Bipolar Disorder

Bipolar Disorders Defined

When I first started out as a psychologist 20 years ago, few people were diagnosed with manic depression. It was considered a fairly rare phenomenon, and the people who suffered with it considered gravely ill.   After working with developmentally disabled children and adults for a few years, I encountered my first manic patient at an inpatient psychiatric unit.  She was well dressed and apparently well-educated. I noticed her tremendous energy at two o’clock in the morning.  She was initially reasonable, calling attention to the bizarre admissions routine. After about 30 minutes in her room, she emerged completely naked, waving a piece of her clothing.  She was angry that I hadn’t told her when I would come to her room for a urine sample.  The patient was not aware of anything out of the ordinary. She believed her behavior to be normal and rational. At that point I knew this woman had nothing in common with the developmentally disabled with whom I had been working.

Since that time, I’ve experienced many flavors of manic behavior.  One of my patients talked so rapidly and for so long that he developed painful sores around his mouth.  Another patient constantly saw her father as the image of a devil.  Many of my patients with mania are unable to sleep for days. Their extraordinary energy can manifest in anger as well as euphoria.  Bipolar type I, as it is now known, is a horrendous illness that profoundly changes the course of one’s life.  The primary medication used to control its symptoms can be fatal, and causes flu-like illness when the level is too high in the body.  Often those with mania reject the use of medication, since like my naked patient, they have minimal awareness of their inappropriate behavior.  Bipolar type II is a newer and milder conceptualization of manic depression.  The mania is not so divorced from reality, and the depressive lows are typically not as bad.  What separates a Bipolar-type Mood Disorder from a Major Depression or Adjustment Disorder is the presence of one or more episodes of mania or hypomania.

Most viewers of this page are unlikely to be acutely manic, since the sustained attention to a computer would be impossible.  It is more common to suffer with hypomania, which often responds to psychotherapy.  Acute mania is not able to be treated with psychotherapy, other than some behavioral programming.  Much like a broken bone, if you have to ask, it’s unlikely you have the disorder.  The therapeutic treatment of hypomania is largely insight driven and psychodynamic, as I have not been exposed to behavioral treatment protocols for hypomania.  Mania is not known to be caused by medical illness, as are many instances of depression.  That is not to say mania is not a biological condition, rather it is not known to be secondary to a medical condition.  Mania appears to be a pure psychiatric symptom, not mimicked by other medical conditions.  Depression can be caused by many medical illnesses, and it even is a prodromal symptom  of neurological illness.  For example, the onset of primary Parkinson’s Disease is often presaged by a clinical depression.  There is no known analogous situation with a state of mania.

We can see that most consumers visiting this site, if they are Bipolar, are likely to be the type two variety.  Please keep in mind that the current nomenclature suggests the only difference between mania and hypomania is an impairment of social and/or occupational functioning.  The newer definition even suggests that hypomanics can suffer with delusions and hallucinations; as long as these patients are not impaired in their daily functioning.  I am unconvinced that someone who believes their food is poisoned, their husband works for the KGB, and they see visions of dead relatives or famous people can be normal in their everyday functioning.   There is no longer a neat discrimination between these conditions, which can be confusing to both patients and doctors.  I believe that the increasingly diffuse boundary between these important diagnoses is leading many people to take common emotional lability as a Bipolar Disorder.

So, is you is or is you ain’t Bipolar?  The quick answer is that it is unlikely if you are gainfully employed, intimately involved with another, and do not have legal difficulties hanging over your head.  If you have suffered with emotional swings since adolescence, have received negative comments about your expansive behavior, and you can’t seem to find steady employment or relationships, then you may want to take a closer look at the diagnosis of type two Bipolar Disorder.

Anhedonia Defined

Some words are not replaceable.  There is no one word that can be used as a substitute.  One such word is anhedonia.  It is rarely used in casual conversation.  It is even rarely used by psychologists.   As the word was typed, the online dictionary underlined the word in red, indicating that it is not in their database.

The meaning is related to its Greek roots indicating a lack of happiness, yet this could be confused as sadness or a numb feeling.  Used in a clinical context, the word means a near inability to derive pleasure from activities once found enjoyable.  For example, a person who avidly collects stamps finds their books going unfilled, and a movie buff can’t recollect the last time they went to the cinema.  If the person went on to other activities they found rewarding, then the dropping of old interests would not be considered anhedonic.  The term is meant to describe a loss of enjoyment that has not found another outlet for expression.  This symptom is highly indicative of a depressive disorder, and may be the least understood of the many depressive complaints.

Patients usually associate sadness with depression, and to a lesser extent, sleep and appetite disturbances.  It is rare that depressive people have insight into how the disorder affects their daily activities.  Typically close others observe the alteration of behavior, and the patient often voices non-depressive rationalizations for the change.  The subjective experience of sadness is generally more figural than a change in behavior.  Said another way, people are generally more aware of changes in feeling than behavior.  This becomes important when someone suffers with a depressive disorder, and they lack a subjective sense of sadness.  They may feel angry or numb, but the lack of subjective sadness prevents the person from identifying the problem as Major Depression.
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It is not uncommon for a person to be labeled by their family and physician as depressed, and yet have no insight into what others see as obvious.  It is common for the person to have an “ah-ha” moment when a microscope is placed on their behavior.  For example, a middle-aged man complained that his family and doctors continually labeling him as depressed, yet he didn’t feel particularly sad-let alone suicidal.  We discussed his daily activities and how they may have changed over the past year.  Subsequently, the man identified a significant loss of interest in professional sports and cooking.  He became aware of his loss of interest in activities that had given him the greatest enjoyment.  Within six months of accepting treatment, the man was again enjoying sports and cooking.  The symptom of anhedonia often serves as an excellent marker of clinical progress.

