Bipolar disorder: When the mood swings just like a see-saw

The word ‘mood’ is often used in common parlance to describe an emotional state at a particular time. People’s moods vary a little from day to day but the shifts are not significant. Everyone has a “usual” mood; it may go up or down in response to events, but returns to baseline soon after.

When does moodiness turn into a ‘disorder’ needing help?
When mood swings are so out of control that the patient’s life is completely disrupted it becomes a ‘disorder’. The change in mood maybe either towards depression (low) or towards mania (high). The changes in mood are obvious to people around him and maybe so even to the patient. For example, the introversion and shyness seen in the depressive phase is in marked contrast to the extraversion and overconfidence seen in the manic phase.
In most patients, bipolar disorder begins during adolescence, usually beginning as a depression. On an average, an episode of mania may appear for the first time after five years.

In an elevated mood the patient maybe disinhibited in his behaviour, talking excessively and rapidly in a loud voice, making grandiose plans and moving about energetically. He may be distractible, his thoughts may be too fast for him to pursue any of them to a conclusion, and he may start several tasks that he is unable to finish. He may laugh and joke, often inappropriately. He may be impatient, angry and demanding, losing his temper if people do not agree with his grandiose plans. No one can reason with him in this condition, and he may end up in damaging situations, eg, make foolish business investments.

A depressive episode may find him slipping into melancholy for no apparent reason. He may feel exhausted and drowsy all day, yet be unable to sleep at night. He may have difficulty getting up in the morning and attending to work and other activities.

The earliest episodes of depression and mania maybe mild and brief and, therefore, not recognised as a problem. bipolar disorder may thus be diagnosed years after it begins.

Stressful events play a part in the onset of the first few episodes; thereafter recurrence may seem independent of obvious stress. Subtle disturbances in circadian rhythm often precede shift in mood state, eg sleep deprivation, or travel across time zones.

How do you deal with mood swings?
The first mood-stabiliser to be used, Lithium, was discovered accidentally in 1817 and has been used as a medication for about 150 years. Several mood-stabilisers are currently in use. Mood-stabilisers help people with mood disorders live normally, without the fear of unpredictable behaviour that can throw their lives into complete disarray.

What happens once the treatment is started?
The natural length of a manic episode is about 4-6 months while that of a depressive episode is 7-8 months. Medicines can control both extremes and help bring the mood closer to the patient’s baseline level within a few days. Contrary to popular belief, the patient does not keep cycling between highs and lows all the time; he reaches baseline and remains there for months-years. A switch directly from mania to depression or vice-versa happens only about 20% of the time.

It must be noted that remission may not be complete and residual symptoms remain for days to weeks. In other words, the medicines do not switch off the unwanted mood immediately.

Another point to note is that there could be a progressive shortening of symptom-free intervals, which eventually level off at an individual limit. Episodes can occur even when a patient is on low maintenance doses of medicines but the symptoms are far less florid than they would be if he were not on them. They can be controlled with relative ease by balancing the doses of mood stabilisers and other necessary medicines that are only given when episodes occur.

What is the cause of Bipolar Disorder?
The cause of bipolar disorder cannot be localised to a single area of the brain. Using techniques of molecular biology, genetics and neuro-imaging, researchers have hypothesised that people with bipolar disorder have fundamental alterations in many parts of the brain.

For the moment, we can only rely on medicines to control symptoms that can be overwhelming if left unchecked, something they do admirably well. Though the treatment may seem empirical and unscientific to some, the fact that it works and improves the quality of the patient’s life should be sufficient to recommend it.

— Dr Shyamala Vatsa is a consultant psychiatrist