Understanding People with Bipolar Disorder

Do you know what Earnest Hemmingway, an American journalist, and novelist; Vincent Van Gogh, a famous and influential Dutch painter of 19^th century; Winston Churchill, the British Prime-minister in early 20^th century; Catherine Zeta-Jones, a known Hollywood star, and Yo Yo Honey Singh, an Indian Pop singer have in common? They have all been either diagnosed or suspected to have Bipolar Affective Disorder at some point in their life. 

Often in day-to-day language, we hear the casual use of the phrase – “Don’t be a bipolar” for people who may be a bit moody or “unpredictable.” However, the term signifies a psychiatric illness that can be debilitating for the individual and their families, and therefore, we all must be sensitive about its usage. 

Bipolar disorder, also known as Manic-depressive illness is a disorder characterized by two poles/extremes of mood-states – mania and depression. The illness is episodic, that is, there are a clear onset and end to the symptoms. The episodes may happen at irregular intervals and between episodes, the individual may be completely “normal” or stable. An individual diagnosed with bipolar disorder may have one or two episodes in their lifetime, or they may have multiple. 

Having a bipolar disorder is different from having ordinary mood-swings. The range of mood changes in the former are extreme, usually happen without any external triggers, last longer, and cause significantly more dysfunction. In the majority of cases, bipolar starts in late adolescence or early adulthood, but it can also manifest in children. The lifetime prevalence of bipolar disorder has been found to be approximately 1% of the world’s population, that is, at any point of time, about 1% of the world’s population would be diagnosed with bipolar disorder (roughly 55-75 million).

Bipolar disorder is associated with significant social, economic, and personal issues; however proper treatment leads to better outcomes and enhanced quality of life. 

Signs and Symptoms of Bipolar Disorder

An episode may have “manic or hypomanic” symptoms; depressive symptoms or a mixture of both. For making a diagnosis, it is required that the symptoms should be present every day for at least 2 weeks (one week, if symptoms are severe). The mood-changes are intense with associated changes in behavior, activity level, and thought processes and they cause disruption in personal, social, and occupational functioning.

Signs of Manic Episode	Signs of Depressive Episode
Over-cheerful or irritable mood; a heightened sense of well-being	Feeling low or sad (maybe irritable in some cases)
Excessive energy, jumpy or feeling more active	Low energy, feeling tired all the time (even getting out of bed can be a chore)
Increased appetite	Increased or decreased appetite
Decreased need for sleep	Increased or disturbed sleep; not feeling fresh after sleeping; nightmares or broken sleep
Racing thoughts (multiple ideas)	Loss of interest in pleasurable activities
Talking too much, or faster than usual	Decreased personal care
Making big plans (e.g., for investments, expenditures, etc.)	Not being able to think clearly; negative thinking – hopeless, helpless, regrets, guilt
Excessive interest in personal grooming	Multiple physical complaints like aches and pains; stomach upsets
Increased interest in sex, impulsive buying or other high-risk behaviors like driving at high speed, drug or alcohol use	Feel life is meaningless; suicidal ideas
The belief that one is excessively important and/or has some power (grandiosity)	Feeling worthless; feels like a burden to others
Increased socialization	A decrease in self-esteem/self-confidence

Some individuals have only a few or less severe symptoms of mania – this is known as “Hypomania”. To be diagnosed with Bipolar Affective Disorder, the individual would have to have at least one episode of hypomania or mania. 

Treating Bipolar Disorder

The first line of treatment for Bipolar Disorder is medical management/medications. Psychosocial methods like psychotherapy and complementary therapies, as additional treatments can improve quality of life and help in rehabilitation and prevention of relapse. 

Medication for Bipolar Disorder fall into two broad categories – Mood Stabilizers and Adjunct medicines (e.g., anti-anxiety medicines, medicines to help a person sleep or anti-psychotic medications). Finding the right medicine with a low side-effect profile can be a challenge. But once the medication stabilizes, the frequency and the intensity of symptoms tend to go down drastically and there are low chances of relapse. 

In severe cases (e.g., psychotic symptoms, violent or aggressive behavior, suicidality), hospitalization may be required. The treating team may also consider Electro-convulsive therapy if the symptoms do not respond to medication. 

The Psychosocial treatment that has been found useful in Bipolar Disorder are:

• Psychoeducation – providing information to the client and family members about illness, causes, prognosis, treatment options available, and the role of family members. It also provides an opportunity for everyone to clarify myths and misconceptions (e.g., I may have caused it or Marriage may make it better). 
• Cognitive Behaviour Therapy – a structured form of therapy usually spanning across 15-20 sessions. The focus is on helping the person in learning stress management, identify dysfunctional patterns of thinking (e.g., catastrophizing), and develop healthy behavioral patterns (e.g., setting goals and accomplishing them, tone down energy levels, etc.). You can also use Wysa for reframing thoughts and practicing CBT.
• Social Rhythm Therapy – a newer form of therapy, introduced about a decade earlier. The focus is on establishing routines, dealing with the grief of having developed a chronic illness, and managing interpersonal relationships so that they act as support systems rather than stressors. 

