Welcome to MY World Bipolar Disorder

In a world entranced with celebrities, it is important to realize that we are all the same: We are all just people. We share the same challenges, the same hopes and dreams, the same struggles and many of the same mental wellness issues. To raise awareness, we are proud to introduce Dr. Emily Lazarou; a respected and highly experienced forensic psychiatrist. Each month, Dr. Lazarou will address a different disorder or mental illness in hopes of normalizing this taboo discussion topic.

One out of four people in America take prescription psychiatric medication. The statistics alone are not enough- we need to stop villainizing mental illness and become educated and informed as to what to do if we are diagnosed, or how to help our loved ones get the help they need. Some of the most famous and successful people in the world have faced the challenges of mental health. We begin our series with an informed article on Bi-Polar disorder: Everything you need to know by Dr. Emily Lazarou.

Before we begin, here is a list of celebrities dealing with Bi-polar disorder:
Mariah Carey, Carrie Fisher, Mel Gibson, Demi Lavado, Russell Brand, Brian Wilson, Kurt Cobain, Jimi Hendrix, Earnest Hemingway, Ted Turner, Catherine Zeta-Jones, Vivien Leigh, Frank Sinatra, Sineaid O’Connor, Jean-Calude Van Damme, Jane Pauley, Winston Churchill.

Welcome to MY World Bipolar Disorder

by Dr. Emily Lazarou MD

Hello! It’s me. Emily Lazarou, MD – General and Forensic Psychiatrist. I’ve been asked to write about a disorder that is near and dear to my heart, Bipolar Disorder. When I was a medical student learning about this disorder in my first psychiatry rotation at the Veteran’s Administration Hospital in San Antonio, TX, I was amazed by it. Why?

The first presentation I saw was a manic Bipolar patient. They were loud, smart, and in my face. They knew everything and they had limitless energy. In my mind, as a business person, I thought, “if I could get a building full of these patients, I could make something great!” The patients I saw with this condition had so many ideas and boundless energy. Even today, in my medical practice, I try to place these patients at the end of my work day because they provide an energy to me. They inspire me. The counter transference from me to them is so positive and the transference from them to me typically is positive as well.

When I’m treating a patient of this type – I try to keep them energized, but not out of control. You see, that is the problem with a patient with Bipolar Disorder. Or, at least the problem with the manic side of their illness – it can get them into trouble. That energy that projects out of them is a manifestation of impulsivity in many areas of their life: sexuality, finances, aggression, and a lack of awareness or significance of their human responsibilities. Whether those are to their family, friends, employer, or themselves. There are no consequences to their activities in the moment. And if there are consequences, the person with mania believes that they can overcome them. The ultimate danger in mania is putting themselves or someone else into harm’s way either because they believe they are invincible, or because they believe that someone is trying to stop them from doing something they want to do.

The flip side of the illness is the depressive side. As happy as someone with mania can be – they can be just as depressed. The depression that someone with Bipolar Disorder has is a sadness that no typical person can understand. Because someone with Bipolar Disorder has a happiness that no typical person can understand – the switch to depression can be unbearable. Because of that feeling of extreme and utter darkness – the risk of suicide is great. As you can imagine – it’s not so fun to treat patients on this side of the illness, but many times – this is the presentation I see. I see this one because they want out of that feeling as fast as they can escape it.

Now that I have given you a glimpse of what I could see clinically, let’s get down the terminology used to describe this illness. This isn’t a fad. Not everyone with “mood swings” has Bipolar Disorder. I want to make that distinction. One of my frustrations as a clinician and also as a Forensic Psychiatrist is that scientific jargon gets thrown around without any science to support it. People call someone “Bipolar” as an insult when it’s not that at all. In fact, when I treat patients with true Bipolar Disorder, I always call them super heroes because they have access to a power that typical people do not have. Many times, my patients with this disorder have done great things – they are famous artists, or physicians, or authors. They have been able to hone the skills that they have and utilize the “wave” of creative energy that Bipolar Disorder brings to them to manifest their wildest dreams. The problem iswhen they can no longer harness the power and a full-blown manic episode occurs that gets them either hospitalized or incarcerated.

There are different variations of Bipolar Disorder – I, II, and Cyclothymic Disorder. We don’t have the space to talk about each in detail, but the distinction is primarily made in the severity of the illness. Bipolar I must have a true manic episode and (in my clinical experience) will have a true major depressive episode as the disease progresses. Bipolar I Disorder is the most severe. It is the classic example of the illness and what we are going to focus on in this article. Bipolar II has touches of mania (what we call hypomania) and must meet the criteria now or in the past of a major depressive disorder. Cyclothymia is essentially when someone has “mood swings.” Over the course of time, they may have felt hypomanic or depressed, but never meet full criteria for either disorder.

