World Bipolar Day (WBD), is observed annually on March 30, the birthday of Vincent Van Gogh, who was posthumously diagnosed as probably having a bipolar condition
DR. GAURAV HALDANKAR
Consider a Maruti Suzuki Alto chassis fitted with a 2.7-litre turbocharged engine from a Toyota Fortuner. While the power generated might initially seem impressive, it would soon become apparent that controlling the vehicle is nearly impossible. Conversely, if the 2.7-litre engine were replaced with an engine from a Hero Pleasure scooter, the car would struggle to move even with maximum torque. Although this analogy is somewhat simplistic, it effectively illustrates the challenges faced by individuals with bipolar disorder.
An ancient disorder
Many people mistakenly think that bipolar disorder is a recent concept, but it has existed since ancient times. Historically known as manic-depressive illness, it was first documented by Aretaeus of Cappadocia in ancient Greece, describing the cycle between mania and depression. Ancient Indian texts also mentioned conditions similar to schizophrenia and bipolar disorder. In the mid-19th century, French psychiatrists Jean-Pierre Falret and Jules Baillarger described “circular insanity”, highlighting its cyclic nature. The term ‘bipolar disorder’ was coined by German psychiatrist Karl Leonhard in the mid-20th century, reflecting the dual nature of mood disturbances.
How common is it?
It is estimated that the worldwide lifetime prevalence of bipolar disorder can vary from one in 80 to 120 individuals. This means that in a class of 100 graduates, at least one individual is likely to have bipolar disorder. Research indicates that women are more likely to experience depression than men; however, in the case of bipolar disorder, the rates are nearly equal between men and women.
While it is commonly believed that this disorder primarily affects adults, the first peak of the illness often occurs around 16-17 years of age. Cases have also been diagnosed in children as young as 13 years old who have been treated successfully.
The disorder stem from a significant genetic predisposition (family history of the disorder) interacting with various environmental factors. These interactions lead to epigenetic, endocrine, and inflammatory changes, causing neuronal modifications that contribute to the development and progression of the disorder. Risk factors include life stressors, unresolved sleep difficulties, trauma and abuse, and substance misuse.
How is bipolar disorder diagnosed?
Bipolar disorder consists of two poles: depression and mania. It is not uncommon for a person with bipolar disorder to present to a mental health professional in a state of depression and develop mania or hypomania (a milder version of mania) during subsequent follow-ups.
Individuals experiencing mania are usually excited, talkative, and hyperactive. Their speech tends to be rapid and loud, often difficult to interrupt, and is commonly referred to as pressured. An elevated, expansive, or irritable mood is characteristic of a manic episode. Individuals in mania exhibit low frustration tolerance, leading to feelings of anger and hostility. Patients report having rapid thoughts, which are evident from their speech. As mania progresses, their speech may include puns, jokes, rhymes, or wordplay. They may appear clever, even brilliant. Patients are often easily distracted, and their cognitive functioning in the manic state is unrestrained. In acute manic excitement, speech can become incoherent, and the individual may develop delusional thoughts.
A depressed mood and a loss of interest or pleasure are key symptoms of depression. The depressed mood typically has a distinct quality that differentiates it from normal sadness or grief. Patients frequently describe this symptom as agonising emotional pain or a physical illness that leads to exhaustion and lack of motivation. Others report feeling numb, unable to cry, and struggling to experience any pleasure. Depression in bipolar disorder can sometimes be atypical, with individuals experiencing excessive sleep rather than reduced sleep and increased appetite instead of
reduced appetite.
Depressive episodes tend to last longer and occur more frequently than manic episodes, although they are often overshadowed by the dramatic symptoms of mania. A person may initially revel in periods of hypomania/mania, citing increased productivity, newfound confidence, and candour. Sleep becomes unnecessary due to engaging in various projects and boasting skills. This surge of energy eventually spirals out of control, often blurring the point at which close relations notice changes in
the individual.
The phase of depression following mania can be particularly challenging, with the person experiencing deep despair and wishing for normality in their altered world. During these moments of emotional hardship, the appeal of mania may seem counter-intuitively preferable.
Bipolar disorder is associated with several co-morbid illnesses such as anxiety disorders, substance use disorders, ADHD, etc. Suicidal behaviour is significantly higher in individuals with bipolar disorders. Approximately 30–50% of adults with bipolar disorders have attempted suicide in their lifetime, and five–20% have completed it.
Media portrayal
There have been a few media portrayals of individuals living with bipolar disorder such as the movie ‘Silver Linings Playbook’, ‘Homeland’, ‘Infinity polar bear’, etc. However, my recommendations would be to read first-hand accounts of lived experiences to get a more nuanced picture. Some suggestions are ‘Em and the big Hoom’ by Jerry Pinto and ‘How to travel light’ by Shreevasta Nevatia.
Living with bipolar disorder
The lived experience of individuals with bipolar disorder teaches us much more than any book could ever do. Some of their key concerns are the struggle to maintain an identity for themselves, engagement in meaningful employment, unpredictable nature of the illness, need for enduring and compassionate relationships, combating societal stigma, etc.
A patient summarises the internal experience exemplarily: “When I said [bipolar is] confusing, what I meant is it’s confusing in that I really don’t know who I am. I question every conversation in every social environment that I’ve been in. Did I say too much? Was I talking too fast? Was I really me? … I don’t really get to just be. It’s always judging.”
Treatment options
Pharmacological intervention is fundamental for achieving therapeutic goals in the management of bipolar disorders, supplemented by psychosocial interventions, neurostimulation, and lifestyle modifications. Mood stabilizers and atypical antipsychotic drugs are recommended for both acute and long-term management of bipolar disorders. Although controversies exist, antidepressants can be used in augmentation or combination with mood stabilizers or antipsychotics to treat bipolar depression.
Due to the complex and multifaceted nature of bipolar disorders, management should include more than addressing mood episodes. Additional therapeutic objectives encompass enhancing cognitive function, addressing circadian disturbances (sleep issues), managing psychiatric and medical comorbidities, improving functionality and quality of life, and reducing suicidality.
Non-pharmacological interventions such as Cognitive Behavioural Therapy, Interpersonal Social Rhythms Therapy, and light therapy play a significant role in recovery, as do allied medical system interventions. Artificial intelligence (AI) and machine learning models show potential in predicting, diagnosing, and assessing the progression of bipolar disorders. The major factor determining treatment outcomes is often the doctor-patient collaboration and rapport, along with the presence of an empowered and receptive caregiver.
On this occasion of World Bipolar Day, an initiative of the International Bipolar Foundation in collaboration with the Asian Network of Bipolar Disorder and the International Society for Bipolar Disorders, let us embrace the theme ‘Bipolar Strong’, which highlights the strength, resilience, and unity of individuals living with bipolar disorder.
(The writer is a consultant psychiatrist)
