Bipolar disorder – a mood disorder characterised by polar extremes of mood – was once known as “manic-depressive disorder”, which sheds light on the symptoms of this often debilating psychiatric condition.While it is normal to experience fluctuating periods of happiness and sadness associated with usual life circumstances, a person diagnosed with bipolar disorder will have triggered swings from extreme happiness and high levels of energy, to extreme sadness and hopelessness, within a matter of hours or days. Extreme happiness presents as mania, such that a person becomes excessively active in behaviour and speech, finds it difficult to sleep or sit still without fidgeting, and may have racing thoughts and ideas that fly quickly through the mind in illogical succession. A person in the manic phase may take more risks, such as being more sexually active, taking drugs or spending more money. Compare the manic phase to extreme sadness, where a person may experience debilitating depression and limited energy. During the depressive phase a person may sleep all day and feel as if everything in their world is hopeless, with no motivation to change things. Both extremes are like a see-saw for the individual with bipolar disorder, who will likely experience no sense of organisation or control over their life. The extremes of bipolar disorder are associated with fluctuating neurotransmitter levels in the brain – a significant rise in dopamine levels for mania and a significant drop in serotonin and opioid levels for depression. Less extreme versions of this debilitating condition – that often see people eventually losing their jobs, becoming withdrawn and not engaging in everyday activities – are known as hypomanic states.
It is important to remember that victims of domestic and emotional abuse may appear – or are led to believe that they are – behaving in a manner akin to bipolar disorder, and if this is happening to you it is vital to seek urgent support. A correct diagnosis of bipolar disorder does not stem from a disgruntled partner, an ex or a psychopathic boss, who may gain pleasure in causing upset and confusion – a manipulative tactic known in modern parlance as gaslighting – but rather stems from meeting strict criteria in the Diagnostic and Statistical Manual Version 5 (DSM-5). The DSM-5 can be relied upon – as the bible of psychiatrists – to determine real cases of psychiatric disorder, so that the individual sufferer can receive vital treatment (such as pharmacotherapy or counselling) to improve their quality of life. The DSM-5 recognises four main types of bipolar disorder. The first is Bipolar I Disorder, where manic episodes last for at least 7 days and severely consume the energy resources of the individual, to the point where they may need hospitalisation. Depressive symptoms usually co-occur for around 2 weeks and may also be present during episodes of mania. The second is Bipolar II Disorder, which is defined as a successive pattern of unprovoked depressive symptoms and hypomanic states that cycle for at least 7 days, and might even surprisingly occur at the same time. The third is Cyclothymic Disorder (also called cyclothymia), defined by numerous periods of hypomanic and depressive episodes lasting consecutively for at least 2 years (1 year in children and adolescents). Finally, Unspecified Bipolar Disorder is a catch-all category, where a person may exhibit episodes of mania or depression, but not usually within the same timescales as the main diagnoses.
What then, are the neuroscientific bases of a DSM-5 diagnosis of bipolar disorder – in other words, which brain regions are more activated in the MRI scanner? Recent studies of bipolar disorder have demonstrated, particularly in response to emotional stimuli like faces, that an over-active connectivity occurs between the amygdalae and prefrontal cortex – brain regions associated with arousal/fear and goal-directed behaviours respectively. This suggests that people with bipolar disorder may not be able to effectively self-regulate their emotional responses to their environment. Such hyperactivity in the brain may also be associated with learned responses that began during significant past trauma, or may even be due to the increasingly stressful, busy and socially-isolated lives we lead today. For example, chronic trauma, stress and social isolation (e.g. due to long working hours and parental separation) may cause a downregulation (reduction) of opioid receptors in the brain – the locks to the pain-relieving brain hormone keys. Opioids are the brain’s natural defense to pain – including emotional pain – and so if chronic emotional pain is experienced, opioids may become less potent over time. We also release opioids and other hormones, such as oxytocin, during intimate pair-bonding. If emotional and/or physical abuse is chronically experienced, a person may begin to exhibit more and more signs akin to emotional dysregulation and bipolar disorder.
And so, if you are a friend or family of a person who may be exhibiting manic or depressive coupled with periods of low energy and hopelessness, in a cyclical pattern over long periods, with no obvious cause, it might be useful to do the following. First, gently communicate with the person, to try to establish if there are serious, underlying causes for this behaviour, such as physical or emotional abuse (don’t simply assume that they are suffering from bipolar disorder). Be prepared that the person may not wish to open up immediately, but be supportive and accepting. If no obvious cause for the behaviour is established, then the second step might be to suggest the person visit a psychotherapist, to talk through with a trained professional who can establish the cause. Finally, with the help of the therapist, a formal diagnosis for the behaviour can be established and treated, usually with a combination of suitable medication and further psychotherapy.symptoms, such as excessive energy, lack of sleep and risky behaviour (promiscuity, excessive spending and debt, gambling),
The ultimate take-home message is this: don’t be quick to give a layman’s diagnosis to a person who may exhibit symptoms akin to bipolar disorder, as there may be other reasons for their behaviour. However, if a formal diagnosis by a trained professional is established, a person suffering with bipolar disorder has a wealth of treatment options available to him or her, that can enable them to continue living a fullfilling, enjoyable life! We must always remember: life is too short and too precious to cause - or exacerbate - human suffering!
Dr Samantha Brooks is a neuroscientist at the UCT Department of Psychiatry and Mental Health, specialising in the neural correlates of impulse control from eating disorders to addiction. For more information on neuroscience at UCT and to contact Samantha, see www.drsamanthabrooks.com. Note: Images royalty free, courtesy of https://commons.wikimedia.org/wiki.