$Unique_ID{BRK03964} $Pretitle{} $Title{Manic Depression, Bipolar} $Subject{Manic Depression, Bipolar BMD Bipolar Disorder, Manic Depression Bipolar Disorder, Mixed Manic Depression Manic Depressive Disorder Manic Depressive Illness Manic Depressive Psychosis Bipolar Disorder, Manic Bipolar Disorder, Depressed Atypical BMD Bipolar II Bipolar Disorder, Atypical Cyclothymic Disorder Dysthymic Disorder (Depressive Neurosis) Major Depression, Single Episode Major Depression, Recurrent} $Volume{} $Log{} Copyright (C) 1987, 1989 National Organization for Rare Disorders, Inc. 449: Manic Depression, Bipolar ** IMPORTANT ** It is possible the main title of the article (Bipolar Manic Depression) is not the name you expected. Please check the SYNONYMS listing on the next page to find alternate names, disorder subdivisions, and related disorders covered by this article. Synonyms BMD Bipolar Disorder, Manic Depression Bipolar Disorder, Mixed Manic Depression Manic Depressive Disorder Manic Depressive Illness Manic Depressive Psychosis Includes: Bipolar Disorder, Manic Bipolar Disorder, Depressed Information on the following disorders can be found in the Related Disorders section of this report: Atypical BMD Bipolar II Bipolar Disorder, Atypical Cyclothymic Disorder Dysthymic Disorder (Depressive Neurosis) Major Depression, Single Episode Major Depression, Recurrent General Discussion ** REMINDER ** The information contained in the Rare Disease Database is provided for educational purposes only. It should not be used for diagnostic or treatment purposes. If you wish to obtain more information about this disorder, please contact your personal physician and/or the agencies listed in the "Resources" section of this report. Bipolar Manic Depression is a mental illness in which intense mood swings occur, usually with remissions and recurrences. Depressive symptoms may be most common and can last at least a full day and perhaps several weeks or longer. Manic symptoms may involve hyperactivity and feelings of invincibility, happiness and restlessness. Symptoms Bipolar Manic Depression consists of two distinct episodes which can alternate every few days or weeks. A manic episode usually consists of an elevated mood with hyperactivity, while a major depressive episode is marked by depression, anxiety, tearfulness and excessive sleepiness, possibly leading to stupor. The course of the disorder varies widely from mild to severe forms. Some individuals may have episodes separated by many years of normal functioning; others may have clusters of episodes; and still others experience an increased frequency of episodes as they get older. However, 20% to 35% of cases follow a chronic course with considerable residual symptomatic and social impairment. MANIC EPISODES: During a manic episode, the patient's predominant mood is either elevated, expansive, or irritable. Associated symptoms of the manic phase include hyperactivity, excessive talking, flights of ideas, inflated self- esteem, decreased need for sleep, distractibility, and excessive involvement in activities which may have an unrecognized potential for painful consequences (i.e. charging large sums of money to credit cards without a thought as to the consequences of having to pay off the loans). The elevated mood may be described as euphoric, cheerful, or "high". Often this good mood has an infectious quality for the uninvolved observer, but is usually recognized as excessive by those who know the individual well. The expansive quality of the mood disturbance is often characterized by unceasing and unselective enthusiasm for interacting with people. Although an elevated mood is considered the most recognizable manic symptom, the predominant mood may also appear as irritability, which may become apparent when the individual's efforts or ideas are thwarted. The hyperactive mood may also involve excessive planning of, and participation in multiple activities (e.g., sexual, occupational, political, religious). Increased sociability, including efforts to renew old acquaintances or calling friends at all hours of the night can also occur. The intrusive, domineering, and demanding nature of these behaviors is not recognized by the person with Manic Depressive illness. Expansiveness, unwarranted optimism, grandiosity, and lack of realistic judgment can frequently lead to irresponsible activities such as buying sprees, reckless driving, foolish business investments, and sexual behavior unusual for the individual. Sometimes these activities have a disorganized, flamboyant, or bizarre quality such as dressing in exceptionally colorful or strange garments, wearing excessive or poorly applied make-up, or distributing candy, money, or advice to passing strangers. Manic speech is typically loud, rapid, and difficult to interrupt. Often it is full of jokes, puns (plays on words), and amusing irrelevancies. In severe cases, it may become theatrical, with dramatic mannerisms or singing. If the manic mood is more irritable than expansive, there may be complaints, hostile comments, and angry tirades. Frequently Bipolar Manic Depression patients experience a nearly continuous flow of accelerated speech with abrupt changes from topic to topic, usually based on understandable associations, distracting stimuli, or plays on words. When this "flight of ideas" is severe, the patient's speech may become disorganized and incoherent. Distractibility is usually intense. The patient may overreact to various irrelevant external stimuli, such as background noise or pictures hanging on the wall. Characteristically, there is inflated self-esteem ranging from intense self-confidence to marked grandiosity, which is often a delusion. For instance, the patient may offer advice on matters about which he/she has no special knowledge, such as how to run a hospital or the United Nations. Despite a lack of any particular talent, a novel may be