Treatment of
Bipolar Disorders and
Manic Depression




By Harold L. Burke, Ph.D.

 

“Bipolar disorder,” “bipolar,” “manic depressive disorder,” “manic depression”: Information, treatments, current research, resources, and helpful hints

All of us have mood swings from time to time. At times we may feel more elated and happy, and at other times we may feel depressed and unhappy. We can usually get over such emotions within a reasonable amount of time, and usually the intensity of the moods is not excessive. However, an individual may be suffering from a bipolar disorder (formerly known as manic-depressive psychosis) if the intensity of the mood swings is sufficiently severe as to cause significant distress or to interfere with occupational, social, or other functioning. The lifetime prevalence is approximately 2.6-5%, and there is a significant genetic component. The age of onset is typically in the 20’s, but it can start in the mid-teens especially if there is a strong family history. Fortunately, on the Web and in libraries, there is much information about the treatment of bipolar disorders, mood disorders, and mental disorders. There are numerous treatments for bipolar disorders including alternative, holistic treatments. The Brain Therapy Center provides information, psychological/neuropsychological assessment, treatment, current research information, and helpful tips.

What is a manic episode?

A manic episode refers to a discrete period of abnormally elevated, expansive, or irritable mood lasting for at least one week (or less if hospitalization is necessary). Irritability is the most common emotion. Moreover, many episodes may last from one to three months if untreated. In addition, several or all of the following symptoms may be present:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (feeling rested after only 3-4 hours of sleep)
• Loud and excessive talking
• Speech pressured and forced as if there were not enough time to say it all
• Subjective feeling that thoughts are racing
• Distractibility
• Increase in goal-directed activities or psychomotor agitation
• Engaging in pleasurable activities that usually result in painful consequences (e.g., spending sprees, sexual indiscretions, foolish business adventures)

Such an episode may be sufficiently severe that an individual is actually psychotic. That is, the person may distort reality, may experience delusions (i.e., false beliefs about reality) or hallucinations (i.e., sensory misperceptions without an external stimulus), or may exhibit disorganized behavior or speech. As an example, a patient believes that she is running for President of the United States and currently has a direct telephone line to the current President. She scurries about public areas many hours per day shaking virtually everyone’s hand, and she sleeps only three hours at night. She is talking fast and loud, and people notice that her speech seems so pressured and that they cannot get a word in edgewise. In fact, when anyone tries, she yells, “Don’t interrupt me!” She races her car at 90 mph from one place to another and uses her credit cards to purchase outfits that “will guarantee that she will be elected particularly since she is already the most beautiful woman who has ever entered politics.” Her purchases far exceed her budget, but she does so anyway. She is drinking copious amounts of alcohol and is “free” and indiscreet with her sexual activities.

This example sounds like some politicians we may know! Seriously though, this example is not an exaggeration of what often happens; and disastrous consequences can result even though the individual may feel elated and better than she has felt in months.

What are some symptoms of a major depressive episode?

A major depressive episode refers to a period lasing at least two weeks during which an individual has experienced several or all of the following symptoms:

• Feeling sad (dysphoria) or empty
• Diminished interest or pleasure in almost all activities (anhedonia)
• Significant change in weight or appetite (not related to diet)
• Insomnia or hypersomnia
• Mental or motor agitation or slowing
• Fatigue
• Feelings of worthlessness or inappropriate guilt
• Diminished ability to think, concentrate, or make decisions
• Recurrent thoughts of death

As with a manic episode, a depressive episode can be sufficiently severe that an individual may become psychotic and may require hospitalization.

What is a mixed episode?

A mixed episode refers to a period in which an individual experiences both depressive and manic symptoms during the same period.

What are hypomanic and dysthymic episodes?

Hypomanic episodes and dysthymic episodes are not as severe as manic and major depressive episodes, respectively. A hypomanic episode is a period of manic symptoms, but it is not as severe as a manic episode. There are no psychotic symptoms, no hospitalization is required, and the symptoms do not significantly interfere with an individual’s life. Essentially, a dysthymic episode is less severe than a major depressive episode, but it usually lasts longer. For individuals to receive this diagnosis, they must have experienced several depressive symptoms for at least two years (one year for children and adolescents), and they must not have been symptom-free for more than two months.

What are the specific bipolar disorders?

Bipolar I Disorder is the type of bipolar disorder with which most people are familiar and which was formerly known as manic-depressive psychosis. To get this diagnosis, an individual must have experienced at least one manic episode. It is presumed that the person will experience at least one major depressive episode at some point even if one has not been experienced to date. Without treatment, it is likely the individual will experience multiple manic and depressive episodes, that the number of episodes will gradually increase, and that the interval between them will shorten. Furthermore, if episodes become more sufficiently severe, psychotic symptoms may develop over a period of days to weeks.

