Variations in moods and energy levels have for centuries been observed as part of the human experience. The words "melancholia" (an old word for depression) and "mania" have their origin in Ancient Greek. The following is a brief history of the development of Bipolar Disorder.
The Old Testament story of King Saul describes a depressive syndrome, as does the story of Ajax’s suicide in Homer’s Iliad.
400 BCE - Hippocrates used the terms mania and melancholia to describe mental disturbances.
30 AD - Roman physician Celsus described melancholia arising from an excess of yellow bile, or a mixture of black and yellow bile.
1854 - Jules Falret described a condition called folie circulaire, in which patients experienced alternating moods of depression and mania.
1882 - Karl Kahlbaum introduced the term cyclothymia, where he described mania and depression as stages of the same illness
1899 - Emil Kraepelin described manic-depressive psychosis using most of the criteria that psychiatrists now use to establish a disorder of Bipolar Disorder.
What is Bipolar Disorder?
From high to low. From mania to depression. From recklessness to listlessness. These are the extremes associated with Bipolar Disorder, a mental illness characterised by mood instability. Bipolar Disorder is also known as manic-depression or manic-depressive illness — manic behaviour is one extreme of this disorder, and depression is the other. One in a hundred people are affected by the illness.
The significant mood swings of Bipolar Disorder may occur only a few times a year which may last for weeks or months, or as often as several times a day. These shifts seem to have little to do with external situations and causes great disturbances in the lives of those affected, including family and friends.
Today, a growing volume of research suggests that Bipolar Disorder occurs across a spectrum of symptoms, and that many people aren't correctly diagnosed. Left untreated, the disorder generally worsens, and the suicide rate is high among those with Bipolar Disorder. With effective treatment you can live an enjoyable and productive life despite Bipolar Disorder.
What causes Bipolar Disorder?
The exact cause of manic depression is not known, but it is believed to be centralised around chemical imbalances in the brain. Several biochemicals, genetic and environmental factors can have an influence on this chemical imbalance:
Genetics / Hereditary - Bipolar Disorder tends to run in families. Some studies also show links between Bipolar Disorder and schizophrenia, pointing to a shared genetic cause. If you have Bipolar Disorder and your spouse does not, there is only a 1 in 7 chance that your child will develop it. The chance may be greater if you have a number of relatives with Bipolar Disorder or depression.
Biochemical - Some evidence from high-tech imaging studies indicate that people with Bipolar Disorder has physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes. The naturally occurring brain chemicals called neurotransmitters, which are tied to mood, may be a contributing factor. Hormonal imbalances are also thought to be a culprit.
Psychological Stress - People who are genetically susceptible may have a faulty “switch-off” point which means that emotional excitement may keep escalating into mania and setbacks may worsen into profound depression. Sometimes a stressful life event such as a loss of a job, marital difficulties, or a death in the family may trigger an episode of mania or depression. At other times, episodes occur for no apparent reason. Research continues to be needed to identify more clearly the causes, of manic depression and to find better ways of treating it. The earlier treatment is started, the more effective it may be in preventing future episodes.
Biological Clocks - Mania and depression are often cyclical, occurring at particular times of the year. Changes in biological rhythms, including sleep and hormone changes, characterise the illness. Changes in the seasons are often associated triggers.
What to look out for
This graph illustrates the significant mood swings experienced with this condition, i.e - from depression and sadness to mania and excitement. The symptoms may vary from mild (hypomania or mild depression) to severe for both of the depression and the manic phases. These alternating episodes of highs (mania) and lows (depression) seem to be characteristic symptoms of Bipolar Disorder.
During the depressive phase you may experience:
Loss of appetite
Suicidal thoughts or behaviour - Some attempt suicide because they believe life has become meaningless or they feel too guilty to go on. Others develop false beliefs (delusions) of persecution or guilt, or that they are evil.
Feelings of guilt and hopelessness
Loss of interest in daily activities - may withdraw and stop seeing friends, avoid social activities and cease simple tasks such as shopping and showering.
Irritability and aggression – be more ‘on edge’ than usual and could easily be angered and irritated. Appears more impatient.
Euphoria - elevated mood where the person feels extremely high, happy and full of energy. The experience is often described as ‘feeling on top of the world’ and ‘being invincible’.