started, music composed, or publicity sought for some impractical invention. In severe cases, grandiose delusions involving a special relationship to God or some well-known figure from the political, religious, or entertainment world are also common. Almost invariably the patient experiences a decreased need for sleep during manic periods. The individual may awaken several hours before the usual time, full of energy. When the sleep disturbance is severe, the individual may go for days without any sleep at all and yet not feel tired. DEPRESSIVE EPISODES: Mood swings marked by rapid shifts from manic episodes to anger or depression often occur. Depression, expressed by tearfulness, suicidal thoughts, excessive sleep or other depressive symptoms, may last hours, days or weeks. At times, the depressive and manic symptoms may intermingle, occurring together, but more commonly, they alternate. In Mixed Bipolar Disorder, the depressive symptoms tend to be more prominent and last at least a full day. Rarely, hallucinations may appear. Their content is usually clearly consistent with the predominant mood (e.g., the patient may hear God's voice explaining that the individual has a special mission). Persecutory delusions may be based on the idea that the individual is being persecuted because of some special relationship or attribute. Less commonly, the content of the hallucinations or delusions has no apparent relationship to the predominant mood (mood-incongruent). MAJOR DEPRESSIVE EPISODES: Major depressive episodes are primarily characterized by either a bad mood, a loss of interest in all (or almost all) usual activities and pastimes, and often a need to sleep excessively. This disturbance is prominent, relatively persistent, and associated with other symptoms including appetite disturbance, change in weight, sleep disturbance, decreased energy, feelings of worthlessness or guilt, difficulty concentrating or thinking, and thoughts of death or suicide. An individual experiencing a depressive episode will usually describe his or her mood as depressed, sad, hopeless, discouraged, down in the dumps, etc. Sometimes, however, the mood disturbance may be expressed as "not caring anymore", or as a painful inability to experience pleasure. Loss of interest in pleasure is always present in a major depressive episode to some degree, but the individual may not complain of this or even be aware of it, although family members may notice. Withdrawal from friends and family, and neglect of avocations that were previously a source of pleasure, are common. Appetite can be either markedly decreased or increased, with attendant loss or gain in weight. Sleep patterns are commonly disturbed, including either an inability to fall asleep (insomnia), or more often an increased need to sleep (hypersomnia) for many hours each day. Insomnia may be characterized as difficulty falling asleep (initial insomnia), waking up during sleep and then returning to sleep with difficulty (middle insomnia), or early morning awakening (terminal insomnia). Psychomotor agitation may also occur. This symptom is characterized by an inability to sit still, pacing, fidgeting, handwringing, possible pulling or rubbing of hair, skin, clothing, or other objects, outbursts of complaining or shouting, or excessive speech. Psychomotor retardation can also be present and may take the form of slowed speech, increased pauses before answering, low or monotonous speech, slowed body movements, a markedly decreased amount of speech, or an absence of speech (muteness). A decrease in energy level is almost invariably present during an episode of depression. Fatigue persists even in the absence of physical exertion. The smallest task may seem difficult or impossible to accomplish during severe depressions. A sense of worthlessness varies from feelings of inadequacy to completely unrealistic negative evaluations of one's worth. The individual may reproach himself or herself for minor failings that are exaggerated, and may search for some confirmation of the negative self-evaluation from others. The sense of worthlessness and guilt may be delusional. Difficulty in concentrating, slowed thinking, and indecisiveness are also frequent symptoms. The individual may complain about loss of memory and may appear easily distracted. Thoughts of death or suicide are common. There may be fear of dying, the belief that the individual or others would be better off dead, wishes to die, or planned or attempted suicide. The symptoms of Bipolar Manic Depressive illness can be so mild that they may not be recognized, or so severe that a patient may be completely disabled. ASSOCIATED SYMPTOMS OF MAJOR DEPRESSION INCLUDE: A depressed appearance, tearfulness, feelings of anxiety, irritability, fear, brooding, excessive concern with physical health, panic attacks and phobias. Causes Bipolar Manic Depression can be a genetic disorder inherited through dominant genes, either autosomal or sex-linked. A chromosome marker has been identified in some people with this disorder which may lead to the discovery of the defective gene that causes this illness. Human traits including the classic genetic diseases, are the product of the interaction of two genes for that condition, one received from the father and one from the mother. In dominant disorders, a single copy of the disease gene (received from either the mother or father) will be expressed "dominating" the normal gene and resulting in appearance of the disease. The risk of transmitting the disorder from affected parent to offspring is 50% for each pregnancy regardless of the sex of the resulting child. In X-linked dominant disorders the female with only one X chromosome affected will develop the disease. However the affected male always has a more severe condition. The exact causative mechanism of this illness is not well understood, but metabolic abnormalities of chemicals in the brain