WHAT IS BIPOLAR DISORDER?

Being diagnosed with bipolar disorder meant that finally not only did my moods have a name but there was also something I could do to get them more under control. This name did not capture all my experience and the impact that bipolar disorder had on my life but it provided an explanation and a way forward. Phillip

Bipolar disorder involves biological changes in mood that are more noticeable, severe, longer lasting and often more disruptive than everyday ups and downs. Recognition of the difficulties and the burdens experienced by people with these extreme mood swings intensified the search for a common language to help describe and treat bipolar disorder. The typical mood changes that occur in the disorder have been organised into specific categories to make them easier to understand, diagnose and treat. In this chapter we discuss the current classification of bipolar disorder. People with bipolar disorder experience the illness differently depending on their symptoms, how often they occur and how their lives are affected. Knowing the current classifications and how they apply to your own experience may assist you in managing your illness.

It is also helpful to be aware of and to recognise symptoms from other disorders, such as drug and alcohol abuse and anxiety, that may be causing additional distress. As we find out more about bipolar disorder, the current diagnostic system may be refined to include milder manifestations of the illness and take into account areas of overlap with other mood disorders.

A BIT OF HISTORY

Bipolar disorder is not a new illness. In ancient Greece, people were aware of melancholia (depression) and mania. In 1851, the French psychiatrist Jean-Pierre Falret described bipolar disorder as la folie circulaire, involving changes from mania to melancholia, and in 1854 neurologist Jules Baillarger described these changes as two different stages of the same illness (folie à double forme). Towards the end of that century, the German psychiatrist Emil Kraepelin distinguished schizophrenia, which involves psychotic symptoms such as delusions and hallucinations without the extreme mood symptoms, from manic depression. Much later, in 1979, Karl Leonhard separated bipolar disorder from unipolar depression, which is the experience of depression with no mania or hypomania, and so the idea of 'bipolar disorder' was conceptualised (Goodwin & Redfield Jamison, 2007).

THE DIAGNOSIS OF BIPOLAR DISORDER

Unlike physical illnesses such as diabetes and stroke, bipolar disorder cannot be diagnosed by a medical test such as a blood test or brain scan. Instead, diagnosis relies on identifying your current and past symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 2000) and the International Classification of Diseases (ICD-10) (World Health Organisation, 2006) stipulate certain criteria as a guide for diagnosis.

This illness usually starts in adolescence or the early twenties, but can occur later or in earlier childhood where it can present a little differently (see the website attached to this book for resources on bipolar in childhood). Many people report that it took a long time for their bipolar disorder to be correctly diagnosed and treated.

Episodes of illness

Bipolar disorder involves 'episodes' of illness. For a diagnosis of bipolar disorder to be made, you will have experienced an episode of mania or hypomania, or a mixed episode, at some stage in your life. Most people experience depressive episodes and milder forms of depression. Episodes differ in severity, occur when you are acutely ill, and exhibit a number of symptoms over a specific period. Once you have experienced an episode of bipolar disorder, the chances of having another episode are high, but ongoing treatment can help to prevent relapse.

An episode of major depression

A depressive episode occurs when you experience depressive symptoms for at least two weeks that cause you distress and affect your relationships, work or daily activities. According to DSM-IV classification, an episode of depression is diagnosed when you have five or more of the symptoms listed below. At least one of these symptoms is:

• depressed mood, which may include intense sadness, emptiness, tearfulness or irritability, or

• a loss of interest or pleasure in things, which lasts nearly all day, nearly every day.

The other possible symptoms include:

• lack of energy, and constant tiredness

• restlessness or alternatively a marked lack of activity, known as lethargy, which is noticeable by others

• noticeable changes in appetite and weight, either up or down

• sleep problems, which might involve difficulty in falling asleep, waking up a lot during the night, or waking up early in the morning and being unable to return to sleep; or equally, sleeping too much

• feelings of worthlessness and excessive guilt

• difficulty in concentration and/or poor memory or difficulties in making decisions

• persistent thoughts about death and suicide or hopelessness.

Some people have psychotic symptoms as part of their depression. This can include delusions (strong beliefs that have no connection with reality) and/or hallucinations (seeing, hearing or smelling things that are not actually there).

An episode of mania

According to the DSM-IV classification, an episode of mania is diagnosed when your mood is excessively happy, elevated, or irritable for at least a week or has led to your being admitted to hospital. At least three of the following symptoms (four if the mood is irritable) must be present:

• needing less sleep than usual

• thoughts racing so quickly that you may get confused and find it difficult to articulate what you want to say

• talking much more than usual or feeling a pressure to keep talking

• being easily distracted from tasks to attend to irrelevant or unimportant things

• feeling a marked increase in self-esteem or thinking you have unique gifts or talents that you do not have

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