Grandiose plans and beliefs - it is common for people experiencing mania to believe they are unusually talented or gifted or are kings, film stars or prime ministers, for example.
Reduced need for sleep
Increased energy and over-activity.
Rapid thinking and speech - thoughts are more rapid than usual. This can lead to the person speaking quickly and jumping from subject to subject.
Lack of inhibitions - this can be the result of the person's reduced ability to foresee the consequences of their actions. For example, spending sprees on items that are not really needed, drug abuse, increased sexual drive.
Lack of insight - a person experiencing mania may understand that other people see their ideas and actions as inappropriate, reckless or irrational. However, they are unlikely to recognise the behaviour as inappropriate in themselves.
Most people who have episodes of mania and depression experience normal moods in between. They are able to live normal lives, manage household and business commitments and hold down a job. Everyone experiences mood swings from time to time. It is when these moods become extreme and lead to a failure to cope with life that medical attention is necessary.
Management and lifestyle
Bipolar Disorder is an ongoing condition that requires ongoing treatment, even during periods when you feel better. Bipolar Disorder treatment is usually guided by a psychiatrist skilled in treating the condition. You may have others on your treatment team as well, since the condition can affect so many areas of your life. These include psychologists, social workers and psychiatric nurses.
Effective and appropriate management and lifestyle changes is vital for reducing the frequency and severity of manic and depressive episodes and allowing you to live a more balanced and enjoyable life. People who skip maintenance treatment are at high risk of a relapse of their symptoms or having minor episodes turn into full-blown mania or depression. If you have problems with alcohol or substance abuse, you must get treatment for those too, since they can worsen bipolar symptoms.
This section focuses on medication, psychological counselling, hospitalisation, lifestyle management, support from others and support groups.
Medication is a vital part of bipolar treatment. Some medication can have side effects which may cause one to be reluctant or unwilling to take medication but it is important to discuss this with the psychiatrist and other health care professionals to find a medication regimen that works for you.
Psychological counselling is another vital part of Bipolar Disorder treatment. Several types of therapy may be helpful.
Individual therapy - The focus of individual therapy is identifying unhealthy, negative beliefs and behaviours and replacing them with healthy, positive ones. In addition, you can learn about Bipolar Disorder and its treatment and what may trigger your bipolar episodes. You also learn effective strategies to solve problems, make decisions, determine goals, manage stress, and to cope with upsetting situations and challenges.
Family therapy - Family therapy involves you and your family members. Family therapy can help identify and reduce stressors within your family. It can help your family improve its communication style and problem-solving skills and resolve conflicts.
Group therapy - Group therapy provides a forum to communicate with and learn from others in a similar situation. It may also help you to develop better relationship skills.
In some cases, people with Bipolar Disorder may benefit from inpatient hospitalisation. Hospitalisation for psychiatric treatment can help stabilise your mood, whether you're in a full-blown manic episode or a deep depression. Partial hospitalisation or day treatment programs also are options to consider.
Stay well with Lifestyle Management
Coping with Bipolar Disorder can be difficult. Medications can have unwanted side effects, and you may feel angry or resentful about having a serious condition that requires ongoing treatment. During periods when you feel better, you may be tempted to stop treatment, but this is never recommended without consulting with your psychiatrist first. Here are some ways to cope with Bipolar Disorder:
Learn about Bipolar Disorder - Education about your condition can empower you and motivate you to stick to your treatment plan.
Stay focused on your goals - Recovery from Bipolar Disorder can take time. Stay motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and financial and legal problems.
Join a support group - Support groups for people with Bipolar Disorder can help you reach out to others facing similar challenges. Many people find it valuable to talk with others who have similar experiences.
Find healthy outlets - Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities, get a pet, look for opportunities for self-nurturance, and do creative and fun activities.
Learn relaxation and stress management - Try stress reduction techniques such as meditation, yoga or tai chi, make your living space pleasurable, comfortable, calm, organized and safe. Engage with your environment – expose yourself to light.
Enhance mindfulness - Be cognisant that you have been diagnosed with Bipolar Disorder. Remain vigilant to your symptoms and physical and emotional responses to the environment. By being aware of you and your body, you will be more effective in your own lifestyle management.
