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| Domains of the bipolar spectrum Bipolar disorder is, almost without exception, a life-long condition that must be carefully managed throughout the individual's lifetime. Because there are many manifestations of the illness, it is increasingly being called bipolar spectrum disorder. The spectrum concept refers to subtypes of bipolar disorder that are sub-syndromal (below the symptom threshold) and typically misdiagnosed as depression. Nassir Ghaemi, M.D., has also contributed to the development of a bipolar spectrum questionnaire. The full bipolar spectrum includes all states or phases of the bipolar disorders. Bipolar depression The vast majority of people diagnosed with, or who may be diagnosed with bipolar disorder suffer from depression. In fact, there is at least a 3 to 1 ratio of time spent depressed versus time spent euthymic (normal mood) or hypomanic or manic during the course of the bipolar I subtype of the illness. People with the bipolar II subtype remain depressed for substantially longer (37 times longer) according to the study findings discussed in the epidemiology section above. A 2003 study by Robert Hirschfeld, M.D., of the University of Texas, Galveston found bipolar patients fared worse in their depressions than unipolar patients. (See Bipolar Depression.) In terms of disability, lost years of productivity and potential for suicide, bipolar depression, which is different (in terms of treatment), from unipolar depression, is now recognized as the most insidious aspect of the illness. Severe depression may be accompanied by symptoms of psychosis. These symptoms include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). They may also suffer from paranoid thoughts of being persecuted or monitored by some powerful entity such as the government or a hostile force. Intense and unusual religious beliefs may also be present, such as patients' strong insistence that they have a God-given role to play in the world, a great and historic mission to accomplish, or even that they possess supernatural powers. Delusions in a depression may be far more distressing, sometimes taking the form of intense guilt for supposed wrongs that the patient believes he or she has inflicted on others. Hypomania Hypomania is a less severe form of mania without progression to psychosis. Many of the symptoms of mania are present, but to a lesser degree than in overt mania. People with hypomania are generally perceived as being energetic, euphoric, overflowing with new ideas, and sometimes highly confident and charismatic, and unlike full-blown mania, they are sufficiently capable of coherent thought and action to participate in everyday life. Mixed state In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and depression occur simultaneously (for example, agitation, anxiety, fatigue, guilt, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, pressured speech and rage). Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. Mixed states can be the most dangerous period of mood disorders, during which panic attacks, substance abuse and suicide attempts increase greatly. A dysphoric mania consists of a manic episode with depressive symptoms. Increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drugs of abuse and antidepressant drugs may trigger dysphoric mania in susceptible individuals. Mania Researchers at Duke University have refined Kraepelin’s four classes of mania to include hypomania (featuring mainly euphoria), severe mania (including euphoria, grandiosity, high levels of sexual drive, irritability, volatility, psychosis, paranoia, and aggression), extreme mania (most of the displeasures, hardly any of the pleasures) also known as dysphoric mania, and two forms of mixed mania (where depressive and manic symptoms collide). Symptoms of psychosis include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). Feelings of paranoia, during which the patient believes he or she is being persecuted or monitored by the government or a hostile force. Intense and unusual religious beliefs may also be present, such as a patients' strong insistence that they have a God-given role to play in the world, a great and historic mission to accomplish, or even that they possess supernatural powers. Delusions may or may not be mood congruent. Mania and over the counter prescription drugs Phenylpropanolamine or (PPA) is a sympathomimetic drug similar in structure to amphetamine which is present in over 130 medications, primarily decongestants, cough/cold remedies, and anorectic agents. A report on phenylpropanolamine, or P.P.A., from the Dept. of Psychiatry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Pharmacopsychiatry 1988 stated: We have reviewed 37 cases (published in North America and Europe since 1960) that received diagnoses of acute mania, paranoid schizophrenia, and organic psychosis and that were attributed to PPA product ingestion. Of the 27 North American case reports, more reactions followed the ingestion of combination products than preparations containing PPA alone; more occurred after ingestion of over-the-counter products than those obtained by prescription or on-the-street; and more of the cases followed ingestion of recommended doses than overdoses. Some reference books have noted that some people developed mental illness symptoms after flu like symptoms, the probability or link to the over the counter medications they were taking for their symptoms was sometimes overlooked. Failure to recognize PPA as an etiological agent in the onset of symptoms usually led to a diagnosis of schizophrenia or mania, lengthy hospitalization, and treatment with substantial doses of neuroleptics or lithium. Rapid and ultradian cycling Rapid cycling, defined as having four or more episodes per year, is found in a significant fraction of patients with bipolar disorder. Ultradian cycling, in which mood cycling can also occur daily or even hourly, is less common. (Although the concept of ultradian cycling has been accepted by many psychiatrists, whether it represents true cycling is far from established.) Cognition Numerous studies show that bipolar disorder affects a patient's ability to think and perform mental tasks, even in states of remission. Deborah Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has argued these deficits should be included as a core feature of bipolar disorder. By the same token, research by Kay Redfield Jamison of Johns Hopkins University and others has attributed high rates of creativity and productivity to certain individuals with bipolar disorder. (See Brain Damage.) There may be no conflict here: Cognitive dysfunction does not necessarily bar creativity. Suicide risk People with bipolar disorder are about three times[citation needed] as likely to commit suicide as those suffering from major depression (12% to 30%).[citation needed] Individuals with bipolar disorder tend to become suicidal, especially during mixed states such as dysphoric hypomania and agitated depression. Suicidal symptoms include: * Talking about feeling suicidal or wanting to die * Feeling hopeless, that nothing will ever change or get better * Feeling helpless, that nothing makes a difference * Feeling like a burden to family and friends * Putting affairs in order (for example, organizing finances (paying debts) or giving away possessions to prepare for one's death) * Putting oneself in harm's way, or in situations where there is a danger of being killed * Abusing alcohol or drugs A patient with these symptoms (or anyone related to said patient) could do the following: * Call the patient's doctor, emergency room, or the emergency telephone number right away to get immediate help * Make sure the suicidal person (be it self or somebody else) is not left alone * Make sure access to large amounts of medication, weapons, or other items that could be used, is prevented |