Bipolar I Disorder is further specified as to whether the most recent episode is a manic, a hypomanic, a mixed, or a major depressive episode. In addition, it is specified whether the patient recovers between episodes, whether the patient experiences depression related to the winter months (“seasonal pattern”), and whether the patient experiences rapid cycling (i.e., has four or more episodes per year). An equal number of males and females experience Bipolar I Disorder.

Bipolar II Disorder occurs when a patient has experienced at least one hypomanic episode without ever having experienced a manic or mixed episode and at least one major depressive episode. In addition, it is specified whether the patient recovers between episodes, whether the patient experiences depression related to the winter months (“seasonal pattern”), and whether the patient experiences rapid cycling (i.e., has four or more episodes per year). Patients with this disorder are depressed the majority of the time, and more females experience Bipolar II Disorder than males.

Cyclothymic Disorder essentially is characterized by an initial period of at least two years (one year if child or adolescent) of hypomanic and dysthymic symptoms. After that period, the individual may also experience manic, mixed, or major depressive episodes superimposed on the cyclothymic disorder.

A person may also suffer from a manic, mixed, or major depressive episode secondary to general medical conditions or to intoxication by or withdrawal from substances (e.g., alcohol, cocaine). Cocaine and amphetamines are particularly infamous for causing manic psychotic episodes in which the individual may be dangerous and behaviorally out of control. 

The causes of bipolar disorders are not definitively known. However, much is being discovered about the relationships among neurobiological factors (e.g., genes, neurochemicals, firing patterns among neurons) and the occurrence of specific environmental stressors.

Such discoveries offer much hope for individuals suffering from bipolar disorders, and there are several well-documented and clinically-proven methods for treating these disorders. These methods include psychotherapy (particularly cognitive-behavioral therapy, patient/family education and support) and psychotropic medications (e.g., mood stabilizers, antipsychotics). In addition, there are several alternative therapies with less efficacy research that have been used by clinicians with reported success. EEG biofeedback (neurofeedback) is one such method that appears to be more holistic and not reliant on medications. (Please see special page on EEG Biofeedback on this website for an explanation of this exciting methodology.) In addition, there are some promising results from the therapeutic use of omega-3 fatty acids.         

Several Treatment Modalities for Bipolar Disorder

At the Brain Therapy Center, our staff specializes in several treatment modalities including individual psychotherapy, neurofeedback, and exercise/diet consultation. We use primarily five types of psychotherapy, depending upon the needs of each client and combined synergistically to optimize effect:

• Cognitive therapy helps individuals replace dysfunctional, inaccurate thoughts and images that may increase depression with thoughts and images that are more accurate and that may decrease depression.
• Behavioral therapy is the systematic application of scientific principles of learning theory to change behavior. By changing certain maladaptive behavioral patterns, mood swings can be decreased in severity and possibly frequency. One very good example of this approach is to help the patient identify the specific stressors that may sometimes trigger episodes and to modify behavior so as to minimize the impact of these stressors. For example, substance abuse is a very common problem for bipolar patients. Behavioral principles (along with other techniques) can be quite helpful in this area. As other examples, sleep deprivation and changes in sleep cycles are both stressors and early indicators of impending manic episodes.  
• Logotherapy assists the client in achieving more meaning in life. Sometimes a person experiences excessive depression due to a lack of direction or purpose in life or to uncertainties about life. Logotherapy helps the individual address these issues and access those dimensions of his/her personality that can neutralize such depression.
• Existential therapy assists the client in examining the relationship between depression/anxiety and very basic life choices.
• Medical hypnosis assists the client in entering an extremely relaxed but focused state so that subconscious processes of healing can occur. This has been found to decrease the severity and sometimes frequency of episodes.  
• EEG Biofeedback (neurofeedback) uses operant conditioning to alter brain waves so that a client’s brain can achieve more flexibility and stability. Such increased stability can smooth out some of the depressive and manic symptoms.
• Exercise/diet consultation is provided by a certified personal trainer (CPT) with a four-year B.S. in Kinesiology with emphasis on exercise physiology. Such consultation can instruct a client about good diet and substances to avoid in excess (e.g., caffeine) and the importance of exercise for improving sleep. This may decrease the probability of a manic episode and decrease depression. There are also some promising research results from the therapeutic use of omega-3 fatty acids for the treatment of bipolar disorders. (The doses used are significantly larger than usually taken for optimal health by those individuals without a bipolar disorder.)

