“From the brain and from the brain only arise our pleasures, joys, laughter and jests, as well as sorrows, pains, grieves and tears... It is the same thing which makes us mad or delirious, inspires us with dread, or fear, whether by night or by day, brings sleeplessness, inopportune mistakes, aimless anxieties, absence-mindedness, and acts that are contrary to habit.”(Hippocrates)
To fully understand the concept of bipolar disorder we have to look beyond the original definition by Emil Kraepelin (1856-1926) “A Manic-Depressive Insanity and Paranoia” and the current description put forward by the American Psychiatric Association (APA). In fact we need to borrow from Dr. Hagop Akiskal his concept of bipolar spectrum to get a clear picture of the multiple manifestations of this illness.
Despite several decades of officially referring to the old Manic-Depressive as bipolar I still hear patients over the age of 40 years saying “I have been diagnosed, manic-depressive, schizophrenic and bipolar.” That old name was actually more objective and descriptive of this disease’s nature because “manic-depressive” can be easily associated with the concepts of mania and depression. One weakness is that mania could sound derogatory and phonetically close to maniac. Bipolar, on the other hand, brings the idea of the “cycling.”
But how did the name evolve from “manic-depressive” to “bipolar”? Dr. Charles Bowden, a world authority in this area, attributes the coining of the term “bipolar” to Dr. Robert Kendell. Dr. Bowden stated that in the mid-1970s, the new name was introduced as an attempt to minimize the confusion between manic-depressive illness and schizophrenia. In 1987 the APA officially accepted the name in its DSM-III-R.
Why the word “bipolar”? One possible explanation for this name is that it came about as an inference from the “follie circulaire” (circular madness), described by the French psychiatrist Jules Falret. I like this theory because the Earth is almost a circle and “bipolar” could be a metaphor for the “emotional journey from the North Pole to the South Pole,” from one state of mind to the opposite...switching from being “high” to feeling “low.”
Unfortunately, precisely this original conceptualization of “Highs” and “Lows” is the main source of confusion and a reason for missing the majority of patients with “soft symptoms” or “mixed states” because they don’t meet the rigid diagnostic criteria delineated by the APA. This could have devastating and life-altering consequences for those with bipolar spectrum disorders frequently diagnosed as having Major Depressive Disorder concurrent with Anxiety. If you continue reading maybe your will concur with the perception hold by a small group of psychiatrists around the world: a significant portion of bipolar patients go both undiagnosed and misdiagnosed. In the real world that clear differentiation between depressed and elevated mood only happens in a limited number of individuals.
Most commonly, we see people with a more subtle separation of moods (and frequently a mixture) in their presentation. This is why Dr. Hagop Akiskal felt the need to come up with the term Bipolar Spectrum Disorder.
In a commentary included in the Journal of Bipolar Disorders of which he is the Editor in Chief, he said:
“The patients seen today in psychiatric practice deviate considerably from such a classical prototype. The rubric classical bipolar disorder is generally reserved for non-mixed euphoric mania that alternates with depression in a cyclical, episodic fashion. I haven’t seen such patients in this strict sense for a long time. Most patients have rather subtle presentation.”
His findings have been replicated by several investigators; among them Giovanni B. Cassano et al. who published a special article in the Journal of Affective Disorders in 1999.
In their paper “The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology” they affirm that failing to identify “sub-threshold” manifestations of mania could be a reason for the under-diagnosis of bipolar disorder. These authors also presented several explanations for the lower rate of recognition of sub-syndromal (those not meeting the full diagnostic criteria) cases of manic-depressive illness. Four years later, Dr. Mark Frye in a poster presentation at the APA Annual Meeting in San Francisco displayed data indicating that 61% of patients who sought help for their mood problems from a primary care physician received a wrong diagnosis. When they visited a psychiatrist, the margin of error was 44%. My data (collected in three states: Arizona, Tennessee and Florida) shows an even higher percentage of failure to identify a bipolar spectrum disorder.
In the November 2000 issue of its official journal the APA sent a positive sign of flexibility when 13 world-renowned researchers published “Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire.”
It is relevant that, even though the authors started by endorsing the doubtful 1 % prevalence for Bipolar I Disorder, in the same paragraph they assigned to the Bipolar Spectrum a 2.6 to 6.5 % lifetime prevalence.
I say that 1 % is inexact because this number is, in part, the consequence of the inflated percentages attributed to other diagnoses like Conduct Disorder (CD), Attention-Deficit Hyperactivity Disorder (ADHD), and the disastrous Oppositional-defiant Disorder (ODD). If they are reported with their real prevalence the percentage for mood disorders would be much higher and the victimization of children (by the mental health and the legal systems) less common.
