Forgotten highs make diagnosing difficult

Bipolar illness was once referred to as “manic-depressive” illness, usually a lifelong disorder, characterised by episodes of atypical and often persistent, highs and lows.

The highs are characterised by an excessively good mood, irritability, increased energy, increased interest in activities, decreased need for sleep, and sometimes, delusions.

Sometimes, people who are in the “manic” phase of bipolar disorder make impulsive decisions or do things that get them into trouble.

The other half of the illness involves depression, which is almost the polar opposite of mania. The person has decreased energy, lower mood, feels sad, empty and depressed. They can be very pessimistic and often there is a possibility of suicide. Depression is not required to make the diagnosis; but there needs to be at least one manic or hypomanic (a less severe form of mania) episode. But in general bipolar disorder is characterised as an illness usually involving episodes of both highs and lows.

Almost everyone has times when they’re feeling good, when they have a lot of energy, like when new projects are coming up or when we are in a new romantic relationship. But it’s different in those with bipolar disorder. Their ups are much more elevated than usual. One symptom that’s characteristic is that the need for sleep decreases substantially in people with mania. People who normally sleep eight hours a night to feel rested may sleep only four or five hours, and wake up in the morning with complete energy. People in the depressed phase of the illness can sleep for 12 hours or more, and still have no energy. There is much more focus now, diagnostically, on the increased or decreased energy element in bipolar disorder, as a major part of a cluster of symptoms.

Bipolar I is the more classic form of the disorder which requires at least one episode of mania. People with bipolar I can have episodes of less severe hypomania, but must have at least one full-blown manic episode.

Bipolar II involves at least one episode of hypomania. Hypomania is less severe than mania and does not require hospitalisation or include delusions. But bipolar II is not necessarily a less severe illness, because the depressions that can occur in both types can be equally severe. Hence, there is an elevated suicide risk in both types.

Often we hear of “rapid cycling” which refers to having frequent episodes – four or more in a year. It’s more common to have one or two episodes in a year.

Those who have frequent episodes are often more difficult to treat. In fact, there are people who cycle even more rapidly, on a two- to three-day cycle. There is disagreement about how to classify such individuals, but many mental health professionals treat people who have cycles as short as a single day in length. They are clearly hypomanic for that day, and then depressed the next day.

Either mania or depression are viewed as occurring in episodes. You can have manic-only cycles or depressed-only cycles. Some people will become manic for a very short period of time, then they return to normal mood; and their next episode could again be manic, or it could be depressive.

Many people are not sure when someone is “just” depressed or in a depressive phase of bipolar disorder. The issue of missing bipolar disorder has been a topic of much research for decades. The problem is that most bipolar patients first come in depressed. About one in five people with depression in fact, have bipolar disorder. The patient coming in with depression may not even remember that they’ve had hypomanic or manic episodes, and they don’t bring it up.

The family isn’t thinking about it. And if the healthcare provider doesn’t ask, it can be easily missed. Sometimes someone comes in, and they’re so low that the health professional can’t imagine this person being high or manic. But they may have been, and so if they don’t ask about it, they are not going to find out about it. A family member can help by coming in with the patient on the first visit because they can often bring very useful information that the patient him or herself is just not able to provide at the moment.

Many people lack insight into whether they have bipolar disorder. In bipolar I, it’s probably 40 to 50% – a very substantial number. In bipolar II, it’s substantially less. In general, those with bipolar II don’t have the devastation to family, career, and education in the same kind of way. But they do have terrible problems with productivity, lost jobs and so on, because they have been depressed and cannot function while untreated. In bipolar I, the most common variety, it usually takes several manic episodes, having devastating consequences, before people with the disorder recognise they actually have an illness and they’re going to have to deal with it for the rest of their life. Often people in their 30s seek help after finally coming to terms with it and they may realise they have lost a decade of their life to the illness. This can be quite a painful awakening.

How can this tumult be prevented?

Becoming aware, not denying it and seeking professional help are key. The problem of self-awareness is real and is one of the reasons the MDQ – the Mood Disorder Questionnaire was created. It’s a 13-question “yes/no” questionnaire, asking things about whether you’ve ever had times when you spent too much money, times when you had an abnormally high mood – it goes through a number of the symptoms of mania, and it takes about five minutes to fill out. You can score it, or a health professional can. It’s available on the internet if you do a Google search.

What should you do after you complete the MDQ?

The MDQ is a screening instrument. If you screen positively, it does not mean you have bipolar disorder. It means that you’re likely to have it and that you should be more comprehensively evaluated. If you score it yourself and are “positive,” then you should discuss the results with your primary care provider, or better, a psychiatrist or another mental health professional. If you are wondering whether you or a loved one have bipolar disorder start with recognising that bipolar disorder is a serious neuropsychological disorder and there’s a huge amount mental health professionals can do to help people with this illness to manage it, to reduce or prevent episodes.

Carin-Lee Masters is a clinical psychologist. Write to her at helpmecarin@inl.co.za Send a WhatsApp message or SMS to 082 264 7774.