June 25, 2009
Manic depression - Cover story
Crazy highs and lows
How could feeling energetic and indestructible be part of a medical condition? But that's bipolar disorder. On its flipside, a patient can sink into deep depression and may even entertain thoughts of suicide
By June Cheong
What do late American president Theodore Roosevelt, actress Carrie Fisher and pop star Britney Spears have in common?
They all suffer from bipolar disorder.
This mood disorder is characterised by recurrent bouts of extreme mood changes.
Dr Adrian Wang, a consultant psychiatrist at Dr Adrian Wang Psychiatric And Counselling Care, said: 'It's a brain disorder because it is caused by chemical imbalances.'
While the mood swings make it appear to be psychological, the cause is biological, he said.
Patients veer between two psychological states - mania and melancholia.
When manic, the patient may be in excessively high spirits, is sometimes irritable, needs less sleep with thoughts racing through his brain constantly, talks quickly and makes grand plans.
Symptoms of melancholia are a persistent feeling of sadness, hopelessness and lethargy. He may be unable to eat or sleep.
Dr Ng Beng Yeong, the head of the department of psychiatry at Singapore General Hospital, said: 'In extreme forms (of mania), they may believe they are exceptionally gifted or rich or are important religious, political or famous people.
'The judgment of those with mania is often impaired because of grandiosity and failure to plan or consider the consequences of their actions.'
Mania often requires hospital admission as the manic patient's energy levels may be too much for their family or caregivers to take. The manic patient is also often prone then to excessive or dangerous but pleasurable behaviours like spending too much or sexual indiscretion.
While manic patients invariably sound like they have more fun, Dr Wang noted that depressive lows often last longer than manic highs.
Dr Chua Tze Ern, a registrar in the department of community psychiatry at the Institute of Mental Health, said: 'Different individuals will have different symptoms. One may be predominantly depressed and another may be predominantly manic.'
In between high and low episodes, patients feel well and normal - like everyone else.
The exact cause of bipolar disorder is unknown but doctors believe it is likely to be caused by a plethora of factors interacting with one another.
Dr Ng said: 'It often runs in families and there is a genetic component to the disorder.
'However, even though someone may have inherited the genes for bipolar disorder, there is no guarantee that he will develop it.'
As the brain controls moods, sense of perception and judgment, imbalances in certain brain chemicals like dopamine and serotonin may result in bipolar disorder. These may be destabilised due to genetics.
Beyond this genes factor, stressful or negative life events like losing a loved one and certain personality traits like being neurotic can also predispose someone to developing bipolar disorder.
A stressful event often triggers the first episode of bipolar disorder, so how one copes with stress and negative experiences influences one's susceptibility to the disorder.
Dr Wang said: 'The current economic crisis is stressful for everyone and stress can unmask underlying disorders.
'I've seen an increase in the number of patients with mood or anxiety problems.'
Asked if bipolar disorder can be prevented, Dr Ng said: 'Stay away from drugs, learn to manage stressful events better and give priority to sleep. Loss of sleep can contribute to the onset and recurrence of depression and mania.'
Although women are more prone to getting mood disorders like depression and anxiety, bipolar disorder seems 'neutral' to gender.
It is most common in people between the ages of 20 and 40 and 1 per cent of adults in Singapore have bipolar disorder.
Bipolar patients are also more susceptible to developing problems like substance abuse, anxiety disorders such as panic attacks and attention deficit hyperactivity disorder, or ADHD.
Dr Wang explained: 'There's an overlap in brain chemicals and functions. If one part of the brain is screwed, other parts may be too.'
Bipolar disorder can be difficult to diagnose for several reasons. One, it may be masked by other conditions like substance abuse or bulimia.
Two, the symptoms of bipolar depression are similar to normal depression and doctors can only confidently diagnose bipolar disorder if the patient does not respond as well to anti-depressant medication.
Like many illnesses, bipolar disorder can range from mild to severe. With regular psychiatric reviews and medication, patients with mild to moderate bipolar disorder can lead normal lives and maintain satisfying relationships.
In such cases, the mainstay of treatment is medication as well as counselling for the patient and his family. Different combinations of mood stabilisers, anti-depressants, anti-psychotic drugs and sedatives may be needed.
In severe cases, electroconvulsive therapy may be prescribed. The treatment is done in a hospital and a controlled electric shock is applied to the patient's head while he is medicated and under anaesthesia.
Asked if medication is more effective in treating bipolar disorder than counselling, Dr Chua said: 'Medication is often more effective as it can directly target the neurotransmitter abnormalities that cause the symptoms.