Anhedonia is a very important symptom of depression because it has little overlap with other psychological disorders.  The depressive phase of Bipolar Disorder and Schizophrenia are two areas of overlap.  Since the anhedonia only occurs during the depressive phase of Bipolar Disorder, it is still valuable in ruling out other diagnoses.  Anhedonia is not a prominent symptom of schizophrenia, and could easily be thought of as a reaction to the auditory and visual hallucinations.  Not so much a direct reaction as a depressive reaction to the effect of the delusions and hallucinations on social relationships.  It is likely that anhedonia has a much greater overlap with medical conditions, since many physical illnesses can impair a person to the point it is difficult or impossible to engage in “normal” activities.

Anhedonia is not just a nifty word to impress others at a cocktail party.  It is a word that often correctly classifies people as depressed who are suffering without insight.  It is a symptom that has little overlap with other psychological disorders, such that it is a significant help in making a correct diagnosis.  A prospective patient needs to rule out medical conditions that lead to chronic fatigue and low motivation.  If this person is deemed physically healthy, yet continues to suffer with a global loss of interest, a trip to the psychologist will help rule out a Mood Disorder.

Depressive Disorders

If you have been to informational websites on depression, then you have a sense of what psychologists consider to be depressive disorders. The typical symptoms are well known, and discussed all the time. Depression actually falls within the general category of “Mood Disorders.” Anyone who has suffered with a bout of moderate Major Depression does not have to be convinced of its impact on work and family life. Many have no doubt run across the term “Bipolar Disorder” and its older antiquated name “Manic-depression.” I consider this diagnosis at greater length in another category on the blog titled “Bipolar.”

The major difference between Major Depression and Bipolar Disorder is a cycle of mania or hypomania. This is not a trivial distinction, whatsoever. Even its milder variant, hypomania, is alarming to others over prolonged periods, and negatively affects occupational and social functioning. Mania is alarming to others over rather brief periods. It is the polar opposite of Major Depression. Often those afflicted are not aware of their expansive mood, or consider it to be a blessing. Depressive people are aware of their symptoms, and sometimes dwell on them excessively. Chronically irritated depressives are often not aware they are depressed, but they are aware of their anger. Consider asking a confidant about your symptoms, since they may provide a fresh prospective. We only know ourselves through the eyes of others.

Bipolar Disorders are less common than Major Depression. Bipolar Disorders are often more debilitating, and with less effective long-term treatment. Severe Major Depression is a nightmare, but add the disorganized frenzy of mania, and it sums to a complete breakdown in functioning. People who suffer with a severe Major Depression have a willingness to commit suicide, and may even experience psychotic symptoms. The type of delusions experienced by people with Major Depression and Bipolar Disorder are quite different, though either disorder may become self-destructive.

Most people using this site are more likely to have a mild form of Major Depression than a Bipolar Disorder. The Bipolar subcategory on this blog is more useful to significant others, than for those who suffer themselves. This is not true for the hypomanic person, as they tend to maintain greater self-awareness than someone with mania. It’s that the hypomanic tends to feel quite elated and energetic, such that a boring old computer blog is not their idea of entertainment. Perhaps those suffering with acute mania are too frantic to web surf, and those with hypomania lack the awareness to consider their condition a problem.

Bipolar Disorder is often misdiagnosed. Hypomania is mistaken for mania, and normal mood swings are taken for hypomania. It is a very serious illness that has almost been reduced to a fad. Twenty years ago, Borderline Personality Disorder was constantly diagnosed and questioned. It is doubtful that Bipolar Disorder will be the last diagnostic fad in the fields of psychology and psychiatry.

Most people have had at least one bout of Major Depression in their lives. Statistically, it’s almost deviant to avoid a Major Depressive Episode one’s whole life. Whereas Bipolar Disorders are rarely aware of their problematic symptoms while manic, the chronic depressive knows they are depressed, but often under-appreciates the severity of their suffering. The depression becomes a backdrop to their life, to the point good spirits seem strange and disconcerting. Once the depression reaches the Moderate stage, it grabs one’s attention in a different way. Physical symptoms rear their ugly heads. Suddenly, you cannot sleep, or conversely, one can’t seem to rouse the whole day. Your appetite is either nil or not capable of being appeased. Chronic anxious rumination is not able to be suppressed. It is not always easy to link all the cognitive symptoms of a depression together, in order for someone to realize they are depressed. Most outpatients initially seek treatment in the moderate stage of a Major Depression, as the physical symptoms assert themselves. It is likely that the moderate stage of depression inspires many web searches.

Generally, treatment is a combination of psychotherapy and medication. The combined treatment is nearly four times as effective as either treatment used in isolation. I believe this rule is most true for Moderate to Severe Major Depressions. I recommend cognitive-behavioral or psychodynamic therapy for treatment of mild depression. I am less concerned about attribution errors in more severe depressions than a milder depression. For example, many of my patients are worried when antidepressant therapy is decreased or discontinued. Often these patients had taken an antidepressant for years without positive results, or were placed on too low a dose of the antidepressant to be clinically effective. Depressive patients often fail to give themselves credit for their hard work in psychotherapy. This is an attribution error, and we all are prone to this sort of error.

1 Comment

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  By Barb howell, December 16, 2012 @ 9:10 pm

  The writer of these articles presumes that anyone reading, researching various disorders, i.e. Bipolar, Major depression, etc. suffers from such disorders. Is it not possible that a relative or friend of one being diagnosed as being bipolar, for instance, wants to know so that they might understand his friend? I have two such friends, the one on lithium has major damaged kidneys, functioning at 20%. Another friend’s son has Aspergers; will never be able to drive a car, but is brilliant pianist.

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