What is manic? What is depressed? Most people know what the word depression means and even how it feels. What makes the distinction between someone just being sad as a reaction to something bad happening and a Major Depressive Episode? Severity of the symptoms. Severity in the number of symptoms and how long they last. Symptoms of Major depression are: sadness, sleep disturbance, not liking things that you typically like, having no appetite, no energy, a lack of an ability to concentrate, feelings of guilt about things you have no control over, and thoughts of suicide. To meet the criteria for a Major Depressive episode, one must have these symptoms for 2 weeks or more. Mania is the opposite of depression in a lot of ways: extreme happiness; they don’t want to sleep because they have so much to do or they feel so good; all foods taste good, but they may not have time to eat or they are focused on their appearance and so they want to be trim and don’t eat; boundless energy; they are impulsive and typically cannot concentrate or they concentrate fully on one thing they are interested in. Suicidal thoughts are not typical in mania, but there can be homicidal thoughts. As I alluded to earlier, if the manic person sees another person or thing that opposes them strongly – that person may potentially be a victim. This can happen to a family member trying to stop the person from spending money they don’t have or refusing sex when they ravenously need it. Mania can also manifest in an irritable way where the person isn’t necessarily very happy – they are agitated.

Now, let’s look into their brains a bit and figure out what would make someone like this? Psychiatry is a complex field and we are touching on all of this very superficially. The very foundation of the diagnosis of a Psychiatric condition is to rule out a medical reason for the same symptoms. What could look like this medically? Hyperthyroidism is the leading medical reason why someone would go manic. The thyroid is an organ in your neck that controls many basic bodily functions such as metabolism and body temperature. The thyroid is constantly working and getting feedback from our brains on whether it needs to put out more thyroid or less. When that system breaks down or if there is possibly a tumor in the thyroid – it starts to hyperfunction despite the brain telling it to stop. In some people, when it does that – it can make them appear manic. It’s very important to check that before starting treatment for Bipolar Disorder because if that is missed – then the person never will get better because it’s not a pure Psychiatric condition. It’s a medical condition causing the psychological symptoms. Another example is intoxication on illicit stimulant drugs such as amphetamine, Ecstasy, or cocaine. In certain sensitive people – even more common stimulants such as nicotine or caffeine could cause these symptoms. Bottom line is, in any work up to look at a patient with a possible Psychiatric condition – laboratory studies must be done to separate out a medical from psychological condition.
A medical cause has been ruled out as a cause of the psychological condition – what next? When treating Psychiatric conditions, a multifactorial approach must be used to treat it because Psychiatric conditions encompass biological, psychological, and social aspects of a disease. We have looked at the biological basis from a laboratory perspective, but there is more to the biology of mental illness. In Bipolar Disorder specifically, there is a strong genetic component. In some twin studies, the heritability could be up to 90%. As a doctor who takes care of these patients, this is a critical detail because like the disorder is heritable – so is the treatment. In the history that I take from the patient, I ask about family members and if a relative with Bipolar Disorder responds well to Lithium, for example, then I am more likely to put this patient on Lithium to treat their condition.

Psychologically, a patient with Bipolar Disorder can have a history significant for trauma and other abuse. Childhood trauma and other environmental factors (which could be related to being the child of someone with Bipolar Disorder) can predispose a person with a propensity to get Bipolar Disorder – for the disorder to manifest the symptoms earlier in the person’s life. The earlier the symptoms manifest, if not treated properly – can lead to a poorer prognosis. Prognosis is how someone will fair in their life overall. Patients with Bipolar Disorder could have faced traumas as an adult due to symptoms of their disorder. For example, a female with Bipolar Disorder could be sexually assaulted or used for sex because in that moment – they were hypersexual. STDs are common in this population because of that.
Social factors associated with the disorder could be a bi-product of the disorder in the sense that a person with the disorder will make bad judgment calls due to everything that we have discussed. Marriages end because of infidelity. Jobs are lost due to impulsivity – making bad judgment calls with someone else’s money or just simply not showing up because in the moment they perceive they have something better to do. People with Bipolar Disorder can have explosive tempers and attack a co-worker due to a seemingly small insult. Many people with Bipolar Disorder can have financial problems due to overspending and being reckless with money.

Another issue that I have yet to discuss about this illness is the propensity to have psychotic symptoms either in a manic or depressive phase. When the illness is at it’s worst, a person can manifest psychotic symptoms. What are psychotic symptoms and how does this manifest in someone with Bipolar Disorder? When a person can hear or see something that isn’t there (hallucination), of if they truly believe in something that isn’t true (delusion) than that is a psychotic symptom. Typically, people with Bipolar Disorder have what we call ego syntonic hallucinations. That means that when someone has hallucinations – they go along with how they are feeling. So, if someone is hypersesxual due to mania and they see me, they may have a delusion (a fixed, false belief) that I am a sex goddess ordained by God called Dr. Geodonna (true story). When someone is hypersexual, they may misinterpret the behavior of someone around them as being flirtatious to them. Unfortunately, this can cause the person with Bipolar Disorder to possibly suffer some legal consequences if they act upon those thoughts and the victim isn’t a willing participant (also, true story).

In closing, this article isn’t inclusive of everything about Bipolar Disorder, but I hope it gives you an idea that Bipolar Disorder isn’t just a word. It’s not a joke. It’s not a fad. It’s not something that someone has when they have mood swings, or you don’t like their personality. It’s a true mental illness with a biological basis which can manifest in true gifts, but also true consequences. Mania is a medical emergency and those who are suffering from a manic episode need to be treated as such. If you have further questions about this or other mental disorders – I’d be happy to answer your questions.

Until next time…