Do you ever feel rapid changes in your mood which are poles apart? You know how one moment you’re all happy and cheerful, then the next you’re sad and lost?
Whatever the reason, be it a thought in the subconscious mind, be it a sudden flashback of a bad memory, just a premenstrual syndrome1, or something that you just don’t know, but it occupies you and keeps you wandering in your own ‘not so good’ thoughts.
This is what we call Mood Swings2, and these are a normal part of life. However, when these mood swings become extremely strong which cross the limit of being called as normal and turn into being disruptive, they become a part of something known as – Manic Depression. This may signify ill mental health.
In this article, we shall discuss Mania, Depression, and Manic Depression3 and learn about how we can deal with such conditions.
Not all people suffering from this condition are psychotics. A person can develop such conditions after suffering a trauma, such as losing a loved one.
Manic Depression is currently known by the term – Bipolar Disorder4.
Mood Disorders include episodes of mania, hypomania, depression, bipolar episodes, and other disorders such as Cyclothymia.
Manic depression was earlier also called manic depressive illness.
As its name implies, Manic Depression is a mental illness characterized by symptoms ranging from mania to depression, which range from high to low.
According to the diagnostic and statistical manual of mental disorders (DSM-5), Bipolar disorder is described as a group of brain disorders causing extreme fluctuation in a person’s mood, energy, and ability to function.
Let’s get familiar with all these terms to understand better.
Mania
Mania is a condition in which you feel euphoric, energetic, full of energy, or unusually irritable.
Hypomania
Hypomania is similar to Mania but is less extreme than that of Mania.
Depression
A depressed person feels unhappy, hopeless, and loses interest and pleasure in practically everything.
Therefore, a mental health condition which causes extreme mood swings, including emotional highs like Mania or Hypomania, and lows like depression, is known as Bipolar disorder, formerly called Manic Depression.
It is defined by recurrent episodes of mania and depression in the same patient at different times.
Symptoms of Manic Episodes
Mania is more severe and causes more noticeable problems in daily activities, at work, and also cause relationship problems.
Manic episodes present as-
Elevated and irritable mood.
- Stage 1- Euphoria or mild elevation of mood- there is an increased sense of well-being and happiness which is usually seen in hypomanic episodes5.
- Stage 2- Elation or moderate elevation of mood- usually seen in mania and presents as a feeling of enjoyment and confidence.
- Stage 3- Exaltation or severe elevation of mood- it is seen in severe mania, and these patients believe that they are not themselves but are some great personality (delusion of grandeur).
- Stage 4- Ecstasy or very severe elevation of mood
-Restlessness
-More talkative than usual
-On-the-toe-on-the-go behavior
-Use of playful language and loud voice
-Has running thoughts in mind and hence, develops a pressure of speech
-A quick and abrupt shift from one topic to another: a flight of ideas
-Inflated self-esteem
-Visual and auditory hallucinations
-Delusion of persecution-feeling that he/she is very great and people are against them and want to harm them
-Easy distraction
-does many things at a time
-increased productivity and creativity, which is impromptu: common in hypomania
-increased planning and execution of plans: common in Mania
-hypersexuality
-reduced self-care in severe manic and hypomanic episodes
-the decreased need for sleep
-increased appetite
-absent insight into the illness
Symptoms of Hypomanic Episodes
According to the American Psychiatric Association, the main difference between Mania and hypomania is the degree of severity and the absence of psychotic symptoms like delusions and hallucinations.
Hypomania has no negative impact on work, social and personal functioning. Hypomania presents similar to that of Mania but in a milder form.
Depressive Symptoms
A depressive episode presents as:
- A feeling of sadness and loss of interest from almost everything
- Crying spells
- Social withdrawal
- Anhedonia- inability to experience pleasure
- Feeling of pessimism
- A feeling of hopelessness, helplessness, and worthlessness
- Lack of energy and easy fatigability
- Impaired concentration
- Slowed thinking
- Suicidal thoughts in major depressive disorder
- Monotonous voice
- Agitation in older patients
- Anxiety
- Easy annoyance and frustration
- Vague aches in the body
- Heaviness in the head
- Insomnia or hypersomnia
- Increased or decreased appetite
- Weight gain or loss
- Loss of sexual drive
- Early morning awakening
- Hallucinations(false perceptions) and delusions(false beliefs)
Bipolar depression is sometimes incorrectly diagnosed as major depression as the symptoms are similar.
Mixed moods
Some people with bipolar disorder experience mixed moods in which there is a coexistence of manic and depressive symptoms.
Symptoms of manic depression depend on which mood the patient is experiencing, either depressive or manic/hypomanic. Symptoms of bipolar disorder can be quite complex but may vary from one patient to another.
Types of Bipolar Disorder
Unipolar Disorder-
As the name implies, unipolar diseases are characterized by recurrent bouts of solely mania or depression. They are rare and may resemble the clinical features of bipolar disorder.
