Up until the 18th Century, unusual behaviour was viewed with suspicion and superstition, and so-called madness was linked to demonic forces and punishment from above. We all have opinions on what’s deemed normal or abnormal behaviour and, to some extent, our current cultural and social environment dictates what that norm is. Doctors rely on certain criteria to make mental illness diagnoses and there are three basic measures that are the starting point:
Deviance: Does behaviour deviate from the norm, and is it deemed abnormal by society at present? For example in the 1500s, King Henry VIII had Mary Boleyn as a mistress and only married her sister Anne when she refused the same status. Prince Charles was heavily slated for his friendship with his current wife Camilla, while married to Princess Diana, indicating that behaviour accepted in King Henry's time is no longer part of societal norms.
Maladaptive behaviour: Enables a person to cope, but isn’t necessarily helpful in the long term. Avoidance of social settings due to anxiety is an example, specifically when this avoidance does nothing to cure or treat the anxiety in the first place.
Personal distress: Everyone experiences times of distress, such as financial pressure or the ending of a relationship, for example. But when this state is prolonged, it’s often a precursor to anxiety or depression.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is seen as the gold standard in diagnosing mental illness. It’s updated regularly and uses five axes to determine diagnoses. These include clinical syndromes; personality disorders or mental retardation; general medical conditions; psychosocial and environmental problems; and the global assessment of functioning (GAF) scale.
All this covers the basics of diagnoses for mental disorders. As more is learnt about human physiology, neurology and psychology, criteria are refined further. Hilgard’s Introduction to Psychology, twelfth edition, published in 1996, states that although depression is prevalent in American adults, bipolar occurs in less than 2% of the population. The National Institutes for Mental Health, US, now states the prevalence to be 2.6% of the population, with over 80% of those being severe cases.
ONE, TWO OR MORE
Characterised by dramatic shifts in mood, energy and activity, bipolar has far-reaching effects not only on the sufferer, but also the people who love and live with them. Manic episodes are one of the key characteristics in identifying bipolar disorder, coupled with periods of depression. There are two different types of bipolar: I or II.
Bipolar I is characterised by one or more manic episodes occurring in one’s lifetime. According to the DSM, a manic episode includes reduced sleep requirements, perceptions or feelings of grandeur, racing thoughts, preoccupation with an idea or thought and overindulgence in pleasurable behaviours which may have negative outcomes (such as sexual adventures, risky financial dealings or extravagant spending). To be diagnosed with bipolar I, you must have experienced both a manic and a major depressive episode. The time periods between the different episodes of mania and depression are often individualised and affect the treatment. It’s possible for a person to experience rapid cycling, where the periods of mania and depression occur four or more times throughout a year, as well as for both mood states to occur simultaneously. Ultra-rapid and ultra-ultra rapid (ultradian) cycles can also occur, where the mood shifts over a period of days or even within one day.
Bipolar II is seen as the less severe type and doesn’t have the accompanying dramatic manic episodes, but one or more hypomanic as well as a depressive episode is required for diagnoses. Hypomania is a less severe form of mania, and can be likened to a heightened state of mind, where thoughts are clearer, the mind works faster and mood is elevated, but without the over-the-top riskiness of a manic phase. Sometimes mania is present, but is overlooked because depressive symptoms can overwhelm its effects.
Cyclothymia is similar to bipolar and diagnosed when mood swings are present, but not severe enough to be termed manic or major depressive. It’s perhaps this refined diagnosis that blurs the line between what’s deemed normal or abnormal. If a mood isn’t high enough to be affirmed as manic, and in that case, not out of bounds enough to be damaging or dangerous, could it not just be called a good mood? So, too, if a down mood isn’t low enough to be clinically addressed as a major depressive episode, perhaps medication isn’t required, but can be dealt with through lifestyle changes. Is labelling necessary then, and is the medical profession possibly creating disorders to satisfy patients' need for tangible answers, as highlighted in an article published by the Citizens Commission on Human Rights International?
With celebrities such as Catherine Zeta-Jones, Sinead O’Conner, Robert Downey Junior and Stephen Fry speaking out about their bipolar diagnoses, the stigma of the disorder is slowly being given a positive slant. However, research shows that self-stigma, as well as others’ perceptions, can have a damaging effect, worsening the consequences of the disorder. Even if negative stigma is merely perceived, the effect can be significantly dispiriting. A report in the Journal of Affective Disorders highlights the positive aspects of bipolar (spirituality, empathy, creativity, realism and resilience) and suggests that treatment would be more effective if these positive traits are encouraged. Creativity is an accepted characteristic of bipolar, although it isn’t a defining factor, a diagnosis of bipolar does not necessarily mean a person is creative. An article published in the Mental Health Review Journal discusses the effects of bipolar on author Herman Melville’s ability to write Moby Dick and concludes that the disorder has positive benefits to society. Johns Hopkins University Professor of Psychiatry, Kay Redfield Jameson, known for her poignant and honest biography “An Unquiet Mind” about the effects of bipolar, encourages doctors to minimise medication as much as feasible to ensure that the inherent creativity of bipolar isn’t dampened.
Currently there’s no cure for bipolar, and sufferers are doomed to a life on medication, such as antidepressants, mood stabilisers or antipsychotics, or a combination, all of which come with their own side effects, from lowered libido to weight gain. In addition to medication, psychotherapy is recommended for the bipolar person as well as their family. However, as science delves deeper into the brain and learns more about the processes of neurons, alternative treatments are beginning to come to the fore. One such treatment is deep brain stimulation (where a device called a brain pacemaker is implanted in the brain, and gives off electrical impulses that are targeted to specific parts of the brain), although it’s only been tested in terms of treating depression in bipolar, not mania.
QEEG (Quantitative Electro-encephalogram), or brain mapping, coupled with neurofeedback is showing promise as a treatment for mood disorders. It’s already shown good results for other brain-related disorders, such as ADHD. Basically, QEEG assesses areas of the brain that aren’t functioning normally, in terms of neuron firing, and neurofeedback offers the opportunity to train neurons to work more cohesively.
Highlighting the positive aspects of the disorder will certainly go a long way in changing public perception of bipolar and patient treatment, and new science could pave the way for less erratic treatment outcomes.
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