Bipolar affective disorder is a mental health problem, rather than a physical illness or disease. It is a condition in which moods become difficult to regulate and may swing from one extreme to another. This causes periods of deep depression, when life no longer seems worthwhile with no energy for normal activities, and periods of elation or hypomania which are associated with excessive activity. These mood changes may become so extreme that an individual loses contact with reality. A person with manic depression becomes more vulnerable to stress, both physical stresses, like illness and lack of sleep and mental stresses, like unemployment. In addition they may suffer from severe anxiety.

Most people experience times of sadness and excitement and these changes in mood are part of a healthy response to every day life. Yet for people with manic depression, sudden changes in mood make it hard to know how they will feel at a particular time. Normal mood changes do not interfere with someone's ability to get on with their life. For people with manic depression, these mood changes can be so severe that their inner world overwhelms them. In this state, it is almost impossible to carry on with normal activities.

To friends and relatives, it appears that the person they know has temporarily changed. For example, it becomes difficult to communicate with them and their conversation may not make sense. This can be frightening unless they know what is happening, whether it is a period of depression or hypomania.

This explains a little about bipolar disorder both for people with the condition and for their friends and relatives. It also includes sources of further information and support.

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  As yet, bipolar disorder is a condition that can be 'managed' rather than cured. Nevertheless the goal can still be to live as fulfilling and normal as life as possible. This will not necessarily be the same life as before bipolar disorder developed as it is impossible to turn the clock back. It almost certainly means changing your lifestyle and expectations. It means accepting limitations and avoiding excessive stress, mental or physical. It involves the discipline of taking medication. It means finding out and learning about the illness, gaining self-knowledge and being prepared to take appropriate action to help prevent further episodes of illness.

There is no answer to the question 'Why me?'. There is often no reason why one person responds to the environment in a different way to someone else.

Nevertheless, despite these cautions, you can look forward to a life that may be different from what you had hoped, but a life that can be as rich and fulfilling in many unexpected ways. It is not easy to accept the diagnosis of bipolar affective disorder and to learn about the condition. However modern therapies and modern approaches to the illness provide opportunities that were not available, even ten years ago.

About Bipolar Affective Disorder
Bipolar affective disorder named after the periods of severe depression and hypomania that occur in this condition. These represent the two extremes of mood, Bi (two) polar (extremes) Affective (of emotion). It is also known as manic depression. The diagnosis depends upon a person having had at least one episode of depression and one episode of hypomania. People who have depression alone are described as having unipolar depression or simply depression.

Hypomania is a state of high energy and activity in which the ability to sleep normally is lost. The person speaks rapidly, often expressing strange ideas. They may be irritable, paranoid, play loud music continously. They lose their judgement, and spend excessively. They may be sexually promiscuous. In the early stages, the individual may start many projects and appear to work productively and creatively. This breaks down as hypomania continues. Hypomania is not happiness, even if it appears exciting or comes as a relief from severe depression. Although it seems as though the person chooses to behave in this way, they are not in control and are driven relentlessly by their impulses. They lose insight and cannot understand what is wrong with their thoughts and behaviour.

Depression This describes a period when life loses its meaning and seems worthless. The person has neither energy nor motivation. Sleeping is affected, either increased or decreased. Thinking is slow and their concentration poor. The person feels distanced from everything and everyone around them, and suicide is a risk. They may have feelings of severe guilt and anxiety.

Psychosis At the extremes of mood, sometimes people lose contact with reality. Their thoughts become paranoid and contain many delusions. It is difficult to communicate and the person makes up elaborate explanations for their behaviour and experiences.

Anxiety Many people may suffer from severe anxiety. This has many causes, and undoubtedly contributes to unstable moods. It is possible to reduce anxiety by tackling the underlying problems and learning relaxation techniques. Psychotherapy can be helpful. Rarely it may be necessary to take medication.

Stable periods This is when life returns to normal after a period of illness. It is the time to build and repair relationships. It is the time to plan to make sure that further episodes of illness are less damaging - this includes financial planning, and ensuring that children will be properly cared for. It is the time to integrate the experiences of the illness. And it is the time to improve mental and physical health. Finally, it is the time to get on with life and enjoy living.  

Patterns of bipolar affective disorder The pattern of illness varies considerably between individuals. Some may have episodes of hypomania followed by depression, others may have periods of depression with only occasional episodes of hypomania. Some people have very few episodes, others may have many more. It is difficult to predict and only experience can show how the condition will develop.

Two common patterns are known as Bipolar I - where a person has chiefly episodes of mania and Bipolar II where they suffer largely from depression, with only occasional episodes of hypomania.

Rapid Cycling This is a pattern of illness where a person has four or more episodes a year. Mood changes can be very rapid and this form of illness can be difficult to control. Typically periods of rapid cycling are interspersed with more stable periods.

Treatments

Drug therapy forms the basis of almost all treatment of bipolar affective disorder. It can often be difficult to accept that drugs are helpful or even necessary during a stable period. Nevertheless scientific evidence shows that, as well as treating hypomania and depression, drug treatments help to prevent further episodes. In addition, psychotherapy and self-management are important for the management of bipolar affective disorder.

