Over time, people can exhibit quite varying patterns of mood swings. Within the clinical depressive disorders, it is important to make a distinction between unipolar and bipolar depression. The terms ‘unipolar depression’ or ‘unipolar disorder’ are used to describe a pattern of episodes of clinical depression in which there are no ‘highs’. By contrast, the term ‘bipolar disorder’ is used to describe patterns of manic behaviour that may or may not alternate with episodes of clinical depression. Approximately 5 percent of those suffering a bipolar disorder experience only highs. The great majority of people with the disorder alternate between highs and lows and, commonly, experience intervals of quite normal mood states in between episodes. For each individual the pattern is quite distinct. Some people with bipolar disorder might have only one episode every decade, while others may have daily mood swings.
In the past, people with severe bipolar disorder may have been admitted to an asylum where they could have remained manic for many months or depressed for many years and then spontaneously remitted, indicating that there is a pattern to even the most severe expressions of the condition. It is important to note that such severe patterns are rare. Mild bipolar patterns are common and often go undiagnosed because they may be viewed as ‘normal mood swings’.
The terms ‘unipolar’ and ‘bipolar’ originally referred to the melancholic depressive sub-type but have, in the last twenty years, been broadened to refer to all expressions of clinical depression. For a clinician to tell a patient that they have a ‘unipolar depression’ means little more than that they have a non-bipolar disorder.
Bipolar disorder was previously called ‘manic-depression’ due to the swings between high and low moods. Mania is indicated by very ‘high’ mood (which may be expansive and/or irritable), by marked social impairment and, often, by psychotic features such as delusions and hallucinations. In hypomania, mood is still ‘high’, but often little more than being distinctly happy, jovial or expansive. For many, the changed mood state is obvious to others but, perhaps for the majority, the mood swing is not so marked that others would be aware of it. This explains why it is difficult to diagnose mild expressions of bipolar disorder. In some cases, the mood variation may appear to be no more than an ongoing personality style.
Bipolar disorder is biologically mediated and strongly inherited. When people develop bipolar depression, they nearly always have psychotic or non-psychotic ‘melancholic’ depressive episodes. There are exceptions, however. For instance, an individual with bipolar disorder may have a sequence of melancholic depressive episodes and then, when faced with an unusual stressful event (such as a job loss), develop a ‘normal’ depressed mood, a non-melancholic depressive disorder or a grief state.
The diagnosis of ‘bipolar disorder’ is not always straightforward for several reasons, explaining why several studies have identified an average period of over ten years between the onset of the disorder and the correct diagnosis being made.
First, mild expressions can be very difficult to distinguish from a normal volatile or cyclothymic personality style. There are many people who swing from being ‘the life of the party’ to being quiet, uncommunicative and even grumpy as part of their personality style and not because they have a bipolar disorder. Creative people can experience self-induced ‘highs’ when caught up by the Muse: a writer, for example, may describe feeling ‘taken over’ during a burst of creative planning, or writing in a state of excitement, needing only a few hours sleep. Some drugs will induce a sense of ‘being high’, both legal and illicit. Nearly all antidepressant drugs can effectively ‘send’ a person into a hypomanic or manic state— whether or not that individual had previously experienced a ‘high’ or had a tendency to do so.
Second, bipolar disorder does not always present in a classic pattern (for example, distinct highs followed by lows, or vice versa). It may commence with a period of insomnia, or follow the unexpected appearance of a physical condition such as an eating disorder, with clear bipolar depression remaining latent for months or even years.
Third, mild experiences of bipolar depression are common— particularly ones where only the individual is aware of their differing ‘state’, while others, even family members, may fail to detect any change.
How, then, can bipolar disorder be diagnosed with any confidence? At the Mood Disorders Unit, we explore a number of parameters with open-ended questions designed to establish whether, during any particular period, an individual has:
• experienced an elevated, euphoric, irritable or more confident mood;
• experienced reduced sleep, but without feeling tired the next day;
• had more energy or felt ‘wired’;
• spent more money than usual or wished to do so;
• made frivolous or unnecessary purchases;
• talked more and made more phone calls than usual;
• experienced increased libido;
• dressed more colourfully;
• been more verbally or behaviourally indiscreet than usual;
• found ‘nature’ more beautiful;
• been more creative;
• sung more.
It is important to understand that such features are noted relatively consistently across different cultures, although cultural factors influence their actual expression. The psychiatrist Kay Jamison documents a saying used by the Old Order Amish that suggests bipolar depression—‘racing one’s horse and carriage too hard’.
If there is still doubt about the diagnosis after working through the list, then it is a good idea to talk to a family member who may provide similar or even quite different information. It is also valuable to pursue the family history to determine whether any family members have had bipolar disorder (even obtaining old hospital and medical records) and to ask to see the individual when the next ‘high’ is experienced.
Even after pursuing all diagnostic options, for a percentage of individuals the diagnosis will remain in doubt. Their situation should generally be reviewed after an interval or, less commonly, mood stabilisers could be trialled to determine if there is any impact on their mood state and functioning.
Regrettably, the diagnosis of bipolar disorder is commonly missed for several reasons. First, some health practitioners are unaware of it or are untrained in its assessment. Second, many practitioners fail to consider it when undertaking patient assessment. Third, many patients with mild bipolar disorder enjoy their ‘highs’ and prefer not to tell anybody about them.
(extracted from) Dealing with Depression: A Commonsense Approach to Mood Disorders y Gordon Parker, published by Allen & Unwin.