But, according to the American Psychiatric Association and DSM-5, Bipolar Disorder includes three conditions, that are-
- Bipolar I disorder
- Bipolar II disorder
- Cyclothymia
1) Bipolar I Disorder
Manic episodes lasting for at least a week and severe depressive episodes lasting for at least two weeks are the common symptoms of Bipolar I Disorder.
It signifies that Bipolar I Disorder is characterized by periods of mania and severe depression.
The manic episodes are very severe, and the patient needs urgent hospital care.
Mania and depression manifest in such a way as to indicate this type of bipolar disease.
2) Bipolar II Disorder
Bipolar II Disorder is characterized by episodes of hypomania and severe depression that persist at least four days.
Meaning that hypomanic and severe depressive episodes are characteristic features of bipolar II disorders.
Hypomanic symptoms are less severe and do not require hospitalization.
Bipolar disorder is a group of mood disorders characterized by disturbance in thoughts, mood, and behavior.
3) Cyclothymic disorder or Cyclothymia
Another type of Bipolar Disorder is Cyclothymic Disorder. It is quite similar to that of Bipolar II Disorder but is a milder form or less severe form of Bipolar Disorder. Bipolar disorder is defined by bouts of mania and depression that last at least two years in adults and one year in children and adolescents.
The mood swings of Cyclothymia are not as extreme and intense as that of Bipolar Disorder. These patients experience milder ups and downs. But, if left untreated, Cyclothymia has a risk of developing into a Bipolar disorder.
Sometimes a patient may experience symptoms of bipolar disorder that might not fit into any of the above three categories, and these are referred to as unspecified Bipolar Disorders.
Rapid cycling bipolar disorder-
Rapid cycling bipolar disorder is a phrase used to describe a Bipolar Disorder characterized by four or more mood episodes alternating between mania and depression over the course of a year.
What Causes Manic Depression?
The exact cause of Bipolar Disorder or the triggering factors of bipolar episodes is not yet known. But, it is said to result from a combination of factors. Although the etiology of mood disorders remains unknown currently, several theories have been put forth.
1) Brain structures
Brain imaging studies have suggested that there is white matter hyper-intensity, ventricular dilatation, and change in blood flow and metabolism to several important parts of the body. These kinds of brain structures cause Manic Depression.
2) Genetic hypothesis
Genetic factors make a person vulnerable to mood disorders, particularly Bipolar Disorders. Family history plays an important role in developing Bipolar Disorder.
3) Neuroendocrine theories
Bipolar symptoms are present in endocrine disorders like Hypothyroidism, Cushing’s disease(Hypercortisolism), and Addison’s disease(Hypocortisolism).
4) Biochemical theories
An abnormality in the catecholamine and serotonin system in the central nervous system is said to develop Bipolar Disorder.
Biochemical and Neuroendocrine mechanisms are interrelated.
5) Psychosocial factors
A stressful event or trauma can lead to a person’s first episode of Bipolar Disorder. It becomes more obvious if there is a genetic predisposition.
6) Other Mental Health Disorders
Obsessive-Compulsive Disorder (OCD) is commonly associated with Bipolar Disorder.
The course of Bipolar Disorder or Manic Depression
Bipolar disorder symptoms have an earlier age of onset that is the third decade of age. But, sometimes, it may occur irrespective of the age if the cause is trauma. It can also affect adolescents and children.
Mania can be controlled in two weeks and depression in six to eight weeks with prompt treatment.
Complications of Bipolar Disorder or Manic Depression
- Suicidal attempts
- Damaged relationships
- Financial problems
- Unstable life
- Criminal behavior
- Poor work and school performance
- Dramatic mood changes can affect sleep, behavior, and judgment
- Difficulty in carrying out daily activities
How is Manic Depression diagnosed?
The diagnosis is almost clinical. When unusual behavior is noticed by the ones staying with the patient, they encourage them to see a doctor.
The doctor will take into consideration the following points during assessment-
- Physical appearance
- Way of expressing and interacting
- Speech and language
- Inability to remember past events
- Aggressiveness
- And all other symptoms that are seen in an episode of depression, mania, or hypomania.
The doctor will also-
- Ask about personal and family history of other mental health conditions like OCD.
- Ask about substance abuse like alcohol or any other drug.
- The doctor or the psychiatrist will also have to rule out other medical and mental health conditions like Schizophrenia, Panic disorder, alcohol or substance abuse, Attention deficit hyperactivity disorder (ADHD), Anxiety disorders, and other depressive disorders.
Sometimes, this condition may get misdiagnosed, as it presents features similar to that of other conditions, but mostly it is misdiagnosed as depression. This leads to inappropriate treatment.
About 75% of patients have relapses. The time interval between 2 episodes of manic depression is about five years if at all the second episode occurs. Some patients have more than four episodes per year. These are known as Rapid Cyclers.