We at the Brain Therapy Center also have the requisite knowledge to allow us to have a close working relationship with physicians who may be prescribing medications for bipolar disorders. (Dr. Harold Burke, Director of the Brain Therapy Center, has earned an M.S. and a Ph.D., has completed two years of basic medical sciences, and is currently enrolled in a post-doctoral Master of Science program in Clinical Psychopharmacology.)

Some Helpful Hints

• Seek help from a mental health professional if you or a loved one are suffering from the above symptoms and mood swings. Please, do not procrastinate in seeking such help even if you have had just one manic episode. There is mounting evidence that the number of episodes will gradually increase and that the interval between them will shorten if left untreated. Furthermore, if episodes become sufficiently severe, psychotic symptoms may develop. In addition, you may be trying to “self-medicate” your symptoms and may be developing serious substance dependence.

 

• There are several reasons why it is particularly important to seek the help of a mental health professional in the case of bipolar disorders. First, diagnosing these disorders can be difficult. Many of the symptoms overlap with other disorders, and it takes a thorough and sophisticated interview to differentiate the correct diagnosis. Because these disorders involve cycles, it is imperative for the professional to investigate the history of previous episodes. It is not sufficient merely to observe the symptoms of the current episode. In addition, the current symptoms may have been caused by either a bipolar illness or by such drugs as cocaine and amphetamine. Second, these disorders may be life-long. You do not want to get the wrong diagnosis especially if you may be placed on medication(s) for years. One example of such a mental health professional would be a licensed clinical psychologist with extensive education and training in diagnosing and treating such symptoms and bipolar disorders. Another important example would be a psychiatrist who would be able to evaluate the appropriateness of psychotropic medications. These medications can make a tremendous difference in a patient’s life. However, they can have significant side effects and may have complex interactions with other drugs including over-the-counter drugs and supplements. Your primary care physician is certainly licensed to prescribe mood stabilizers, anti-manic medications, and anti-depressant medications. However, psychiatrists have had much more training and experience in prescribing such medications and in treating bipolar disorders.

 

• Be particularly careful to follow the recommendations of your physician if you are taking medications for one of these disorders. Not taking medications as prescribed is one of the primary reasons for treatment failure in treating bipolar disorders. It can be difficult to take a medication if you are in the throws of a manic episode and happen to experience bountiful amounts of energy, are being unusually productive, or believe that you are going to accomplish something incredible. If you are also experiencing certain uncomfortable side effects, it is understandable that you may simply not want to take a medication. However, this may result in disastrous consequences (e.g., financial crisis) and hospitalization.

 

• Exercise, particularly if it includes aerobic exercise, can be very beneficial. This exercise does not have to be intense for benefits. Even 10 minutes of walking will increase your energy for 60-120 minutes and improve your mood. If possible, do 10 minutes of gentle stretching, 20 minutes of aerobic exercise, and 5-10 minutes of stretching as a cool down. Do this at least three times per week, but remember that the level of intensity does not make that much difference. Research has found that such exercise increases deep sleep, decreases stress reactivity, increases self-esteem, and increases such chemicals as BDNF (brain-derived neurotropic factor) that actually “heal” the brain. Of course, consult with your physician if you have any questions or doubts whatsoever about the wisdom of your doing exercise.

 

• Decrease your stress levels as much as possible. Stress can trigger manic and depressive episodes or make existing ones worse. Psychotherapy, biofeedback, exercise (e.g., aerobic, yoga, Tai Chi) and meditation/prayer have been shown to be effective in decreasing stress.

 

• Try to improve your sleep by practicing good, healthy sleep hygiene. As examples, get sufficient amounts, keep a regular sleep schedule, avoid stimulants late in the day, exercise regularly, and avoid activities in the bedroom that may interfere with sleep (e.g., making business contacts on the telephone, working on your laptop in bed). If you are depressed, insomnia may be one of your symptoms; and you need to get adequate amounts of sleep. On the other hand, only requiring 3-4 hours of sleep may be one of the earliest symptoms of a manic episode. If this happens to you, please seek help immediately.

 

• Avoid using illegal drugs and alcohol. Psychostimulant drugs such as cocaine and amphetamine may cause symptoms that mimic a manic episode, but they can also trigger manic and psychotic episodes that may last months. Alcohol will make depression worse since it is a central nervous system depressant, and it often interferes with prescribed medications. If you are abusing alcohol and/or drugs, seek professional help. These drugs will only make your mood swings worse and will serve to exaggerate the negative consequences of those swings.   

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