A scene that is all too common in fiction, and real life I’ve noticed, is when some character’s mood changes multiple times in a short period. Either and argument will ensue or the mood-swinger will leave the room, but either way the aftermath will contain a line like “What are they? Bipolar?”
This is incorrect. The first disorder we shall discuss today is Bipolar disorder which, rather surprisingly I must admit, has very many aspects to it. After that we will discuss the true identity of this mysterious mood-swinging illness which has so maligned BD.
Bipolar (Affective) Disorder
This disorder is formally known as manic-depressive disorder which, in my opinion, gives a better indication as to what is actually going on.
Firstly bipolar is a mood disorder that is defined by the present of one or more episodes of mania (elated energy/cognition/mood) with/without one of more depressive episodes. Just so you know what I’m going on about, I will list the definitions of those the different episodes.
Depressive Episode: Persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal ideation.
In the more severe cases, psychosis may occur with the sufferer experiencing unpleasant delusions and (less commonly) hallucinations. The episode will persist for at least 2 weeks and may exceed 6 months if untreated.
Manic Episode: This is the “signature characteristic” of BD and it’s severity dictates how the disorder is classified. Generally, mania is a distinct period of elevated mood, sometimes euphoria. Other symptoms include increased energy, decreased need for sleep (as little as 3 or 4 hours a night or even a few days without sleeping), pressured speech (talking fast and frenzied), racing thoughts (random thoughts and memories moving quickly), low attention span, and being easily distracted. In this state the sufferer’s judgement may be impaired such that they may indulge in behaviour that is abnormal for them (e.g. spending sprees) and some may go as far as substance abuse particularly alcohol (depressants), cocaine (stimulants), and sleeping pills. Behaviour can get aggressive, intolerant, or intrusive and the sufferer may feel out of control, unstoppable or like they are on a special mission or some such grandiose delusion. In related news they may experience an increased sex drive. Manic episodes can vary from person to person and where some may experience severe anxiety and irritability to the point of rage, others are grandiose and euphoric.
In the case of Bipolar I (discussed soon) the sufferer may experience psychosis or a break from reality – basically where their thinking is affected along with their mood.
For such things to be called mania they must last for at least one week, unless hospitalization is required. There are various scales used to measure the severity of a manic episode, including the self-reported Altman Self-Rating Mania Scale and clinician-based Young Mania Rating Scale.
Hypomanic Episode: Basically a mild/moderate version of mania, mainly characterized by optimism, pressured speech and activity, and decreased need for sleep. Unlike those inflicted by typical mania, many of those inflicted by hypomania will actually be more productive since they get all the energy associated with mania but none of the shortened attention span. Of course, they can also suffer some of the other symptoms such as increased creativity, poor judgement, irritability, and hypersexuality. However, they will not get the delusions or hallucinations.
While this actually sounds rather neat (I mean the more energy and inspiration deal – not the bipolar disorder that’s attached) hypomania is harder to diagnose since it just looks like happiness despite carrying the same risks as mania (the impaired judgement and possible substance abuse). Often those who experience hypomania will deny it since it actually feels good – if they can remember what they did as sometimes one cannot remember what happens while in hypomania.
It is stressed that hypomania is not a bad thing on its own – in fact, when it’s not irritable, it’s typically called hyperthymia or happiness. It’s when it’s accompanied by depressive episodes or when the mood changes are uncontrollable and mercurial (also known as volatile but mercurial is such a pretty word) that the problem.
“Indeed, the most elementary definition of bipolar disorder is an often "violent" or "jarring" state of essentially uncontrollable oscillation between hyperthymia and dysthymia.”
Hypomania can last from a few days to a few years – more commonly in the weeks to months category though.
Mixed Affective Episode: This is where symptoms of both mania and clinical depression occur at the same time – so, exactly what it says on the tin. This state presents itself as a combination of the two symptoms – like tearfulness during a manic episode, or racing thoughts during a depressive one. This can frustrate the sufferer as in this state they can feel like crap but have a “flight of ideas” (basically ideas going through your head so fast that you can’t keep track).
This is a very dangerous state as complications such as substance abuse, panic disorder and suicide attempts increase greatly.
Now, usually when a person meets the criteria for BD it is because they experience a number of episodes, averaging 0.4 to 0/7 a year (lasting 3 to six months). However, there is rapid cycling which is defined as having 4 or more episodes a year and is found in a significant portion of BD sufferers. Ultra-rapid (days) and ultra-ultra rapid or ultradian (within a day) cycling have also been described. Rapid cycling can happen in any of the Bipolar subtypes, which I will now discuss.
