feel considerably better than before.

Medications will usually need to be continued, however, as after just one episode the risk of another occurring in the first year, even if treated may be as high as 50%.  This is due partly to some patients feeling so much better that they stop their medications.  Unfortunately, however, not every patient will be sufficiently stabilized even taking their medications to avoid future relapses.

The treatment of depressive symptoms in Bipolar Disorder has been studied less often and there are very few treatments that have been proven to work.  Psychiatrists will use a range of treatments, however, and it is not uncommon for an individualized “cocktail” of medications to be taken, to try to control the patient’s symptoms.

Psychological During a mood episode there is little evidence that psychological therapy works well in Bipolar Disorder.  There are some benefits seen in some patients in between episodes, particularly in dealing with minor symptoms medications may not have controlled. The most evidence for psychological therapy is for those treatments that promote understanding of the illness by the patient, and that help the patient to understand the need to take medication.

Social There are benefits to be had from helping people with Bipolar Disorder repair relationships that may have broken down during an episode.  Formal Family Therapy, marriage counseling, and treatments designed to help friends and family become an effective “emotional buffer” for the person with the illness can all have a part to play.  None of these things are likely to be of much effect if a mood episode is still present, however.

A reduced-stimulation environment can be very helpful for patients who are manic. Regular work, rest, and sleep habits are important even between episodes.  A good question to ask someone you know has Bipolar Disorder from time to time is, “How are you sleeping?” For other helpful questions to consider asking, see this post.

Spiritual Care must be taken with people who have Bipolar Disorder that normal spiritual practices are not encouraged to the extent that they become unhealthy.  Hyper-religiosity is a definite feature of mania in some cases.  Faith can become unreality all too easily.  Prayer may even become an obsession.  If someone’s behavior seems out of the ordinary spectrum you are familiar with, if an alarm bell is going off internally, perhaps this is a sign that the person concerned may in fact be unwell. A general point that pastors and concerned Christians should watch for is an extreme or sudden change in a person’s interest in activities connected with their faith.  Not every person with Bipolar Disorder will become more religious when manic, sometimes the opposite will be the case.

Pastoral care will need to be full of wisdom and sensitivity when dealing with people who have this disorder, as they may present with remarkable challenges in every area of their lives.  Bipolar Disorder can greatly damage lives that may otherwise have great potential for good in our communities.  There is real potential locked inside many with this disorder. They may just need a friend or pastor to help them accept the help they need from the medical world.

Real care should be exercised in praying for healing for people with Bipolar Disorder. In between episodes many with the condition will appear very well. A person who is wrongly convinced that God has healed them and then stops their medication may seem fine for months, or even years.  But if a severe episode is the eventual result, that may only be made harder for the person themselves to recognize if they have been told by a well meaning Christian how wonderful it is that God has healed them.

Occasionally after someone has been well for a long time psychiatrists will agree with the patient that a trial of no medicine is ok.  However, they will always advocate a gradual reduction in dose and stoping of these medications which have a powerful effect on our brain chemistry and really should not be stopped suddenly. Restarting the medication is often necessary surprisingly quickly in such circumstances even when someone has been well stable for years.

Working with people with Bipolar Disorder can present massive challenges, but it can also be massively rewarding.  With the right support it really can be possible in many cases to greatly reduce the sometimes devastating consequences of this condition.

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