may interfere with the normal transmission of electrical impulses between the nerve cells of the brain. These chemicals (neurotransmitters) include norepinephrine, dopamine, or serotonin. Drugs such as steroidal contraceptives, sedatives, and amphetamines can cause depressive episodes, while corticosteroids, amphetamines, and tricyclic antidepressants may cause manic episodes. Certain infectious diseases such as influenza, mononucleosis, and syphilis can also cause depression and/or manic episodes. The autoimmune disease Lupus, and neurologic disorders such as Parkinson's Disease or Multiple Sclerosis, may also cause depressive mood swings. Stress can trigger these episodes in people who are susceptible to these mood swings. (For more information on these disorders, choose the following words as your search terms in the Rare Disease Database: lupus, ms and Parkinson. Information on syphilis and mononucleosis can be found in the Prevalent Health Conditions/Concerns area of NORD Services.) Affected Population 0.4% to 1.2% of the adult population may have Bipolar Manic Depression although only a small portion may have symptoms severe enough to interfere with functioning. Average age of onset of Bipolar Manic Depression is 35 years old. The disorder appears to affect more females than males. Related Disorders Major Depression is a common mental disorder affecting perhaps 2 million adults in the United States. Recurrent Major Depression involves all the symptoms of a Major Depressive episode, but episodes are recurrent. Cyclothymic Disorder is characterized by a chronic mood disturbance of at least two years' duration, involving numerous periods of depression and a mild form of over-elation and hyperactivity (hypomania). Symptoms may be less severe than those of major depressive and manic episodes. Dysthymic Disorder (Depressive Neurosis) is characterized by a mild chronic depression or loss of interest or pleasure in usual activities and pastimes. Severity and duration of episodes are often less than in a major depressive episode. Atypical Bipolar Disorder is a category for individuals with manic symptoms who cannot be classified as having Bipolar Disorder or Cyclothymic Disorder. For example, an individual who previously had a major depressive episode and now has an episode with mild manic symptoms that are not of sufficient severity and duration to meet the criteria for a manic episode can be classified as Atypical Bipolar Disorder; this illness is also referred to as "Bipolar II". Therapies: Standard Standard treatment of Bipolar Manic Depression is usually with the drug lithium. Several tests should be performed to insure tolerance for this drug. Side effects of lithium therapy which occur often are a need for excessive fluid consumption and frequent urination. Tricyclic antidepressants may also be prescribed to treat depressive episodes. If the patient does not respond to the tricyclics, monoamine oxidase inhibitors (MAOIs) may be prescribed. Psychotherapeutic interventions with patient and family may also be helpful. In general lithium is an effective therapy for Bipolar Disease if a patient complies with the treatment regimen. Since some patients miss the euphoria of manic episodes, they may stop taking the medication against physicians advice. For the depressive symptoms in Bipolar Manic Depression electroconvulsive therapy (ECT) has been used in the most serious cases. Therapies: Investigational Since the chromosome defect that causes Bipolar Disease has recently been identified it is hoped that a genetic test may be developed in the near future. Furthermore, discovery of the gene may lead to a better understanding of Bipolar illness so that it may someday be prevented or more adequately controlled by improved drugs. This disease entry is based upon medical information available through September 1989. Since NORD's resources are limited, it is not possible to keep every entry in the Rare Disease Database completely current and accurate. Please check with the agencies listed in the Resources section for the most current information about this disorder. Resources For more information on Bipolar Manic Depression, please contact: National Organization for Rare Disorders (NORD) P.O. Box 8923 New Fairfield, CT 06812-1783 (203) 746-6518 The Manic & Depressive Support Group, Inc. 15 Charles Street, 11 H New York, NY 10014 (212) 924-4979 Manic Depressive/Depressive Association P.O. Box 753 Northbrook, IL 60062 (312) 446-9009 NIH/National Institute of Mental Health (NIMH) 9000 Rockville Pike Bethesda, MD 20205 (301) 443-4515 or (301) 496-1752 (800) 421-4211 (24 hrs.) National Mental Health Association 1021 Prince Street Alexandria, VA 22314 (703) 684-7722 National Alliance for the Mentally Ill 1901 North Fort Meyer Drive, Suite 500 Arlington, VA 22209 (703) 524-7600 National Mental Health Consumer Self-Help Clearinghouse 311 South Juniper Street, Room 902 Philadelphia, PA 19107 (215) 735-2481 Helping Hands 109 Chestnut Street Andover, MA 01810 (617) 475-6888 (617) 475-3388 For genetic information and genetic counseling referrals, please contact: March of Dimes Birth Defects Foundation 1275 Mamaroneck Avenue White Plains, NY 10605 (914) 428-7100 Alliance of Genetic Support Groups 35 Wisconsin Circle, Suite 440 Chevy Chase, MD 20815 (800) 336-GENE (301) 652-5553 References LITHIUM AUGMENTATION IN PSYCHOTIC DEPRESSION REFRACTORY TO COMBINED DRUG TREATMENT: J.C. Nelson, et al.; American Journal Psychiatry (March 1986: issue 143(3)). Pp. 363-366. ATTEMPTED SUICIDE IN MANIC-DEPRESSIVE DISORDER: N. Goldring, et al.; American Journal Psychother (July 1984: issue 38(3)). Pp. 373-383. ECT IN PRIMARY AND SECONDARY DEPRESSION: C.F. Zorumski, et al.; Journal Clin Psychiatry (June 1986: issue 47(6)). Pp. 298-300. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 3d ed.: R.L. Spitzer, et al., Eds; American Psychiatric Association, 1984.) Pp. 206-218.