MOOD DISORDERS INFORMATION FOR CLIENTS AND FAMILIES

MOOD DISORDERS INFORMATION FOR PATIENTS AND FAMILIES 1.

DEFINITION OF BIPOLAR DISORDER

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SYMPTOMS a) High phase b) Low phase

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TYPES OF MOOD PROBLEMS a) Bipolar Disorder I b) Bipolar Disorder II c) Unipolar Depression d) Cyclothymia e) Dysthymia

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ALCOHOL AND OTHER DRUG USE

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THEORIES REGARDING CAUSES a) Genetic b) Biochemical c) Environment

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TREATMENTS a) Medications b) The role of education c) Light therapy d) Self-management techniques

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TIPS FOR FAMILY MEMBERS

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READING REFERENCES

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WEBSITES

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MOOD DISORDERS 1.

DEFINITION OF BIPOLAR DISORDER:

Bipolar Disorder is an illness where a person’s mood level swings more than the usual ups and downs of most people. These are called mood disorders because the most prominent features for many people are the mood problems. However, some people experience other problems such as sleep or relationships or physical feelings such as tiredness. In the past, the severe form of the disorder was called manic-depressive illness. Sufferers may experience periods of normal mood between the high and low episodes. Bipolar disorder affects approximately 2 to 2.5 in 100 individuals in the general population. Onset is generally prior to age 30 (sometimes as young as childhood) and risk decreases after age 50. 2.

SYMPTOMS OF BIPOLAR DISORDER:

When the highs are extreme, they have been called mania. When they are apparent but to a milder degree, they are called hypomania. When symptoms are only definable on careful questioning or noticed by people who know the person well, they are called hyperthymia. People usually regard mild highs as desirable or ideal. The manic or high phase includes: A) A distinct period lasting at least a week of abnormally and persistently elevated, expansive or irritable mood. • The individual may feel “on top of the world”. • Excessively cheerful mood can quickly change to anger or irritability. Many people find the highs extremely unpleasant. • The mood level is not consistent with reality. B) Inflated self-esteem or grandiosity. • A person may feel able to do anything and that nothing can stop them or feel irresistible or overly generous. This feeling may lead to disregard for personal safety or the safety of others. • A person may feel they have a special relationship with famous people, e.g., with God or Satan, or even with a movie star or athlete. C) A person may feel the need for less and less or no sleep. D) A person experiencing a high may be more talkative than usual, and feel pressured to keep talking. They sometimes make more phone calls and write more letters.

E) A person may feel their thoughts are racing or skipping from idea to idea. F) Attention may easily be diverted to unimportant details. G) Over-activity: • The person may become involved in numerous activities in all aspects of their life, e.g., work, home, social activities. • There may be excessive involvement in pleasurable activities which have a high potential for painful results such as spending sprees. • Intimate involvement with casual or new acquaintances, or associating with people in whom not normally interested. • Speeding • Gambling or increased use of alcohol The low phase/depression includes: A) Depressed or diminished interest or pleasure in activities for at lease two weeks. B) Increase or decrease in appetite or weight not related to dieting. C) Increase or decrease in the amount of sleep. D) Slowed movements. E) Chronic fatigue or lack of energy. F) Feelings of worthlessness or guilt. G) Inability to concentrate, think, or make decisions. H) Thoughts of death or suicide.

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TYPES OF MOOD PROBLEMS:

Some individuals experience symptoms of highs and lows at the same time or very close together. This is called a mixed state. Not all individuals who suffer from a mood disorder will necessarily experience this type of mood problem. Due to the combination of increased energy and depression, a mixed state presents the greatest risk of suicide. An individual may experience a combination of mania, hypomania/depression a combination of 4 episodes in one year. This is called rapid cycling. A brief description of the types of mood disorders follows: A. Bipolar Disorder I Bipolar Disorders are now considered on a continuum, from mild highs and lows that are almost part of the person’s personality to the extreme form. Bipolar Disorder I is the most extreme form. The essential feature of Bipolar Disorder I is a current or past experience of a manic episode lasting at least one week when one’s mood was abnormally and persistently elevated, expansive or irritable. The manic episode is sufficiently severe to cause marked impairment in social or occupational functioning. B. Bipolar Disorder II Bipolar Disorder II is the same as Bipolar I except the highs are never as high as in Bipolar I. These less severe highs are called hypomanic episodes. The hypomanic episodes do not usually last as long as full-blown manic episodes but the types of symptoms are exactly the same, only milder in intensity. These symptoms include sleep problems, irritability, increased activity, and an inflated sense of self and abilities. Although people suffering hypomanic symptoms do not cause big problems at work, in the family, or in social life, they often experience interpersonal problems such as increased argumentativeness with spouse, less patience with children, or increased drinking of alcohol. Hypomanic episodes do not usually require hospitalization in contrast to manic episodes which almost inevitably do. Hypomania can be quite enjoyable to the person experiencing it. Others may be confused by the person with hypomanic symptoms as they do not behave as usual for them and may be put off by their increased activity and driven or overbearing attitude. The irritability is particularly difficult to cope with. Conversely, significant others may be relieved by what they see as the disappearance of the depression that often precedes the overactive one. Hypomania, although seductive because of increased activity, joviality and optimism, can quickly be followed by the development of depression. The depressive episodes are typically longer and more frequent than the hypomanic episodes, and almost always it is the depressive episodes that cause the person to seek help. C. Unipolar Depression Individuals experience only the low phase.