There are quite a few types of BD (not as many as schizophrenia but we’ll get to that at a later date). The DSM-IV-TR and ICD-10, conceptualize bipolar disorder as a spectrum of disorders occurring on a continuum. Here are the main ones.
Bipolar I disorder
One or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode. A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.
Bipolar II disorder
No manic episodes, but one or more hypomanic episodes and one or more major depressive episode. A bipolar II diagnosis is not a guarantee that they will not mania in the future. As discussed in the hypomania section, it is difficult to identify hypomania and this bipolar II is also difficult to diagnose for those reasons as well as it being reported less frequently than a “distressing, crippling depression”.
Cyclothymia
A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. The “low-grade” cycling of mood can be confused for a personality trait and interferes with functioning.
Bipolar Disorder NOS (Not Otherwise Specified)
This is a catchall category, diagnosed when the disorder does not fall within a specific subtype.
Causation:
Okay, BD has been theorized to have genetic, physiological, and environmental causes – though most studies seem to agree that with that there is some sort of trigger event in the former cases.
Now, in BD sufferers we have rather high suicide rates – 1 in 3 will attempt, or complete, suicide and the annual average suicide rate is 0.4% - 10 to 20 times that of the general population. However, in terms of symptoms that can signal the oncoming BD, as children the sufferers can have suffered mood abnormalities, full major depressive episodes, and ADHD. The onset of BD is accompanied by changes in cognitive processes/abilities including reduced attention, executive capabilities, and impaired memory.
4% of the population will suffer “broadly defined” BD in their life. The lifetime prevalence of BD type 1 is estimated at 2% and is equally prevalent in men and women and across society.
Late adolescence and early adulthood are the peak years for the onset of the disorder but, interestingly, in 10% of bipolar cases the onset of mania happened after the age of 50.
In terms of the age of the sufferer, BD can affect all ages though in the case of the elderly while it is supposed that it becomes less prevalent, it is difficult to tell if they are suffering from BD as they may also be suffering from dementia or side-effects of medications for other conditions.
(Bipolar disorder in children)As for children, mania episodes are rare before puberty and due to the discovery of conditions like ADHD it is hard to differentiate the two in children as instead of euphoric mania they get outbursts of anger, irritability, and psychosis. Also, the stereotypical view of BD appears in children – that is the fast mood swings.
The main treatment for Bipolar Disorder is lithium – the lightest metal known. Side-effects of this include significant weight gain, possible birth defects in new born babies if the sufferer is pregnant (as it’s a teratogen), and dehydration.
Fun fact: the dehydration is caused because lithium competes with the receptors for the antidiuretic hormone in the kidney, causing more water output in the urine – this is called nephrogenic diabetes insipidus (mentioned in the clinic case of a House episode). Now, while lithium is usually cleared from the kidneys with the help of medication it can lead to more depression than before as well as suicidal thoughts/actions and will reduce activity of thyroid hormone (hypothyroidism). So while lithium is the only drug known to reduce suicide in Bipolar sufferers, some of the drugs required to get it out of the your system will increase suicidal impulses… great.
(… actually, the thyroid condition that results from the medication may be the cause of the misconception that bipolar means moodswings – I am very closely acquainted with someone who suffers hypothyroidism and they do get severe mood-swings from that condition. Huh, that’s fridge brilliance for you…)
I mention these side effects as I’ve actually heard of people taking Lithium recreationally and I just find that idiotic (just look to the Wikipedia page on what happens when you overdose – it’s not pretty). That above piece of inspiration was not planned – but now we
Aaaaand back on track! –looks up at the page- Ok... I think that’s quite enough on Bipolar Disorder.
Now, Bipolar is often mistaken Unipolar depression as while Bipolar has both stages of mania and depression it is inconsistent as to the which mood is prominent in sufferers. Also, the younger the age of onset, the more likely the first episodes are to be depressive ones. Because it may take a while for sufferers to have their first manic episode (10% of sufferers don’t get their first manic episode till they’re 50) many are misdiagnosed as having major depression. Actually, Bipolar is so difficult to diagnose it can be mistaken for schizophrenia, schizoaffective disorder, drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder.
However, in fiction the thing that is mistaken for BD is… Borderline Personality Disorder. Why? Mood swings of course!
However, in the case of BD moodswings refer to the previously discussed episodes, which can last for weeks or months and disrupt appetites and sleeping patterns.
In BPD, the moodswings are the actually marked lability (uncontrolled displays on emotion such as laughing or crying) and reactivity of mood (poorly modulated emotional response that does not fall within the conventionally accepted range of emotive response) to external stressors. These have negligible affects on sleep and appetite. These mood swings can last for a matter of seconds through to a matter of days and everything in between.