Having a positive attitude and mindset - Use therapy and educational materials to improve your self-esteem and change negative thoughts into positive ones. Surround yourself with people who are affirming, fun and positive. Record your thoughts and feelings in a journal.
Establish control - Because of the emotional level of this condition, make it a priority to think before you behave or check with someone you trust before you act on something. Stop, analyse the situation you are in, and then make a positive choice.
Establish routines - Develop a daily planning calendar. Manage your time and energy well. Have a healthy eating plan by avoid foods that could have a negative effect. Have a bedtime-routine. Sleep at approximately the same time and for the same duration daily.
Externalise the Bipolar Disorder - Realise that Bipolar Disorder is an illness and that it does not define who and what you are. You are an individual who can manage the illness and monitor the treatment.
Suicide prevention - If you are suicidal, immediately seek assistance. Suicidal thoughts/behaviour can be resolved if managed.
Make a crisis plan - Write a personal crisis plan to be used if your symptoms become so severe and/or dangerous that you need others to take over responsibility for your care. The list should include: a) a list of your supporters, their role in your life and their telephone numbers, b) a list of all medications you are taking and information on why they are being taken, c) give completed copies of your plan to your supporters so they have easy access to it when necessary. Update your plan as needed.
Support from others - What can families and friends do to help?
Psycho-education - If you are a family member or friend of someone with Bipolar Disorder, become informed about the patient’s illness, its causes, and its treatments. If there is a recurrence of the illness, you may notice it before the person does. Try to plan, while the person is well, for how you should respond when you see these symptoms. In a caring manner, indicate the early symptoms and suggest a discussion with the doctor. You will be thanked later! Both you and the patient need to learn to tell the difference between a good day and hypomania, and between a bad day and depression. Patients taking medication for Bipolar Disorder do have good days and bad days that are not part of their illness - just like everyone else. Treat people normally once they have recovered, but be alert for telltale symptoms.
Encouragement and support - Encourage the patient to stick with the treatment, see the doctor, and avoid alcohol and drugs. If the patient has been on a certain treatment for an extended period of time with little improvement in symptoms or has troubling side effects, encourage the person to ask the doctor about other treatments or getting a second opinion. Offer to come to the doctor with the person to share your observations. If you’re loved one becomes ill with a mood episode and suddenly views your concern as interference, remember that this is not a rejection of you – it is the illness talking.
Crisis planning - Learn the warning signs of suicide. Take any threats the person makes very seriously. If the person is “winding up” his or her affairs, talking about suicide, frequently discussing methods of follow-through, or exhibiting increased feelings of despair, step in and seek help from the patient’s doctor or other family members or friends. Confidentiality is important but does not stack up against the risk of suicide. Call an ambulance or a hospital emergency room if the situation becomes desperate. Encourage the person to realise that suicidal thinking is a symptom of the illness, and that these thoughts, and the depression, will pass. Always stress that the person’s life is important to you and to others and that his or her suicide would be a tremendous loss and not a relief.
Putting safeguards in place - Take advantage of periods of stable mood to arrange “advance directives” – plans and agreements you make with the person when he or she is stable to try to avoid problems during future episodes of illness. You should discuss and set rules that may involve safeguards such as withholding credit cards, banking privileges and car keys. Just like suicidal depression, uncontrollable manic episodes can be dangerous to the patient. Hospitalisation can be life saving in both cases. If you are helping care for someone at home, try if possible to take turns “checking in” on a patient’s needs so that the patient doesn’t overburden one family member or friend.
Don’t push too hard - When patients are recovering from an episode, let them approach life at their own pace and avoid the extremes of expecting too much or too little. Don’t push too hard. Remember that stabilising the mood is the most important first step towards a full return to function. On the other hand, don’t be overprotective. Try to do things with them, rather than for them, so that they are able to regain their sense of self-confidence.
Use support groups - Take advantage of the help available from support groups.
Support groups are an invaluable part of treatment. These groups provide a forum for mutual acceptance, understanding and self-discovery. Participants develop a sense of camaraderie with other attendees because they have all lived with mood disorders. People new to mood disorders can talk to others who have learned successful strategies for coping with the illness.
Helping yourself, helping others: The value of support groups.