D. Cyclothymia Some people do not exhibit severe enough symptoms for a sufficient period of time to be diagnosed as having Bipolar Disorder but are often described as moody, impulsive, volatile or irritable. Their mood swings are predominantly lows and they frequently experience disturbances in social functioning. The cycles tend to be short and abrupt with infrequent periods of normal mood. The episodes do not always lead to full-blown high or low episodes. The mood level change may be slight. They generally describe repeated relationship breakdowns, unusual sleep patterns, and sometimes substance abuse. E. Dysthymia Dysthymia is a form of low grade intermittent depression. Individuals tend to be gloomy, brooding, self-blaming and over-sleepers. They may describe remembering feeling this way since childhood. 4.

ALCOHOL AND OTHER DRUG USE

In people who are likely to develop Bipolar Disorder, there is increased risk of use of alcohol, marijuana, street drugs, caffeine, cigarettes and a lack of sleep. The use of some of these substances may also hide/mask symptoms, making Bipolar Disorder difficult to diagnose. 5.

THEORIES REGARDING CAUSES

Research into the possible causes of Bipolar Disorder is active in many centers. It is likely that the emergence of the illness involves several factors. Below is a brief description of some of the areas under investigation. a) Genetic It has long been known that mood disorders run in certain families. About 80% of Bipolar Disorder patients report having a relative who suffers from some form of mood disorders. The genetic link has been confirmed by family, twin and adoption studies. b) Biochemical Neurotransmitters are small molecules that carry messages between nerve cells. There are 60 or more neurotransmitters identified and any one or perhaps several systems could be involved in the emergence of symptoms of mood disorder. It may be that the transmitters themselves are not the main issues, but rather the receptors on which the neurotransmitters act. “Second messengers” and other biochemical events within neurons are being studied. c) Environment Although there appears to be clear biological factors involved in Bipolar Disorder, other factors may also effect the emergence of the disorder. Many

well known individuals such as Princess Diana, Robin Williams and Ernest Hemingway likely suffered from Bipolar Disorder. There may be an association between very stressful events in childhood and later susceptibility to stress. Other theorized precipitants include major life events such as stress in marriage or family, financial difficulties or work problems. Interference with the normal sleep cycles may precipitate an episode of mania. This could occur because an individual travels across time zones, leading to a lack of sleep. Other causes could be shift work, caring for small infants, or worry about life events. It has been suggested that sleep deprivation might be the common pathway by which many events precipitate mania. Season also has an effect on mood. In general, depression is more common in winter, and suicide is more prevalent in spring. When the mood swings occur predominantly at certain seasons, most commonly winter depressions and summer highs, the condition is called Seasonal Affective Disorder (SAD).

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TREATMENTS

a) Medications The treatment of Bipolar Disorder has been revolutionized by the discovery of mood stabilizing medications. Although the exact manner in which these medications work is unclear, they have been shown to return many patients to a more productive, functioning life. These medications have been shown to be useful in treating the periods of mania or depression (sometimes in combination with other drugs) and appear to play a role in preventing recurrences of illness. The most commonly used mood stabilizing agents are Lithium, Tegretol, Epival, Lamictal and more recently Seroquel. Researchers are attempting to develop more effective drugs. Patients should obtain further information about their own medications through their physician. b) The Role of Education Bipolar Disorder is a potentially debilitating illness. Because of the cyclical nature of the mood swings, patients are often tempted to discontinue the long-term treatment necessary to prevent recurrences of the illness. Patients who are treated and return to a normal level of functioning often feel that they no longer require the medication. It is important for patients to understand the nature, treatment, and course of the illness so they can make informed decisions for themselves. Education about the symptoms of highs and lows can help patients to identify the signs of relapse earlier and thus facilitate earlier treatment. The signs of depression are often noticed and reported to a mental health professional. Unfortunately, the symptoms of mania are rather attractive in the earlier stages and may not be reported. Initially patients may find they are very productive and happy in comparison with depression, this may feel like a welcome change. Being high conveys a feeling of power and control. However, this rather productive period will sometimes progress to a state of serious impairment with detrimental effects on work, finances and interpersonal relationships. c) Family Concerns Because of the potential disruption in overall functioning caused by the symptoms of bipolar disorder, it often results in serious concerns for family and friends. Hence, it is important for families to understand the disorder. Family Education can help prevent the anger and frustration that comes from dealing with the illness. This is clearly a biochemical illness, not an attempt to deliberately disrupt the family life. It is important to remember that when the illness reaches a certain stage, the patient no longer has the ability to make reasonable decisions. The grandiose plans and irritability often lead to conflicts. It is therefore important for families to encourage treatment, but not to take reasonability for it, including medications unless requested by the individual or in a crisis. If possible, it is helpful to form an alliance with the patient to identify signs of relapse early. Some patients find that seeking feedback from others about