A main contributor to such diagnostic confusion is the way that many clinicians interpret the illness of individuals whose mood fluctuates from happy to angry, instead of happiness to depression and vice-versa. They rarely are classified as bipolar.
In Dr, Cassano’s paper, and most articles on mood disorders, you will find the terms “manic” and “hypo-manic”. If you wonder about the difference between these two categories, the manual of diagnoses (DSM-IV) offers a set of clear criteria to differentiate one from the other. The most important factor distinguishing hypomania is that the person with this state of mind does not require hospitalization if no significant social impairment is present. Notably, psychotic symptoms (hallucinations, paranoia, delusions) are not part of its presentation.
In simple words, the “manic” individual is usually lacking insight (unaware of how his disruptive/erratic behavior is affecting others) and his judgment is seriously impaired. The “hypo-manic,” on the other hand, is generally functioning somewhat well (or even being more productive and creative) and enjoying his natural “high.” A common feature in both situations is a decreased need for sleep and a feeling of “racing” thoughts, when the mind is “going too fast.” Friends and relatives perceive that fast-paced mind, as “he can’t keep his mouth shut” or “it is hard to understand what he is trying to say.” One clear example is this description from the mother of a 9- year- old boy:
“He doesn’t know when it is time to make jokes…He will ask the silliest questions.”
I can give testimony that I have seen her child behave like this even though he has superior intelligence. Another example comes from a 45-year-old lady who described her sudden mood change with these words:
“All of the sudden I felt like I went to hell in a hand basket.”
What probably puzzles some professionals, who follow the rigid diagnostic concepts spelled out in the official classification, is this well-known fact: The “classic” bipolar cycling described by Kraepelin at the beginning of the 20th century is the least common presentation of this illness. Most frequently, in clinical practice, we encounter a very wide spectrum of mood disorders that can range from “one to ten” in terms of severity. A clear example of a severe episode would be a patient who asked me to call the Secret Service to notify them of his hospitalization because “his name was Bill Clinton.” Do you want to guess the name of his wife? He said: Hillary Clinton, of course.
Ten days later cleared of his grandiose delusions and with his mood stabilized, he laughed when he was told what he had said. After his release home, he returned to his career as a successful businessman. In milder cases, of course the individual never has to be hospitalized and he may go through divorces and business failures and bankruptcy, related to impulsive behavior or gambling, but he manages to stay afloat. Between the severe and mild cases, there are many forms of presentations that could fill this book entirely.
A composite of the bipolar symptoms could be like this:
• Very fast speech
• Can’t stop talking
• Grandiose & histrionic, theatrical
• Too Funny
• Angry w/o a clear reason
• Racing thoughts “I would think better if my mind would slow down a little”
• Dresses provocatively
• Craving for attention
• Sexualized behavior and language
• Asking staff for a date
From another perspective, if I could give a nickname to bipolar disorder I will probably chose something like “The Silent Killer,” a label given to high blood pressure in the1970s, but I am afraid that it would sound like the headlines from one of the supermarket tabloid newspapers. Unfortunately the statistics about this illness are very scary: 50 % of the people with bipolar disorder will attempt suicide in their life span and 10 % of those without treatment will kill themselves.
This trend continues even with the sophisticated treatments now available, probably due to multiple reasons. One of them could be the refusal by many of the people afflicted by this condition to accept the existence of a problem and to seek treatment. Sadly, a significant amount of those in active treatment can flip out of a stable mood due to stress, lack of sleep, a concomitant illness or other reasons, as hard to imagine as getting a shot of cortisone for an asthma attack. Other triggers of suicidal thoughts include substance abuse, less than optimal drug treatment combinations and impulsivity. This is why, in every case, I encourage family involvement because it could be the only source of reality check and support when the patient’s stability is falling apart and self-monitoring is gone.
Because this my goal is to empower families and patients, I am going to offer ready-to-use information about the bipolar spectrum, undoubtedly one of the most common psychiatric diagnoses in the world, second only to anxiety disorders.
Maybe I should start by explaining that the knowledge of its existence is as old as the practice of medicine. It goes back to the “father of medicine,” Hippocrates (c. 460-c. 377 B.B.) describing “mania and melancholia” in one of his writings. Ironically, in those ancient times he used only clinical observations to diagnose mood problems, but now, with the reliance on current classification guidelines, clinicians are having problems diagnosing similar conditions.