Over the years, some alternative or complementary methods have been tried, however, studies for those have not been conducted with the same scientific rigor as for medicines and psychotherapy and therefore the effects are questionable. These include – homeopathy, acupuncture, nutritional supplements such as Omega-3 Fatty Acids, and Ayurveda. However, it is advisable to “err on the side of caution” when considering these alternative therapies. 

Challenges faced by people with bipolar disorder – Living with Bipolar Disorder

Apart from the challenges of the episode itself (esp. depression), the individual with bipolar disorder can have multiple other struggles:

• Finding the right treatment:- Medications prescribed for bipolar disorder need to be adjusted for each individual client and can have multiple side-effects (weight gain, lethargy, decreased concentration and difficulty in retention, and a need for regular medical follow-ups). Thus, finding the right medicine, which suits the client and has minimum side-effects can be a major challenge.

• Finding non-pharmacological treatment:- Often, individuals with bipolar struggle with finding appropriate non-pharmacological intervention due to lack of awareness. 

• Stigma and Discrimination: As with any psychiatric illness, bipolar is fraught with stigma. Even between episodes, the person may be seen as unpredictable. Once diagnosed with the illness, finding appropriate jobs, or getting married becomes difficult. 

• Depressive episode or presence of psychotic symptoms during the manic phase may make the individual fearful about re-emergence of symptoms; while a person with hypomanic episodes may actually miss being in the state (as they were able to speak up their mind more freely or in general, felt better and happy). 

• Even post-recovery/during an episode, the individuals may have to contend with functioning at a lower level (because of not being able to finish education; poor functioning during episodes; inability to work as efficiently due to lethargy and/or decreased concentration)

• Economic losses: direct costs like expense on treatment or excessive money spent during a manic episode as well as indirect costs such as absenteeism from work or unemployment can drain a person and the family’s resources

• Acceptance of being diagnosed with a severe mental illness is not easy. 

• Re-integration into society; friends; colleagues can be challenging as most individuals are either vary of the person’s mood; are over-critical or over-protective. Also known as “Expressed Emotions” – can negatively impact a person’s recovery and rehabilitation.

How a person with bipolar think?

Our moods, thoughts, and behavior are inextricably linked. Thus, a person with bipolar disorder thinks and behaves as per the underlying mood:

During a hypomanic/manic episode

• Makes big plans – may be unrealistic or unachievable
• Makes too many plans 
• Have too many thoughts (“racing thoughts”)
• The belief that he/she is special/have special powers
• Acts without thinking (impulsive behavior)
• Disinhibition (not paying heed to social norms)
• Poor judgment about situations
• High-risk behavior (driving fast, having sexual encounters with strangers, using drugs and alcohol)
• Psychotic symptoms may be present during manic episodes (hallucinations – hearing or seeing things that are not there; delusions – firm and unshakeable belief about one’s superiority of having special powers given by God or belief that someone is trying to harm them)

During depressive episode

• Difficulty getting up from bed 
• Not being able to think clearly (reports not having many thoughts – the paucity of thoughts)
• Having negative thinking (“I am a burden”, “things will never change”, “I don’t deserve to be happy”)
• Having suicidal thoughts/death wishes (“It would be better if I die”; “I should kill myself”)
• Having regrets or guilts (“I wish I had worked harder”, “I must be a sinful person to suffer like this”)
• Social withdrawal (“Others will find me boring”, “they all are happy, I am a failure, I cannot face them”)
• Difficulty in carrying out day-to-day activities (“What’s the point?” “I am too tired”, “I would mess it up anyway”)

Tips for explaining bipolar disorder to loved ones

If you have ever been diagnosed with a bipolar disorder, it is not the end of the road and it does not mean that you cannot have new meaningful relationships or sustain old ones. As long as the foundations of a relationship are strong, it would not fall apart. Therefore, it is important that you:

• Should be honest about the diagnosis, and help the partner/family-member gain an understanding of what is a bipolar disorder – in general as well as specific signs and symptoms that you have experienced. Also, tell them about the prescribed medication so that they can ensure compliance esp. during an episode. 

• Should discuss the Do’s and Don’ts with the family members – e.g., “they should encourage you to exercise or do some chores but not tell you to snap out of it”; “it would be better if they don’t respond to anger with more anger”. 

• Should discuss early warning signs with them: The family members/partner should be helped in identifying the early warning signs and chalk out a plan on what they can do to help at that point in time to prevent relapse. 

• Should introduce them to the treating psychiatrist/clinical psychologist, if you feel comfortable – so that they can have their queries answered, know where to go in case of emergency and can request for marital or family sessions if required. 

Supporting your Loved One Having Bipolar Disorder

It is distressing when your family member or partner is diagnosed with bipolar disorder. The illness hits the family in multiple ways – how to deal with the ill family member; with one’s own sense of helplessness; with stigma; with the economic burden imposed by the illness? How to ensure the safety of the ill member? Whether to stay with the partner or seek a divorce? These are only some of the many questions that families tend to struggle with. 