Now, while BD is a mood disorder, BPD is actually a personality disorder like OCPD from last week - though some may argue that BP is some sort of threshold condition between the two.
Borderline Personality Disorder
BPD is a personality disorder (duh) which is characterized by variability of moods.
Symptoms include:
Inability to relate to other people and the world around them: Self explanatory.
Changing views of others: Sufferers can rapidly change between idolizing a demonizing a person depending on fear and disappointment.
Deep feelings of insecurity: This includes fear of abandonment and loss and will be exhibited in continually seeking reassurance even for small things; inappopropriate displays of anger towards those the sufferers deem responsible for their feelings are; fragile sense of self and their place in the world. These feelings of insecurity make their relationships with other difficult and the sufferer will often do anything to get their partner to stay.
This also means that criticism will hit them hard.
Persistent impulsiveness: Abusing alcohol and other drugs; spending excessively; gambling; stealing; driving recklessly, or having unsafe sex.
Confused, contradictory feelings: Frequent questioning and changing of emotions or attitudes towards others, and towards aspects of life such as goals, career, living arrangements or sexual orientation.
Self-harm: While this includes cutting, burning, and drug overdoses (both prescription and illegal) it also includes more "subtle" methods such as binge eating or starving, abusing alcohol/drugs, and repeatedly putting oneself in dangerous situations or attempting suicide. (Note that self-harm is considered a separate symptom to "trying to get people to stay")
Mood swings: The aforementioned "mood swings". These emotional outburst are often unsuitable and poorly regulated - think of the expression "crying over spilt milk" in the literal sense.
Manipulative: In their ways of using attention.
As with most disorders it's possible that sufferers to suffer from other disorders alongside BPD, or symptoms traditionally associated with other disorders. For instance those associated with anxiety or mood disorders such as excessive worrying and having panic attacks, obsessive behaviour, hoarding or having unwanted thoughts, feeling persistently sad, moving or talking slowly, losing sexual interest or having difficulty concentrating on simple tasks.
They may even experience psychotic symptoms such as delusions or false beliefs such as excessive paranoia.
And on that note we look to Millon's subtypes:
Discouraged borderline — including avoidant, depressive or dependent features
Impulsive borderline — including histrionic or antisocial features: this would easily fit in with those who seek attention in order to avoid abandonment
Petulant borderline — including negativistic (passive-aggressive) features
Self-destructive borderline — including depressive or masochistic features
As you can see, not every disorder allows for certain other disorders to feature in smaller capacities - for instance narcissism does not feature here. The "featured" disorder has to, well, I guess "get along" with the main one and it's overall theme - if you get what I mean. Like how they either reinforce the impulsiveness or the inner turmoil.
Much like many disorders a stigma comes attached to BPD - mostly that sufferers are manipulative attention-whores. It ought to be remembered that the reason for their actions is rooted in their disorder which causes them to feel lonely, desperate, and hopeless - they want the attention so they aren't lonely anymore but they can't help that. Obviously medication is a help but hardly a cure-all.
Also, just because of the sheer ridiculousness of it I will post that some feminists have a problem with the diagnosis of BPD as it fits with the "stereotypical hysterical woman". -facepalm-
Between 2% and 5% of the population will be effect by BPD in their lives.
Symptoms will typically first appear in mid-late teens or early adulthood. Women are 3 times more likely than men to be diagnosed.
Fun fact: The reason this was called "borderline" personality disorder was because it was originally used when the clinician was unsure of the correct diagnosis because the client manifested a mixture of neurotic and psychotic symptoms. Many clinicians thought of these clients as being on the border between neurotic and psychotic, and thus the term “borderline” came into use.
Those are the main features of BDP. So...
Even more elegant and finely crafted links which basically restate what I already said and the things I said I wouldn't cover!
We once more end on the International Classification of Disease by the World Health Organization ICD-10 who call it emotionally unstable disorder and have symptoms under two types:
F60.30 Impulsive type
At least three of the following must be present, one of which must be (2):
marked tendency to act unexpectedly and without consideration of the consequences;
marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized;
liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions;
difficulty in maintaining any course of action that offers no immediate reward;
unstable and capricious mood.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
F60.31 Borderline type
At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:
disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);
liability to become involved in intense and unstable relationships, often leading to emotional crisis;
excessive efforts to avoid abandonment;
recurrent threats or acts of self-harm;
chronic feelings of emptiness.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Reiterating the end of my last post - if you have any symptoms see professional healthcare people. Do not take weird internet quizzes.
I have realized that regular updating will become more difficult once studies start up again given how much reading some of these disorders take. However, I will do my best as usual but it may become fortnightly for a little while.
Til next week! (Hopefully!)
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