Closer to our times, Emil Kraepelin (1856-1926) one of the fathers of psychiatry described “A Manic-Depressive Insanity and Paranoia.” I suggest to those who are skeptical about the validity of childhood mania to pay attention to this information:
He even described mood swings in pre-pubertal children, back in 1921. But long before Kraepelin, the French psychiatrist Jean Etienne Dominique Esquirol published a book in 1845 that included a report of several cases of manic-depressive illness in school-age children. 161 years ago he thought that this disease could start in childhood but the good Sigmund Freud came with his revolutionary ideas and children were “instructed” not to get depressed. That Freudian influence can still be perceived in some of our colleagues who believe children are unable to suffer from the bipolar spectrum disorders.
To give the benefit of the doubt to those professionals, I should say that a frequent source of confusion comes from having a restrictive view of the original description of manic-depressive illness. Kraepelin, and even the APA in its DSM-IV manual of diagnosis, describe a cyclical condition with well-defined stages of mood.
Another question that it is frequently asked is this:
How do you get bipolar disorder?
The available evidence from experts in the field points to a genetic problem. Social, psychological stressors and drugs like prednisone, amphetamines and antidepressants can function as precipitating factors. Several chromosomes are “prime suspects” but as of June 2006, nothing concrete and final has been found.
The statistical evidence proving the hereditary nature of mood disorders is conclusive. It could be even more overwhelming if every patient had a thorough psychiatric evaluation, including a detailed family history yielding more accurate diagnoses. By thorough I mean the opposite of perfunctory questions. It implies asking with the intent of gaining deeper knowledge of the patient, not just using the routine “is there a history of mental illness in your family?” The usual interviewer will take a “no” for a good answer and continue to the next question. An investigative clinician, for example, will make sure that the person being evaluated is talking about his biological family and not about an adoptive one. In other cases, after having said that there is no history of mental illness in his or her family, a parent might say:
“Well, in fact, my father was never diagnosed and he didn’t believe in doctors, but I swear there was something wrong with his mood.”
We should also search for the possibility of a very common scenario: the patient is certainly a biological son but one of his parents was an adopted child. That would open a big window of possibilities with grandparents.
At times we need to talk with each parent separately and apart from the child. In several instances I have read the embarrassment on faces as the interview progresses. I usually change the subject then, and a few minutes later, I ask to talk alone with that person. That was the case with a violent adolescent that belonged to a family where everybody was laid back and calm. During a follow-up visit, his mother (a European immigrant), opened up and said:
“I was pregnant when I got married. His real father is a very crazy man.”
On the other hand, with divorced parents, we never ask about the absent parent in front of the child. It is not uncommon to get an answer like this:
“Oh my God, he is carbon copy of his real father. It is amazing, they never spent time together, and I feel like I am going through that hell again.”
Sometimes it is revealing to ask with the child out of the room:
“Who in your family does your child act like, or remind you of?”
Getting more scientific, in terms of pinpointing specific areas in the brain that are implicated in the development of this condition, significant advances have been made. Investigators all over the world have found these locations within the brain as well as the substances and chemical reactions responsible for the elevation or depression of the mood.
Some researchers like Dr. Husseini K. Manji (National Institute of Mental Health) have even described how the medications used to treat Bipolar Disorder affect the gene expression. I should emphasize the importance of this concept because it could explain why there is a “waiting period” between initiation of treatment and therapeutic results. By the way, that delay is a confusing element for many educators and counselors who are accustomed to seeing immediate results in children treated with stimulants for ADHD. They usually perceive it as a failure when the expected waiting time to obtain a therapeutic response from a mood stabilizer is extended in a person previously exposed to stimulants or antidepressants.
That delayed response is even worse when the child has been on stimulants with an incorrect diagnosis of ADHD. This delay is due to the destabilizing effect that amphetamines have on their mood.
Dr. Frederick K. Goodwin of George Washington University and Dr. Manji have explained in detail how giving stimulants to a person with bipolar disorder can make the illness more difficult to manage or even treatment resistant. The clinical picture of a child being switched from ADHD medications to mood stabilizers can also be complicated by a withdrawal reaction from the amphetamines.
As you will see in the following chapters, the so-called symptoms of hyperactivity and poor concentration are misleading. To prevent confusion sometimes it can be productive to ask:
“What do you mean by hyper”.
The answers can be surprising. For example, the mother of one of my patients described her father as hyper but, with further questioning, she stated that he was “always on the go, never will stop talking, was very impulsive and funny, very creative and smart”.