When Manic and depressive phases alter very rapidly, the condition is called ultra-rapid cycling. The mortality rate in Bipolar Disorder is two times more than that of the general population. In depression, the most important cause of death is suicide.
Prognosis of Manic Depression
Generally, Bipolar Disorder has a good prognosis.
The diagnosis is poor if-
- There are comorbid conditions, alcohol or drug dependence
- There is a chronic ongoing stress
- If there is an unfavorable environment
- There is a poor response to treatment.
Management of Manic Depression
Medications
Many drugs are available to treat Bipolar Disorder or Manic Depression.
1) Antidepressants
These are the treatment of choice for depressive disorders. The commonly used antidepressants are-
- Tricyclic antidepressants(TCAs) like Imipramine and Amitriptyline.
- Selective Serotonin Uptake Inhibitors (SSRIs) like Fluoxetine, Sertraline, and Citalopra-
- m.
- Venlafaxine and Duloxetine are SNRIs (serotonin-norepinephrine reuptake inhibitors).+
It should be kept in mind that it may take up to 3 weeks to appreciate a response after a particular drug is given. Hence, antidepressant drugs play an important role in elevating a depressed mood.
2) Antipsychotics
Indications for using antipsychotic drugs are- manic episodes, delusional depression, and bipolar depression. Many antipsychotics are successfully used in the maintenance treatment of Bipolar Disorder. Some antipsychotic drugs are-
- Risperidone
- Haloperidol
- Aripiprazole
3) Mood stabilizers like Lithium
Lithium is a drug of choice for the treatment of manic symptoms and for the prevention of further episodes of manic depression. An appreciable response of Lithium is observed after 1-2 weeks.
Investigations like general physical examination, complete blood count, urine examination, thyroid and renal function tests, electrocardiography, and others are to be done before starting lithium therapy. Endocrinal and nephrological side-effects are common.
4) Other Mood Stabilizers
- Sodium Valproate for treatment of acute mania and for the ones who are refractory to lithium. It is an important and widely used mood stabilizer.
- Carbamazepine and Oxcarbazepine for prevention of bipolar disorders and treating mania.
- Benzodiazepines like lorazepam and clonazepam are now rarely used for treating manic episodes alone.
5) Antianxiety drugs
Most people with Manic Depression take more than one medication.
Electroconvulsive Therapy (ECT)
When a person is suffering from a severe depressive episode and the danger of suicide is substantial, this procedure is used. It is proved to be life-saving in such conditions of major depressive episodes. The response is usually rapid, and 6-8 sessions are required.
However, there is no sustained result after stopping ECT. Therefore, antidepressants are often given with ECT.
Psychosurgery
It is an extremely rare method of treatment and is used only and only if there is an absent response to any other mode of treatment and in very severe forms of Bipolar Disorder. The procedures performed are-
- Stereotactic subcaudate tractotomy
- Stereotactic limbic leucotomy.
Psychosocial Treatment
Although medications are the primary mode of management in bipolar disorder, psychosocial treatment is also useful and can be used alongside medications.
1) Cognitive Behavior Therapy
CBT aims at correcting negative, depressive ideations such as pessimism, helplessness, hopelessness, worthlessness, and so on and replaces them with new and positive ideations. It can be used with or without medications and ECT.
2) Interpersonal Therapy
According to IPT, interpersonal and social tensions are among the things that trigger depression.
3) Group Therapy
In moderate cases of depression, it may be beneficial.
4) Behavior Therapy
It includes problem-solving techniques, social skill training, self-control therapy, and decision-making techniques. It is useful in mild cases of depression.
5) Family-focused Therapy and Marital Therapy
It helps loved ones to learn about the nature of illness. It also helps them to understand that how bipolar disorders can affect a person. Also, it can help them manage these patients. This therapy can help decrease intrafamilial and intrapersonal difficulties.
As suicidal thoughts are common among people with bipolar disorder, if you notice a loved one trying to commit suicide, seek immediate help and move him to the nearest hospital emergency room under the guidance of health care providers or call 911.
In a nutshell, manic depression or bipolar disorder is a lifelong mental health condition. It involves episodes of high and low moods. To prevent bipolar disorder is difficult as the exact cause remains unknown. It can only be managed after it develops.
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- Richards, Ruth, and Dennis K. Kinney. “Mood swings and creativity.” Creativity research journal 3.3 (1990): 202-217. ↩︎
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- Geddes, John R., and David J. Miklowitz. “Treatment of bipolar disorder.” The lancet 381.9878 (2013): 1672-1682. ↩︎
- Lex, Claudia, Martin Hautzinger, and Thomas D. Meyer. “Cognitive styles in hypomanic episodes of bipolar I disorder.” Bipolar Disorders 13.4 (2011): 355-364. ↩︎
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