Spending an evening with a group of people with depressive disorders may sound intimidating at first. But, keep in mind that support groups provide a forum for mutual acceptance, understanding and self-discovery. Your involvement with a group gives you something proactive to do while you’re waiting for a new medication to take effect or your next therapy session. A strong bond can be established and you may find yourself rediscovering strength and humour which you thought you lost. As with any chronic illness or serious injury, we can sometimes fall into the mistaken belief that we are inherently defective people. In a support group, where you have the opportunity to reach out to others and benefit from the experiences of people who have “been there”, it becomes a little easier to remember that depression or manic depression does not define who you are.
Issues related to Bipolar Disorder
Reckless behaviour - When manic, people tend to be reckless and engage in uncharacteristic behaviour which could have serious consequences. Typical behaviour could include sexual promiscuity, spending sprees and substance abuse. People diagnosed with Bipolar Disorder are often found to abuse substances such as alcohol, drugs or prescription medicine as a symptom of mania or to numb the feeling of depression. Alcohol and drugs are chemicals which cause an imbalance in how the brain works. This can, and often does, trigger mood episodes and interferes with your treatment medications. You may sometimes find it tempting to use alcohol or illicit drugs to “treat” your own mood or sleep problems – but this almost always make matters worse. If you have a problem with substances, ask your doctor for help and consider self help groups such as Alcoholics Anonymous.
Relationships – Dealing with the ups and downs of bi-polar mood disorder are stressful to the person as well as their family, friends and significant others. Uncharacteristic behaviour and depression adds stress to any relationship, especially if others are not educated about the disorder and find it difficult to separate the symptoms caused by the disorder from the person they know and care for. You can deal with such issues by explaining to others what Bipolar Disorder is, and how they can help you to identify the onset of an episode. Keep communication lines open between you and others. Also have other sources of support with which you can communicate other than family and friends, such as support groups. If you struggle to deal with your relationships, seek emotional support from a professional.
Suicide – Extreme depression and reckless manic symptoms often lead to suicide attempts. Therefore it is important that symptoms are identified and treated early to prevent extreme mood fluctuations. It is wise to have a suicide prevention plan and to discuss this with your professional and informal support system. An example of such a plan is as follows:
Identify and treat your symptoms early;
Set up a system with others so you are never alone when you are deeply depressed or feeling out of control
Have regularly scheduled health care appointments and keep them;
Throw away all old medications and have firearms locked away where you do not have access to them. If you are suicidal and concerned that you might overdose on your medication, you could also ask somebody you trust to be in charge of all your medication and to dispense the necessary doses when necessary;
Keep pictures of your favourite people in visible locations at all times;
Instruct a close supporter to take away your credit cards, cheque books and car keys when you are feeling suicidal;
Always have a contact number handy of somebody you can phone when you feel suicidal, or that you may harm yourself, or when you don’t trust yourself.
Always have something planned to look forward to.
Psychosis (hallucinations and delusions) - Psychotic Bipolar Disorder symptoms are mostly associated with mania, but is not uncommon with mixed moods and occasionally with depressive Bipolar Disorder symptoms. Psychosis merely refers to a break with reality. Psychosis can be in the form of hallucinations (experiencing things that are not there) or delusions (false beliefs). Hallucinations can be both auditory (hearing voices, etc.) and visual (seeing things). An example of delusions could be that a person falsely believes that he or she is actually some famous historical figure.
Holistic Wellness Lifestyle Management Plan – What is my plan?
After reading through the pamphlet, which tips can you use in your action plan to living healthier?
UNTITLED they come, they go
perhaps it is me who chases them away
i long for their love
i yearn for their touch
they don't understand me
they just don't get me
a simple mind, complicated issues
i am different to them
my world might not seem real
i live in a dream
my soul awaits to be set free
they have chosen not to be part of my journey
i will stand on my own and continue to be
Brown, J.L., & Russell, S.J. (2004). Staying well with bipolar disorder. Australian and New Zealand Journal of Psychiatry. 2005, 39:187 – 193.
Sadock, B.J, & Sadock,V.A. (2007). Kaplan and Sadock’s Synopsis of Psychiatry – Behavioral Sciences/Clinical Psychiatry (10th edition). Lippincott Williams & Wilkins, Philadelphia: PA
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