To me, that portrait of a “hyper” father looks closer to an elevated mood than to the usual presentation of a person with ADHD.
Going back to the informative part of this fast walk through the puzzling world of mood problems I could list here the official diagnostic criteria for Bipolar Disorder, but this information is widely available. It can be simply stated as:
Significant mood changes that create emotionaldiscomfort and/or interfere with social functioning.
If you want to expand your information on the diagnostic criteria, the following are good websites:
• http://www.psych.org American Psychiatric Association
• www.nami.org (National Alliance for the Mentally Ill)
• www.chadd.org (Children & Adults with AD/HD)
• www.mhsource.com/bipolar ( by the Psychiatric Times journal)
• http://www.isbd.org/ International Society for Bipolar Disorder
• http://ajp.psychiatryonline.org American Journal of Psychiatry
Instead of expanded academic discussion it seems to be more practical to use this space to remind you of some important facts, like this one:
Many other conditions can imitate Bipolar Disorders.
One of the more common is substance abuse. In fact, many clinicians believe that unmedicated individuals use alcohol as a “home remedy” to control a racing mind, to be able to think straight and to sleep.
Another category to remember is personality disorders. Individuals diagnosed with a character problem might be very sensitive and feel hurt so easily, that to be around them becomes an unpleasant task. Such is the case of Borderline and Narcissistic Personality Disorders. Many books and treatment strategies aim to treat this type of problem but several outstanding psychiatrists believe that these personality disorders are in fact cases of bipolar spectrum disorder in disguise. If this theory is correct that could explain why these individuals “never get better.”
My take is that antidepressants, officially blessed as the standard of treatment for the “borderline” patients, could actually worsen their mental functioning. I encourage the reader to take at several Letters to the Editor and commentaries included in this website under the tab “Psychiatric Press” to get more information on this important issue. Even though this subject is an academic discussion, I bring it here because learning that antidepressants are detrimental to bipolar disorder patients could assist some readers (or their friends and relatives) to stop unnecessary suffering.
Going back to the list of facts about bipolar to keep in mind, a relevant one is this:
There is not a Federal Law to prohibit a person to have more than one disease at the same time.
A beloved professor of Pediatrics, Héctor Cruz (in Arecibo, Puerto Rico) used to tell his residents “there is no Federal Law that prohibits having more than one illness at the same time.” This is the equivalent to an expression frequently used by a respected professor of psychiatry and philosopher, Dr. Ronald Pies:
“The body can have as many illnesses as it pleases.”
Dr. Cruz was talking about Pediatrics while professor Pies is thinking of Psychiatry and medical conditions that can mimic psychological problems but the fact is that we find bipolar disorder in a person that also can have drug addiction, anxiety, Obsessive-compulsive Disorder, Post Traumatic Stress Disorder, sexual abuse history, and so on.
Another condition that could be mistaken as bipolarity, if we do not take a good history, is the Pre-menstrual Syndrome (PMS). Many women actually go through obvious mood changes every month to the point that, in severe cases, partners and friends can describe the changes in the person’s demeanor as a “180 degrees shift for the worse.” Curiously, I have observed that close relatives of bipolar individuals, who do not have bipolar spectrum disorder, sometimes are the one who have severe PMS.
Another clue: an excessively flirtatious manner and an extroverted personality may lead you to suspect a mood disorder. Fortunately most of the time it is very easy to separate socially acceptable behavior from “out of line” interactions. In children it is even more obvious. Here is one example:
Molly Duran is a very attractive and tall Texan lady who was the receptionist at the Goodyear office of Comcare, in Arizona. She has a very likeable personality but she is also the mother of grown up children and no surprisingly she inspires respect in most children. Still, being friendly is a plus for a receptionist but also a magnet for flirtatious men.
It would not be surprising if a visiting case manager or a therapist tries to start a conversation with her. What was really amazing is that a 5-year-old boy with an adult-like demeanor approached this 6 foot-tall woman, and flirted with her as a grown up would do. This happened one morning in the spring of 1997. The child was in a full-blown state of mania but still taking the amphetamine medication Dexedrine, prescribed by his pediatrician against my advice.
This five-year-old had a severe elevation of mood that drove him to display a behavior that would have been in a person 30 years older than him as he lost the normal shyness a child his age would have with a motherly figure. His case should remind us that in childhood and adolescence, mood instability is often expressed as irritability, hypersensitivity, anger and acting out behaviors, or lack of inhibitions. This assertion was obvious to the mother of an eight-year old Floridian boy that described his impulsivity with these words:
“He said to a teacher “you better brush your teeth… At the supermarket he approaches women and says “you have beautiful eyes and he starts conversations with strangers at the Mall.”