Both phases of the illness can be distressing. It’s like “walking on a tight rope” – balancing between being supportive and being pushy. As a family member or partner of someone diagnosed with Bipolar, the first step is understanding all the phases and acknowledging it as an illness and the second step is helping the ill member to go through the phase:

Communicating with Person when he/she is depressed

• Speak in a calm, quiet tone
• Do not talk about too many subjects at the same time
• Try and pick non-threatening conversation (e.g., weather, what’s for lunch or dinner)
• Develop empathetic listening (the depressed person may just want to lament on their problems and sometimes, just listening to them and acknowledging their distress can be helpful)
• Be patient – they may take time to respond or may only answer in monosyllables)
• Do not give advice or ask them to “just snap out of it” (e.g., “You just need to get up and you will feel better.”), but try and do the activity together (“I know it’s hard, but let me help you with your bath. I have put your clothes in the bathroom”)
• Do not constantly ask them about what is making them depressed
• Pace yourself – when a family member is severely depressed, their company can be draining. It’s good to have brief, frequent contacts rather than being with them 24*7. However, if the person is suicidal, then family-members can take turns to keep a watch. 
• Help them set small goals (e.g., brushing teeth, eating food on time, taking medication), support them through the task and appreciate them when it’s done. 

Communicating with Person when he/she is in hypomanic/manic state

Hypomania or mania poses another type of challenge – it may be somewhat fun if the symptoms are less severe as the person becomes jovial, more interactive, full of energy, ready to carry out different tasks. A spouse may like it when their partners become more sexually free and disinhibited. However, gradually, the novelty declines and the stress begins – the person may become boisterous and argumentative; their disinhibition may be socially embarrassing; reckless spending may drain the family’s resources; their constant demands and activity levels can be draining for other family members. Moreover, a person in hypomanic or manic episodes may not have an insight into their illness and therefore may think that they are correct and everybody is wrong, hence provoking irritable or aggressive behaviors. 

• Conversations should be brief and to-the-point
• Reduce environmental stimulation, e.g., not having too many visitors or parties in the house
• Do not reason or argue with them. It’s important to keep calm otherwise it can turn into significant conflicts
• Try to be firm, practical, and realistic. Being authoritative will not help
• Do not jump to a person’s demand. If possible, postpone it (e.g., “why not go out with your friends tomorrow)
• Encourage them to engage in physical activity
• They may make elaborate plans about the future – neither stop them abruptly nor get into the discussion with them. 
• Ensure their safety (e.g., putting a limit to their credit card)

Some other points to be considered for family members are:

• Getting as much information as possible about bipolar disorder
• Ensuring treatment compliance
• Be aware of warning signs of relapse and seek help as early as possible
• Taking care of one’s own self:
  • Acknowledging your feeling
  • Finding an outlet for your feelings
  • Having a “time-out” when you can do things you enjoy or just to relax
  • Taking care of your well-being (proper sleep routine, eating on time, exercising)
  • Do not blame yourself for the person’s condition
  • Too much worrying about the future will only make you more vulnerable to developing physical or mental health issues
  • Ask for help from other family members – it’s not your burden to be borne alone
• Connect with the family member when they are in a “normal” or “well-phase” and plan for crisis-management, how they expect you to respond to their moods, and how you can help them in getting back to the mainstream. 

Diagnosed with Bipolar Disorder – Taking Care of Yourself

Once the severity of the episode has subsided, you would need to make certain changes to your lifestyle so as to prevent relapse, have a better quality of life and fit into the mainstream:

• Understand the illness – ask your treating doctor (psychiatrist or clinical psychologist) to suggest reading material or you can look up information from trusted sites. Seek clarification from your doctor if required. 
• Healthy lifestyle – sleeping on time, taking care of diet (healthy and nutritious food) and exercising on a regular basis
• AVOID temptation to use drugs and alcohol
• Medication compliance is very important. You can involve a family member to remind you to take medicines. Please remember that missing doses can make you resistant to the positive effects of medicines. 
• Learn to cope with stress (e.g., meditation, problem-solving strategies, time management, etc.)
• Do NOT isolate yourself: Yes, some people will not understand, and yes, you may be lagging behind. But isolating yourself will make you feel worse. 
• Learn to manage time – e.g., not having too much time on your hand to overthink or not doing any pleasurable activity. 
• Recognize the early signs (e.g., decreased need for sleep, feeling more lethargic than usual) and make an action plan to respond to the same 
• Be vary of triggers – e.g., conflicts, financial stressors, late-night parties and plan how to deal cope with them. 
• DO NOT victimize yourself – the more sorry you feel for yourself, it would increase your depression and make you motivated to even try to make life better. 
• Set small goals that are realistic and achievable and appreciate yourself for the accomplishments. 
• Remember, it’s an illness and it does not indicate a character flaw or weakness unless you allow it to become one.