Major Symptoms

The type of bipolar disorder a person has is largely determined by identifying the severity, number, type, and duration of manic and depressive symptoms the person has or is experiencing. Diagnosis of bipolar disorders is complicated by the fact that many symptoms of unipolar depression and manic-depression overlap. As an example, agitation and insomnia can occur in the depressed and in the manic state. Hypersomnia and psychomotor retardation, however, are observed more in bipolar than in unipolar depression.

Mania is one of the most dangerous of the abnormal mood states, but fortunately it is not present in all forms of bipolar disorder. Mania or manic behavior produces extreme and dramatic symptoms that can endanger the person's social and economic well-being and cause the individual to take life-threatening risks. The early stages of mania are experienced as pleasant and uplifting. The person feels energetic, creative, highly spirited, and capable. In the beginning of a manic episode, individuals are filled with a pleasant mood, ambitious thoughts, and self-confidence. They see great promise in their relationships, personal talents, skills, careers, and future. Goals are more clear, tasks seem less difficult, and life becomes magically filled with cosmic meaning and understanding. These exuberant and positive feelings, however, quickly pass and change into more pronounced psychiatric symptoms.

The person's cognitive information processing skills are disrupted by rapidly occurring thoughts that not only collide together but form incomplete and incon-gruent ideas. Additionally, the ability to screen and judge the appropriateness of one's thoughts, behaviors, productivity, and quality of work largely disappears. Furthermore, the previously elated mood filled with self-confidence, grandiosity, and positive symbolic meaning turns into unexplained, almost random anger and irritability. Whereas some individuals alternate between periods of elation and irritability, most slip into a state of mania dominated by dissatisfaction, frustration, intolerance, and an unsettling irritated mood. Some individuals also experience a constant internal rage that, with almost no provocation, can explode into verbal or physical violence. Mania also blunts and distorts learned social-cultural judgment while simultaneously stimulating a need for increased activity and excitement. In an attempt to alleviate these pressured feelings of desire, anxiety, anger, and grandiosity, the person behaves and makes decisions that are erratic and often dangerous. Without forethought or consideration of the consequences, individuals in a manic episode may run up large credit card debts, buy enormous quantities of a single and unusual item, engage in risky sexual activities with multiple unknown partners, drive recklessly, feel justified driving the wrong direction down a one-way street or disobeying traffic lights, indulge in large quantities of food and alcoholic drinks or go without eating and sleeping, drive aimlessly until the car runs out of gas, lose inhibitions and speak crudely or go nude in public, dress bizarrely, or verbally and physically lash out at others. Mania is always dangerous. As grandiosity is stimulated and judgment severely suppressed, the manic person can become extremely reckless and cause serious self-injury or death. The inability to foresee consequences and consider multiple solutions along with impulsive, agitated thinking and anger can induce rapid suicidal thoughts and behaviors. Depressed patients ruminate, plan, and deliberate the possibilities of suicide. For the depressed, death is often a means of ending mental anguish and hopelessness or stopping an unexplain-able, but nonetheless constant drive and obsessive desire to die. In contrast, manic individuals kill themselves over poorly conceived, impulsive, almost momentary issues and feelings. Furthermore, severe mania often triggers physical violence and aggressive property destruction in people who have a more severe form of manic-depressive illness. People with a manic-depressive illness more often make death threats to presidents and other famous individuals than patients diagnosed with schizophrenia.

As the severity of a manic episode proceeds, thoughts can rush through a person's mind so fast that half-way through a sentence the beginning point is forgotten. This occurs when manic symptoms disrupt or block the brain's working memory. Under normal circumstances, working memory allows us to pull appropriate information from long-term memory, lock it in our mind, and manipulate the facts into interlinking complete thoughts and logical problemsolving models. In the most severe stages, mania can cause the person to experience psychotic hallucinations and delusions. Without medication, the person's manic hyperactivity and psychotic state will evolve into a stressful fatigue and loss of psychological orientation to time and place that causes the individual to appear completely confused, bewildered, and stupefied. In the past this was referred to as delirious mania. Fortunately today's modern medications and supportive treatment prevent most people with a manic-depressive disorder from reaching this level of severity.

Euphoria and hyperactivity that create difficulties but do not reach the level of severity of manic episodes is known as hypomania. This psychiatric condition was first described in the late 1800s by the German psychiatrist Mendel. A hypomanic mood produces behavior that resembles the first phase of a full manic episode. The person has an elated mood, increased energy, rapid thinking and speaking, and reduced information processing skills. Though thoughts occur quickly, information is processed in a more narrow, concrete, and restricted manner. As an example, one's abilities to form alternative solutions, empathize, consider input from others, or perform problemsolving tasks requiring an exact sequential sequence are substantially reduced. Additionally, hypomania causes problems perceiving, organizing, and analyzing fragmented social information and interpreting social cues that have multiple meanings. As a result, hypo-manic individuals make impulsive decisions, fail to consider behavioral consequences, and seldom perceive how others experience their actions. The symptoms may also include an inability to screen verbal communications. That is, the person feels an actual need or urge to voice almost every thought. When this symptom occurs, the individual interrupts others, talks incessantly, and has little concern if his or her words insult and upset the listener. Furthermore, hypomania, like the first phase of mania, can cause grandiose self-perceptions. During periods of grandiosity individuals overvalue their skills, status, or personal magnetism and may engage in behaviors like risky investments and business decisions, overspending and credit card debt; sexual experimentation and excess, and careless and reckless activities. A hypomanic person often displays seductive and addictive behaviors that may first appear as spontaneity or personality characteristics. A closer examination, however, will show that the individual's actions extend beyond the boundaries that are acceptable for most people within the same age and cultural group. Many times individuals with hypomania are labeled by families, schools, and community agencies as immature or delinquent and neither receive a referral nor seek mental health treatment.