In adults, mood disorders may present in many different ways. If they are afflicted by mania or hypomania, we could see the classic “party clown” that throws spicy jokes to strangers or people in a position of authority. These individuals can also lose job after job (and relationships) because of their lack of boundaries, non-stop talking, gambling away the mortgage money, impulsively buying a car they cannot afford, and etc.
Mania can also present as unprovoked aggression, very poor frustration tolerance, and an untimely short temper. We might also see intolerant, inappropriate and grandiose demeanor. That was the case of a 53-year-old man at an Emergency Department, waiting to be evaluated for a possible hospitalization due to suicidal thoughts. He had the following answer to my usual courteous introduction:
“What do you me want to do? Give you a dollar? “
This type of attitude can be understood by reading the brilliant explanation given by Dr. Peter Whybrow during the Annual Neuropsychiatric Review (1999). This distinguished professor and Chairman of the Department of Psychiatry of the University of California at Los Angeles (UCLA) said:
“A manic person, for example, who is very intrusive socially, as you know, will not take the usual “code” coming back saying, “please, stay out of this”. They will continue to move forward, telling you that your tie is outrageous that you possibly shouldn’t wear a paisley shirt with that particular pattern, etc., etc. The memory acquisition and storage system, the Hippocampus is also disturbed and deregulated. People can’t decide what tie to put on. That’s why they put on paisley ties with checked shirt. They can’t make decisions very well. Body homeostostasis: "They wake up early in the morning or they sleep too long.”
To conclude this brief discussion of bipolar spectrum disorders I want to mention that I like to tell my patients and parents that bipolar disorder can present very differently from one person to the other and that the severity of the illness could fluctuate from mild to severe. In fact this characteristic is one of the validations to the concept of bipolar spectrum disorder coined by Dr. Akiskal. Sometimes I talk of two famous actors and call the two most common presentations of bipolar illness the “Robin Williams type” and the “Jean-Claude Van-Damme type”. One always happy and making jokes, the other one, mostly irritated and aggressive in their on-screen characters.
I find these terms relevant because the majority of those adolescents with the angry type are usually labeled with the unfortunate Oppositional-Defiant Disorder diagnosis. On the other hand, adults with this type of bipolar spectrum disorder are, more than 50% of the time, labeled as being just depressed and prescribed with anti-depressive medications, which only worsen their anger and agitation. Sadly too, in children the happy type of these kids hardly ever gets right diagnosis; they contribute to the inflated the percentages of the misleading ADHD statistics, because they are “hyper.”
Finally, if you wonder why the bipolar individual has poor attention span and can be wrongly diagnosed as having ADHD, this is what the eminent Dr. Husseini Manji said in an academic publication:
“An errant enzyme linked to bipolar disorder, in the brain's prefrontal cortex, impairs cognition under stress, an animal study shows. The disturbed thinking, impaired judgment, impulsivity, and distractibility seen in mania, a destructive phase of bipolar disorder, may be traceable to over activity of protein kinase C (PKC), suggests the study, funded by the National Institutes of Health (NIH) National Institute of Mental Health (NIMH) and National Institute on Aging (NIA), and the Stanley Foundation. It explains how even mild stress can worsen cognitive symptoms, as occurs in bipolar disorder, which affects 2 million Americans".
Abnormalities in the cascade of events that trigger PKC have also been implicated in schizophrenia. Amy Arnsten, Ph.D., and Shari Birnbaum, Ph.D., of Yale University, and Husseini Manji, M.D., of NIMH, and colleagues, report on their discovery in the October 29, 2004 issue of Science. Either direct or indirect activation of PKC dramatically impaired the cognitive functions of the prefrontal cortex, a higher brain region that allows us to appropriately guide our behavior, thoughts and emotions, explained Arnsten. PKC activation led to a reduction in memory-related cell firing, the code cells use to hold information in the mind from moment-to-moment. Exposure to mild stress activated PKC and resulted in prefrontal dysfunction, while inhibiting PKC protected cognitive function.
In the future, drugs that inhibit PKC could become the preferred emergency room treatments for mania, added Manji, currently Director of NIM's Mood and Anxiety Disorders Program, who heads a search for a "fast-acting anti-mania agent.”
Excess of ornaments in this vehicle resembles the colorful makeup and/or clothes that people tend to wear during a “manic” episode.