their mood levels, plans, thinking, and level of activity helps them sort out what is normal from what is unrealistic. Reassurance that this is a treatable illness can help patients feel more hopeful and willing to undertake treatment. Understanding the illness helps families to feel less frightened by the illness and enables them to support the patient’s return to a healthy lifestyle following an episode of illness. It also helps to clarify when the patient needs to be relieved of some of their responsibilities. d) Light Therapy There is evidence that some individuals who suffer from episodes of depression respond favourably to exposure to sunlight. This can also be achieved artificially by the use of light and is known as light therapy or phototherapy. Regular exposure to light is part of maintaining regular rhythms. e) Self-Management Techniques It is encouraging that there are techniques available to help people reduce their symptoms and minimize the chance of a reoccurrence. Some of the techniques are the following: •

Regular compliance with medication – the mood stabilizing drugs are the main therapeutic tool. It is important for patients to continue with the medications for as long as their physician suggests, even if they feel well.

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Decreasing stress – this is good advise for anybody. If there are marital or family problems, regardless of the cause, dealing with them could lead to decreased stress and perhaps decreased danger of relapse. Resolving conflicts and reducing criticism within the family can be very beneficial.

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Maintaining a regular sleep schedule – because sleep deprivation is known to trigger mania in susceptible individuals, it is important to avoid this. Sleep hygiene techniques that you may want to try include: ( Avoiding vigorous exercise within 2 hours of bedtime, sleeping in after a poor night of sleep, excessive liquids/heavy evening meals, caffeine, nicotine and alcohol before bed. ( Hiding the clock. ( Scheduling a ‘wind-down’ period before bed, avoiding arousing activities such as late night phone calls, work, television. ( Remembering alcohol may help you get to sleep but impairs the ability to stay asleep and may also make other sleep problems worse. ( Avoid staying in bed if you are not able to sleep, go to another room and relax. Return to bed only when sleepy.

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Increasing your level of physical activity – this is good advise for anyone. Regular exercise contributes to a sense of general well being. Regular exercise helps the body to maintain its natural rhythms, e.g. sleep.

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Avoiding the use of alcohol and stimulant drugs, including caffeine, may also be helpful. Many of these drugs interfere with sleep.

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Establish regular and consistent follow-up for yourself with the therapist of your choice. It is possible that some forms of psychotherapy may be useful for you. Establishing regular follow-up may help you to seek help appropriately and head off any potential problems. Regular follow-up allows you ready access to answers to questions you may have about your illness, and ensures proper management of your treatment, including medications.

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Learning to recognize the early signs and symptoms of an episode. This helps you not to become caught in the self-defeating thinking of depression, the power and control of highs, or the suspiciousness of irritability.

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Self-help groups.

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Looking after nutrition. Some experts believe that Omega3 fatty acids, found in fish oil, have a beneficial effect, particularly in anxiety.

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Learning the skill of relaxation can also help to manage moods. One such technique, known as the Rectangular Pattern of Breathing.

Lie down or sit in a comfortable position with your eyes closed. You may imagine yourself walking around a small rectangle, breathing in as you walk along one side, holding as you turn the corner and walking along the second side, breathing out as you walk along the third side and holding again on the fourth side. And so on as you walk slowly round and round the block.

1. Breathe in to the count of 4. 2. Breathe out to the count of 8.

USES: • Racing thoughts • Insomnia • Power nap • Power walk

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TIPS FOR FAMILY MEMBERS

When a family member has an illness, such as Bipolar Disorder, it affects the entire family. This is true of a physical illness, such as diabetes or asthma. When your spouse or relative has a mental illness, you must cope with extra stressors – they may be stress related to financial difficulties, work problems or just the day to day dealings with mood fluctuations. •

Learning/educating yourself about the illness is likely one of the most important things you can do for yourself and your loved one.

