What exactly is bipolar disorder?

You've probably heard of this disorder before, but it is usually shrouded in self-diagnoses and misinterpretations. Some people will claim that they are 'manic' because they have a good mood or like to party. This misnomer often confuses the general populations' understanding of what BD is.

The two types

To start, BD comes in two varieties: Bipolar Disorder Type 1 (BD1) and Bipolar Disorder Type 2 (BD2). It was previously called Bipolar Mood Disorder, but with the text revision of the Diagnostic and Statistical Manual 5 (DSM-5-TR), the name was changed to remove the emphasis on the mood. BD1 and BD2 are still largely related to the self-reported mood a person may experience, but there are several other important factors to consider when making the diagnosis.

What mania actually is

The first is the hallmark symptom of BD1 and that is mania. Mania is described as an elevated or irritable mood that persists for at least seven days (or less if hospitalisation is required) for most of the day and is accompanied by at least three of the following (four if the mood is only irritable): inflated sense of self; decreased need for sleep; increased or pressured speech; racing thoughts; distractibility; increased goal-directed activities (either at work or school); excessive risk-taking behaviour (buying without thinking, engaging in unusual sexual activities).

Additionally, the manic episode needs to cause some form of impairment, either at school or work, and cannot be attributed to another medical condition (such as hyperthyroidism) or substance use. Thus, going out for a party and having a really good time may meet some of the above criteria, but unless it is a sustained period, it does not constitute an actual manic episode.

It is important to realise that once mania is experienced and correctly identified, it becomes a signpost of BD1; only one lifetime manic episode is necessary for the diagnosis. Thus, if you have ever experienced an actual manic episode as described above, it is important to seek medical assessment and treatment for the condition.

Hypomania and bipolar type 2

BD2 resembles BD1, but instead of the elevated or irritable mood lasting seven days, the manic episode only needs to last four days to constitute what is called hypomania (just below the threshold of actual mania). Additionally, the episode cannot result in hospitalisation or marked functional impairment as that would automatically constitute full blown mania, and it cannot be due to medication (such as antidepressants).

Why is there a distinction? This is because the treatment approach, expected progress of the condition, and impairment have been shown to be vastly different between the two groups, despite sharing strong similarities and falling under the same umbrella group.

The depressive side

However, this is all leaving out an important aspect. The term is called Bipolar, because like the Earth, there are two poles. Thus, if there is a high and elevated mood, there must be a reciprocal low and depressive mood. The Major Depressive Episode (MDE) that can occur in BD1 and BD2 is the same that occurs in Major Depressive Disorder (MDD). In fact, atypical presentations of MDD often harken an oncoming BD (whereas MDE on its own would constitute MDD, if there is a lifetime history of mania, it would always be related to BD).

This makes the treatment of BD difficult, because treating the MDE with antidepressants can cause 'switching' which is when a patient becomes manic due to the medication given to treat the depressed mood.

Why mania needs early treatment

Mania is arguably a worse state to be in compared to MDE and the reasons are plenty: whilst manic, patients can make life-altering decisions that they can come to regret later (such as making expensive purchases or engaging in a sexual encounter); they tend to neglect their health as they sleep and eat less; they refuse advice from others due to their inflated sense of self; they can become aggressive and start fights or destroy long-standing relationships. Sometimes, the good mood is so addicting that patients don't want to take treatment despite knowing they have the condition.

Mood stabilisers

As you can see, mania is a self-feeding cycle, and as such, it is important to note the symptoms early to begin treatment. The treatment for BD are mood stabilisers, the gold standard being lithium. Lithium is a naturally occurring mineral on the periodic table. The exact mechanism by which it acts in the body is poorly understood, but trials have shown that it works exceedingly well in managing the symptoms of mania and preventing further episodes.

However, the drawback is that lithium can be very toxic and requires regular blood monitoring to ensure that the correct dose is administered and that it is not affecting the kidneys and liver. It is also highly teratogenic (dangerous in pregnancy). As a result, despite being highly effective, it is seldom used as a first-line agent in South Africa.

The next class of agents used as mood stabilisers are antiepileptic drugs. Because of the way they act in the brain to prevent the neurons from firing unnecessarily, they also prevent excitation and reduce mood fluctuations. They are thus useful in both the manic and MDE (stabilising from above and below). The most used antiepileptic drug is Sodium Valproate. However, just like lithium, it has several drawbacks: it can cause weight gain, increased cholesterol, increases the chances of developing Diabetes, and is unsafe in pregnancy (but less teratogenic than lithium).

As such, all women of childbearing age must be counselled on using dual protection when taking medication for the treatment of BD.

BD can only be treated with medication, and psychotherapy is often less effective. If you have a history of mania or suspect that you have experienced an episode prior, it is vitally important that you seek prompt professional care. Sometimes the condition can be undiagnosed for years and only looking back does one realise it was BD, but that does not mean that treatment is futile or it is too late to start. Take back control of your life, book an online appointment with one of our industry experts in mental health today.

If you are in immediate danger or thinking of harming yourself, this is not the place to wait. Call 10177 for an ambulance, or 112 from a cell phone.

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