'Having said that, counselling plays an important role too in educating patients about their illness and in helping them to manage their stress levels.'
Dr Wang said: 'I get my patients to recognise certain dysfunctional thought patterns. For example, if they say their boss hates them, I show them how it's not true and to recognise their own faulty reasoning.
'It's more than thinking positive. I challenge my patients to change their behaviour. If they think no one likes them, I ask them to smile or go up to people first.'
As bipolar disorder is a long-running illness, continual consultation and treatment is necessary. Patients may experience long periods of feeling normal but the disorder may suddenly return.
Once diagnosed, patients usually require medication for at least a year to remain stable.
More than 90 per cent of patients with a single manic episode go on to have more. Between 5 and 15 per cent of patients have four or more episodes in a year while 10 to 15 per cent eventually commit suicide.
Bleak statistics aside, there is a positive aspect to having bipolar disorder - greater creative powers. Researchers have found a link between bipolar disorder and a higher level of creativity.
That explains why the ranks of bipolar disorder patients read like a who's who of the arts world, including American writer Ernest Hemingway, British novelist Virginia Woolf and American comedian Ben Stiller.
Dr Ng said: 'I often find myself marvelling at the intensity with which individuals with bipolar disorder experience life.
'Many patients with mild bipolar disorder enjoy their highs and prefer not to tell anybody. Once diagnosed, they are concerned that medication will take away the pleasurable states and their creativity.'
Her dream of becoming a university academic was blindsided by bipolar disorder.
Ms Choo Kah Ying, a freelance writer and editor, was diagnosed with the brain disorder when she was 19.
The 37-year-old said: 'I wanted to be an academic but I didn't go on to do that or get a PhD because of my bipolar disorder. My dreams were interrupted.'
She was in her second year of university in Australia when she found herself struggling with her studies and feeling insecure about her relationship with her then-boyfriend.
She said: 'The initial trigger was his going to Los Angeles. I panicked when he was out of reach.
'At school, I couldn't focus. I'd prided myself on being a good student.'
Things came to a head a few months later when she tried to hang herself at her then-boyfriend's place. She failed but he saw the rope marks on her neck and called her parents.
Ms Choo's parents then sent her to a psychiatrist who diagnosed her as bipolar and put her on lithium treatment, one of the most common drugs for bipolar disorder.
Lithium helps reduce the severity and frequency of mania as well as relieves bipolar depression.
Ms Choo did not respond well to the three-month treatment and experienced side effects like grogginess and a dry mouth.
She said: 'I was an uncooperative patient. I'd show up at the psychiatrist's and not say anything.'
She stopped taking lithium after three months as her mood swung towards mania.
Symptoms of manic states in bipolar patients include restlessness, increased energy, euphoric mood, racing thoughts and provocative behaviour.
Ms Choo described her manic episodes as feeling like James Brown's song, I Feel Good, all the time.
She said: 'That's the treachery of the condition. You mistake mania for recovery as the episode has semblance of health and liveliness.'
After graduation, she moved to Los Angeles. While there and under the influence of mania, she indulged in risky behaviour like having one-night stands, dancing all night at parties and clubs and shopping even when she was broke.
Then she found out she was pregnant. After giving birth to her son in 1996, she suffered severe post-partum depression.
Her mother flew over to Los Angeles to help her look after the baby and to persuade her to see a psychiatrist.
Ms Choo said: 'The psychiatrist told me 'I know you really want to take care of your baby but if you want to take care of him long-term, you should be on medication'.'
She was prescribed a cocktail of sleeping pills, anti-depressants and mood stabilisers.
The boy, now 12, is autistic. But he marked the turning point in Ms Choo's life.
She said: 'He was my anchor back then and he's still the reason I get out of bed regardless of how I feel.'
She started popping five mood stabilising pills every day until 2005. However, she began cutting back on her medication when she tried to buy health insurance and was told she was 'medically uninsurable'.
Later that year, she returned to Singapore with her son. By then, she had cut down her medication to half a pill every other day.
She said: 'Every time I cut down on my medication, I'd watch for symptoms. It's important not to do it alone and to enlist the help of loved ones.'
Keeping busy with work and settling back into Singapore led Ms Choo to forget her pills. Soon she had been off them for a year.
Meanwhile, she found time to pen a book about her experience entitled Five Little White Pills... And Then There Were None: A Journey From Manic Depression To Recovery.
Asked how she has managed to keep her condition under control without medication, she said: 'I don't take medicine anymore because I have a disciplined lifestyle.
'I exercise for an hour every day and I meditate.'
Ms Choo's book Five Little White Pills... is available at major bookstores at $16.