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Encourage your family member to follow his/her treatment regime.

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Learn the warning signs of suicide. Often family members are too frightened/hurt/scared to acknowledge these signs but it is very important that they do. Take any threats that the person makes very seriously and get help immediately.

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Discuss with your loved one, when they are well, an “action plan” to try to avoid relapses/crises. These may include who they would “allow” you to contact (i.e. their physician, counsellor, etc.), how to prevent the harmful results of overspending or reckless driving.

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Remember that recovery from an episode is slow and gradual. Try to avoid doing for him or her but rather with him or her.

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Remind yourself that Bipolar Disorder is an illness NOT a character flaw. Treat them as you would want to be treated once he or she has recovered from an episode. Conversely, watch for possible signs of recurrence. Remember, however, that people who suffer from Bipolar Disorder are human and do have ordinary human weaknesses as well as the illness.

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Your reactions and emotions are normal. You may experience a variety of emotions from empathy and understanding to frustration to anger to even maybe hatred. Again, try not to take the behaviour personally. REMEMBER – it is often the illness, not them, you are seeing.

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Remember your own needs!

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Take care or yourself Avoid isolating yourself Share the responsibility with others, if possible Keep up your own support network Do not allow Bipolar Disorder to take over the family life

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Last, but certainly not least, learn to distinguish a good day from hypomania and a bad day from depression. Like everyone else, people with Bipolar Disorder have good and bad days that are not part of the illness – allow them that.

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READING REFERENCES 1. Duke P. A Brilliant Madness. New York: Bantam, Books, 1993. 2. Theriault C. On An Even Keel: Understanding Bipolar Mood Disorder. Beresford, NB, Publik-Art Limited, 1992. 3. Oliwenstein L. Taming Bipolar Disorder, Penguin Books Ltd., 2004 ISBN 159257-285-5 4. Jamison KR. An Uniquiet Mind. New York: Alfred A. Knopf, 1995. 5. Jamison KR. Touched by Fire. New York: The Free Press, 1993. 6. Burns D. The Feeling Good Handbook. Penguin, 1990. 7. DePaulo JR, Ablow K. How to Cope with Depression: A Complete Guide for you and your Family. New York: McGraw-Hill, 1989. 8. Papolos D, Papolos J. Overcoming Depression. New York: Harper and Ros, 1987. 9. Copeland ME. The Depression Workbook, A Guide for Living with Depression and Manic Depression. New Harbinger, 1992. 10. Sheffield A. How You Can Survive When They’re Depressed. Random House, 1998. 11. Fast JA., Preston JD, PsyD Taming Someone With Bipolar Disorder, Understanding & Helping Your Partner, New Harbinger Pub., Ltd. 2004 ISBN 1-57224-342-2 12. Fast JA., Preston JD, PsyD Wellness 2006

Take Charge of Bipolar Disorder, Warner

13. Miklowitz, D.J. The Bipolar Disorder Survival Guide, What You and Your Family Need To Know. Guildford Press, New York, 2002. 14. Copeland, M.E. Living Without Depression and Manic Depression. New Harbinger, 2002.

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MENTAL HEALTH WEBSITES

www.canadian-health-network.ca

Link to Mental Health. A truly amazing resource!

www.fhs.mcmaster.ca/direct

Depression and Anxiety Information and Resource Center Access to toll free information lines for the public. Excellent information on Bipolar Disorder.

www.mentalhealth.com

Canadian site with lots of other links to other related sites.

www.pbkids.org

The Child and Adolescent Bipolar Foundation. In a ‘community’ center with an extensive library, message board, chat room, ‘ask the expert’ feature, drug database and children’s art.

www.rpnas.com

Registered Psychiatric Nurses Association of Saskatchewan. Links to many mental health sites.

www.canmat.org

The Canadian Network for Mood and Anxiety Disorders. Provides information of Depression, Bipolar Disorder and Anxiety, including Social Phobias.

www.nami.org

National Alliance for the Mentally Ill (USA). The key advocacy group in the States. A lot of good information and current news.

www.dbsalliance.org

Depression and Bipolar Support Alliance. Fantastic site for information about resources on mood disorders and many, many links to more!

http://checkupfromtheneckup.ca

A Canadian website from the Ontario Mood Disorders Association. Provides information on Mood and Anxiety Disorders, as well as links to other sites.

NOTES:

ANXIETY AND MOOD PROGRAM A PARTNERSHIP OF SASKATOON HEALTH REGION MENTAL HEALTH & ADDICTION SERVICES AND THE DEPARTMENT OF PSYCHIATRY UNIVERSITY OF SASKATCHEWAN (306) 655-7950

April 2009