Drug Therapy 
There are three main types of drug used in the treatment of bipolar affective disorder. These are mood stabilising drugs, anti-psychotic drugs used to treat hypomania and antidepressant drugs that treat depression. Other drugs include sleeping tablets and drugs for anxiety.

Mood stabilisers The three most commonly prescribed mood stabilising drugs are lithium, carbamazepine and sodium valproate. If taken continously they reduce the number of episodes of illness. Each drug works differently and has different side effects. It may take time to find the most suitable drug. Newer mood stabilising drugs include gabapentin and lamotrogine.

Antipsychotic drugs These drugs are used to treat hypomania. Rarely, they are used to help stabilise someone's mood over a longer period of time. They can be taken at the start of a hypomanic episode to prevent it progressing further. Examples include, haloperidol, chlorpromazine, olanzapine, risperidone and sulpiride.

Antidepressants These drugs treat depression and may more rarely be prescribed long term to prevent depression. They can have side effects but often they may reduce significantly after a few weeks. Examples include; amitriptyline, dotheipin, prozac, paroxetine, sertraline amd venlaflaxine.  

Psychotherapy for depression
Three types of psychotherapy have been shown to help depression. Cognitive therapy that helps people change their 'depressive' style of thinking, 'pleasure seeking' therapy that encourages people to undertake pleasurable activities and social skills training that helps improve communication. These therapies are challenging but are safer and more effective than drug therapy in the long term. A combination of drug therapy and psychotherapy can often be most helpful

Psychoanalysis and counselling therapy may not help depression even though they can sometimes appear to be supportive. In my personal experience, I know three people whose bipolar disorder started during forms of intense psychoanalytical therapy. Psychoanalysis can be destabilising and I would not recommend it for anyone who has potentially unstable moods. 

Self-Management
Self management of bipolar affective disorder is not an alternative to drug therapy or psychiatrists. It is an approach that gives an individual a measure of control of their illness, by learning to monitor moods, recognise episodes early and take effective action. This is similar to a person with diabetes learning to monitor their blood sugar and adjust their diet and insulin.

The first episodes of hypomania or depression are often related to severe emotional or physical stress. As time passes, it seems that episodes are triggered by fewer and less severe stresses. Eventually they can seem to happen almost without any cause. Nevertheless, with experience, it is almost always possible to recognise that an episode is starting. By taking appropriate action the episode can usually be managed without too much disruption to ordinary life. The more experienced someone is at managing their condition, the less likely they are to have further severe episodes.  

For further information about self-management, follow this link Self-Management

Causes of Bipolar Affective Disorder
The cause is not known, indeed there may be several causes. Often the first episode occurs during a time of severe emotional stress. More rarely it may follow a severe physical illness, head injury or course of drugs, such as antidepressants. Bipolar affective disorder can run in families, about a fifth of people with bipolar affective disorder have a parent with the condition. Searching the family tree further may reveal more relatives who have had mental health problems.

It appears that the mechanism in the brain that controls mood becomes disturbed, either because of a genetic problem or as the result of a severe stress. This disturbance in the brain almost certainly has a chemical basis and this explains why drugs can be so helpful. Nevertheless, drugs alone are not the answer. Just as there are many factors that can cause bipolar affective disorder so there are many factors that can help its management.

 Bipolar affective disorder is a relatively common problem, 1.2% of the population are affected. (This is similar to diabetes) Typically it develops when someone is in their late twenties or thirties, although it is occasionally diagnosed in childhood. It is important to choose a General Practitioner who knows about mental health problems and is sympathetic to how you would like to be treated.

The future for mental health problems looks promising. There are many new drugs available and many more being researched. Psychotherapy and psychological approaches are coming into their own and are widely available.

Friends, relatives, and bosses  
One of the hardest things about manic depression is talking about your illness to other people. It is not advisable to tell everyone, especially at the first meeting. Nevertheless, if you can present a positive picture and, most importantly, show that you are at ease with your illness, the overwhelming majority of people will respond in kind. Bosses, too, if you can show that you are responsible and in control, are likely to be surprisingly sympathetic and helpful. A local MDF group provides a supportive place to learn about and to talk about your condition.

Voluntary Organisations

www.BipolarAssociation.org    

Manic Depression Fellowship 020 7793 2600
The Manic Depression Fellowship produces a quarterly magazine for its membership - Pendulum. It produces information booklets about aspects of manic depression. It also runs self-management training courses and organises meetings and lectures about manic depression. Many people find it helpful to meet other people who also have manic depression. Relatives and friends may also find it helpful to other people who are involved with someone who has manic depression. The Manic Depression Fellowship has a large network of mutual support groups that meet regularly.

Depression Alliance       020 7633 9929
Depression Anonymous 01482 860619
MIND

Further Information 

Summaries of the latest medical research can be viewed on The Bipolar association web site: Bipolar Association

Lithium Treatment of Manic Depressive Illness. A Practical Guide. Mogens Schou

The Depression Workbook A Guide for Living with Depression and Manic Depression. Mary Copeland. New Harbinger Publications $18.95 ISBN 1-879237-32-6

Malignant Sadness The Anatomy of Depression Lewis Wolpert Faber and Faber £9.99

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