Only a brief overview of depression symptoms is provided in this section. Readers are directed, however, to the complete article on the subject that is included in this volume. Depression is different from sadness, grief and bereavement, feelings of loneliness and isolation, or disappointment. Each of these situations creates a normal, but nonetheless unpleasant mood reaction to a real or perceived event. More importantly, one is able to shift away from the reaction, receive relief, and often block the feelings by engaging in nonrelated activities. That is, normal depressive feelings are mood reactions that seldom pervade every domain of our life for an extended period of time. Even when one's mood is lowered by a specific event, most individuals continue to experience a range of positive thoughts and feelings.

Unlike reactive sadness, depression is a downward spiraling or narrowing of feeling and emotional range across most major life domains for an extended period. Dulling and despondent feelings relentlessly occur from depression and prevent one from experiencing pleasure, accepting solace and praise, and finding emotional relief. Rumination over issues like regret, guilt, personal loss, shame, incompetency, disappointment, and hopelessness is often experienced as emotional stress and pain. Severe depression can also create a numbing emptiness and an inability to care about oneself, family, others, or the future. Additionally, during a depressive episode most people with a bipolar disorder experience not only a feeling of gloom but also restrictions and deficits in their cognition, information processing, motor, and perceptual skills. Concentration and working memory are always reduced by depression. Abstract thinking along with simple social cognitive information processing is greatly slowed. Other common symptoms include social withdrawal, insomnia or hypersomnia, weight loss or gain, fatigue, headaches, constipation, loss of sexual drive, and loss of interest and enjoyment in past pleasures or life skills. In severe depressive episodes a bipolar disordered person may also develop delusional thinking, hallucinations, catatonic states, or other forms of psychotic symptoms. Approximately 50% of all people with a bipolar disorder will exhibit psychotic symptoms. Additionally, even without entering a psychotic state, severe depression can usher in and maintain paranoid thinking for an extended period. To stop the emotional pain stemming from hopelessness, lost cognitive skills, and hurt from burdening others or feeling unloved or undeserving of love, far too many bipolar disordered patients during a depressive episode make serious and deadly suicidal attempts. Approximately 15% of individuals with a bipolar disorder make a serious attempt to take their life.

Another cluster of manic-depressive symptoms forms the mixed affective mood states or simply mixed episodes. A small subgroup of individuals with bipolar disorders will, for a week or more, concurrently experience the symptoms required for diagnosing a major depressive and a manic episode. This is a highly torturous state that simultaneously inflicts the rushing frenzy of mania and the restrictive negative sensations of depression. Even though the mood abnormality was first described by a seventeenth century doctor, modern medicine continues to struggle with and debate the exact characteristics that define a mixed state. The prevailing symptoms can vary greatly for patients having a mixed episode. Some individuals, as an example, will feature psychotic symptoms, whereas others become highly irritable and yet others manifest more depressive behaviors. There is, however, growing evidence that a mixed state does not occur in all bipolar disorders. As a result, many experts believe that mixed episodes need to be thought of as a form of bipolar disorder or mixed mania that is separate from both depression and mania. Dysphoric mania is similar to mixed episodes, but the symptoms are less severe, often have a shorter duration, and do not qualify as full depressive and manic episodes. Patients who rapidly cycle between depressed and manic or hypomanic states can appear to be, but are not technically, in a mixed state.

The length of time between episodes of illness varies greatly among all patients with manic-depressive illness. For many people the cycle lengths shorten, causing more frequent episodes, then plateau at approximately 3-5 episodes per year, and finally shift to episodes that occur more or less annually. This appears to be the natural course of the illness. As the interval between psychiatric crises lengthens, most patients will have extended periods where their mood, and cognition, motor, and information processing skills return to normal. Unfortunately around 5-20% of bipolar patients have at least 4 manic or depressive episodes per year. This is known as rapid cycling, and episodes may take place in any combination and order.

Diagnostically, rapid cycling episodes do not differ in criteria from those that take place in non-rapid cycling. The symptoms must meet the criteria required for a manic, hypomanic, mixed, or major depressive episode. A smaller group of patients has ultrarapid cycling in which a depressive, manic, or a hypomanic episode may last for only a day or trigger multiple episodes within a 24-hr period. Unlike rapid and ultrarapid cycling, individuals with continuous cycling move through episodes without returning to their normal baseline or feeling normal for a significant period of time. With these individuals one depressive, manic, or hypomanic episode melts into another. Correct and prompt diagnosis of this illness is extremely important. Rapid cycling appears related to morbidity, is pharmacologically difficult to treat, and requires specific medication regimens. Studies show that these patients do not respond well to medications that are normally used with other bipolar disorders like lithium and antidepressants. Moreover, antipsychotic drugs may actually stimulate or exacerbate the cycling process.

BiPolar Explained

BiPolar Explained

Bipolar is a condition that wreaks havoc on those that it affects. If you suffer from Bipolar, chances are that your family suffers right with you. No matter if you are that family member trying to learn to cope or you are the person that has been diagnosed, there is hope out there.

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