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What is Bipolar Disorder?

The truth is, no one knows what causes Bipolar Disorder. If you ask the average psychiatrist to explain the disease, they will list a set of symptoms and not a pathology. Broadly, Bipolar Disorder is defined as alternating periods of mania and depression. 

In the manic phase, patients present with periods of hyperactivity, pressured speech, insomnia, impulse spending, hypersexuality, and perhaps even euphoria. Patients also seem to have a distortion of their internal clock and circadian rhythm. This results in waking, sleeping, and performing normal tasks at odd hours. Often manic patients will work or call friends late at night, not realizing the average person is sleepy and in bed at that hour. 

This is offset by the depressive phase, which is often where most patients spend a majority of their time. This phase involves deep dark periods of fatigue and sadness, perhaps even to the extent that patients are unable to get out of bed or consider suicide. These periods are often prolonged in the early stages of Bipolar Disorder and in Bipolar type 2 resulting in the misdiagnosis of Major Depressive Disorder. Initially manic symptoms may also result in the misdiagnosis of an Anxiety Disorder, as increased energy can often be uncomfortable. 

Bipolar Disorder can be classified into subcategories. Though there are many, the main classes are Bipolar type 1 and Bipolar type 2. Type 1 is generally more severe. Patients have full blown uncontrollable manic phases, can sometimes become psychotic, and sometimes end up hospitalized. Bipolar type 2 is a milder form of the disorder. Often these patients spend most of their time in the depressed phase and will have rare cases of hypomania, which can still be difficult to deal with, but is not as severe as a full type 1 manic episode. 

But these are all symptoms and classifications. I have always found the lack of an explanation as to what actually causes Bipolar Disorder to be extremely frustrating. In fact, Bipolar research is lacking on all fronts, and government funding remains relatively low. This is perhaps what draws me to treating this disease. Its lack of representation in the psychiatric world makes its sufferers underdogs, and I have always loved an underdog. 

So here are some theories: First, Bipolar Disorder may be the result of erratic electrical conduction within the physical structures of the brain. Essentially, this would make the disease somewhat similar to a seizure disorder that affects solely the psychiatric centers of the mind without involving its motor centers. This would explain why anti-epileptics, also known as seizure drugs, are a mainstay in its treatment. 

The second theory relates the disorder to a chemical imbalance. The dopamine pathway is often targeted in medical treatment. This would make Bipolar Disorder a relative of Schizophrenia, and would explain why antipsychotic drugs originally meant for Schizophrenia are usually effective in its treatment. If this is the case, I would posit that other neurotransmitters may be involved as well. This would also explain why serotonergic drugs are contraindicated as monotherapy, since they can induce a manic phase.

Lastly, there does appear to be some relation to adverse life events, specifically in childhood. Though there certainly are bipolar individuals who have lived happy, peaceful lives, often those diagnosed can describe patterns of adversity which eventually trigger their initial episodes. This would relate Bipolar Disorder more closely to diseased such as Major Depression, Generalized Anxiety, and Borderline Personality Disorder. 

Therapy does seem to help with Bipolar Disorder, though on its own it's ineffective. I believe coaching as to healthy life habits and emotional support are crucial, especially after an initial diagnosis. The disorder is a difficult one, there is no cure and treatment is lifelong. A strong support system can make a huge difference. 

So what to do? How do you treat such a difficult and ethereal disease? Well, medications are a mainstay of treatment. Likely, patients will have to stay on medication lifelong to prevent episodes and improve mood stability. Rarely, patients do have medication-free periods, however this is not the recommendation of the American Psychiatric Association, and can be somewhat risky. 

What is frustrating is that there are very few drugs primarily intended to treat Bipolar Disorder. Often, the drugs we use are initially intended for epileptics or schizophrenics. Lithium is the one drug I can think of which is solely used for Bipolar Disorder, and though it has been used for over 70 years, no one knows exactly how it works. It is an old drug and though it is effective, especially in severe cases with suicidality, it does have some drawbacks. 

Lithium, especially at higher doses, can cause kidney disease, thyroid dysfunction, hair loss, acne, and weight gain. That said, a lot of patients who take this drug do very well and do not experience any of these side effects. There are newer drugs on the market, but they have not yet passed the test of time. 

Most of the drugs used to treat Bipolar Disorder have side effects. Most cause weight gain and many cause cognitive slowing. Sometimes slowing down the mind is beneficial, especially in treating and preventing the manic phase of this disorder. But side effects are often the reason patients try coming off their meds, which can be detrimental.

Often, Bipolar patients will self medicate with drugs or alcohol. I can’t blame people for trying this. Moods can be extreme and labile in Bipolar Disorder and at first the side effects of marijuana or alcohol can seem tolerable. Eventually, however, patients find they end up with two problems. Co-occuring Substance Use Disorders and Bipolar Disorder are a common phenomenon. 

Lamictal is my favorite medication for this disorder. It is a seizure drug which is sill used in eplieptiform disorders to this day. Its side effect profile, I believe, is the best in its class. It does not cause weight gain or cognitive slowing. In some studies, it even improved mental performance and life expectancy in Bipolar mice. 

There are a few drawbacks with Lamictal, however. It can rarely cause a rash which can even more rarely progress to a dangerous skin disorder known as Stevens-Johnson Syndrome. SJS is rare, and slowly tapering Lamictal doses up over a period of several months can profoundly reduce the risk of occurrence. Additionally, not all rashes progress to SJS. Sometimes the rash resolves and dose adjustments can ameliorate the issue. 

Lamictal also is unfortunately not the best drug for preventing mania. It is often used in milder cases of Bipolar Disorder, in which severe manic episodes are not observed. Commonly, it is used in a combination of therapies with an antipsychotic or an additional mood stabilizer in order to provide a synergistic effect requiring lower doses of the second medication and thus reducing side effects. Lamictal is great for improving the depressive side of the disorder, and though it is not perfect, does also have some anti-manic properties. All things considered, it is not uncommon to see patients, especially Bipolar type 2 patients, doing well on Lamictal monotherapy. 

The choice of treatment in Bipolar Disorder is as unique as the patients themselves. A tailored treatment plan is optimal. A close relationship with a mental health team is especially beneficial. Treatment is lifelong, but it does not have to be life limiting. Medications are a mainstay but so is a healthy lifestyle. A regular sleep-wake cycle, exercise, and avoidance of drugs and alcohol can make a world of difference. There is hope, and we’re here to help. 

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