If there is one word that describes our life today, and describes it very well, it is the word "instability". We can attribute it to the pandemic, climate change, political changes, and technological advances, or find other causes; but this condition specializes in destabilizing us when we don't expect it. It is in our minds, perspectives, feelings, desire to live, and reasoning. We become unstable; our lives get complicated, and it disturbs us.
Among the disorders or diseases in the area of mental health, we find a pathology that is characterized precisely by the instability generated in our mood: bipolarity or bipolar disorder. As described in DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition), it can be classified into several subtypes, but the best known are types 1 and 2.
The first type is demonstrated when at least one manic episode and one depressive episode appear in the history of the disease. In the second type, there is at least one hypomanic episode and another depressive episode. We will seek to understand these types further.
I will simplify these terms with an example from my day-to-day practice. Let's understand Type-1 Bipolarity by describing a patient with the following complaint:
“Dr. Pablo, I don’t know why I’m here. My wife forced me to come, but I’m very well. In fact, I’ve never felt better in my life… I was bad last year; I didn’t want to do anything; I couldn’t even get out of bed; I didn't eat or bathe; life was meaningless; and I even thought about killing myself.
“But for a few months, as if by magic, I feel very good. I am working on two major projects in the company, and I am already thinking about a third. Ideas flow in my mind like never before. I hardly need to sleep; my mind works much better at night, and when I sleep for a few hours, I get up as if I had slept for 15 hours.
“I do physical activity every day, and it seems that I feel like doing more. I have already talked to some friends to get together to play football at the club, and I am organizing everything. Everyone asks me how I have the energy to do so many things.
“The other day, I changed my car. My wife almost killed me when she found out because I bought the pickup truck I always wanted, and I already talked to another friend who is selling a motorcycle. I want to give it to my five-year-old son. I know it is very small, but it is an incredible offer!
“What I need to tell you is that I have been drinking more alcohol for about twenty days, and the other day, I wanted to try cocaine. It wasn’t much, like three or four lines, and that, please, don’t tell my wife, but it was a few times. Besides, nothing happens to me.
Changing the subject, so you can see that I'm like an airplane, on the sexual side, I look like a teenager—I never get tired. I have to admit some difficulty in controlling myself, and don't say anything to my wife, but the other day I went to one of those places… you know… anyway, what did I say? I am very well!"
In this story, we see several characteristics that are considered diagnostic criteria or manias: the mood is abnormal, elevated, expansive, or irritable, with lots of energy that lasts at least a week, most of the day, almost every day. We can also notice high self-esteem, less need for sleep, abundant verbiage (speaking a lot or at high speed and with great eloquence), and lofty ideas.
Also notice an increase in activity (social, work, sexual), and you can get involved in risky situations (uncontrolled purchases, sexual activity, substance abuse, or economic investments). On the other hand, there has been a major depressive episode for a year, which helps to make a probable diagnosis. Either of the two centers may need hospitalization to stabilize the condition and care for the patient.
In Type-2 Bipolarity, the hypomanic condition is similar to that of mania, but with less intensity. Usually, hospitalization is not necessary to control symptoms. The changes are clearly identified as different in the person's normal, day-to-day life.
In the manic phase, there are times when symptoms can be so severe that the patient may have an associated psychotic condition, such as having delusional ideas that you are being persecuted, auditory hallucinations—hearing voices saying what to do—or constantly saying irritating things.
It is very easy for this disease to destroy families, cause divorce for betrayal or violence, or place family members in complex social situations. Companies are destroyed or created so quickly with incredible ideas that they cannot be maintained. If the change of mood to the depressive pole occurs halfway, it can cause sexually transmitted diseases, stimulate abuse, and even foster dependence on substances such as alcohol, tobacco, or cocaine, among others.
It is always much more difficult for the patient to seek help or accept treatment when one is in the manic or hypomanic phase, as that person will feel very well. However, those who suffer are family members or close friends. Often, help is requested in the depressive phase, when you may even have suicidal ideas or attempts. The patient feels really bad and seeks medical help quickly.
Frustration at changing the pole “without an apparent cause” generates a lot of discouragement, frustration, and even an almost-obsessive need to remain in the most joyful and productive pole. This causes you to not accept the treatment well, stop taking the medications, or take only those that do not let you down. The instability of the mood is accentuated, and the cycle is repeated.
There are some people who experience these polarity changes for very long periods, and this often makes it difficult to make a correct diagnosis, making the treatment less effective. Others experience these changes very quickly, happening several times in the same day, or over the course of a few days, which greatly facilitates diagnosis and implementation of treatment.
Therapy and Medication
Speaking of treatment, depending on the severity, the same can occur with mood-stabilizing medications and/or psychological therapy. In my experience and that of many colleagues, combining the two therapeutic strategies (therapy and drugs) produces a much better result, stabilizing the condition in less time.
The great pharmacological stabilizer is lithium, but there are other drugs that also act as stabilizers. Among them are quetiapine, valproic acid, and lamotrigine. All of them require psychiatric medical indication and control.
Along with this combination and understanding that human beings are complex, it is very important to take care of other areas, such as healthy eating, maintaining adequate moral and spiritual principles, taking care of sleep, and maintaining adequate physical activity.
With these concepts I tried to summarize and exemplify, I leave some practical advice:
- Do not be angry with the person until you understand it may be the illness that is driving your actions, thoughts, and words.
- When in doubt, consult a mental health specialist so you can have a direction of what you need to do and understand.
- Understand that the euphoric phase is phenomenal, but it also needs to be controlled, and do not resist treatment, as it is for your own good.
- Some drugs used in manic conditions make you sleepy, so don't be alarmed. It is often necessary for the patient to decrease activity to protect him or her.
- Begin to analyze the actions and understand they may be outside expected normality; you have to talk, verify if it's just an impression, and ask for help.
- Bipolarity is a disease, not a lack of faith! In fact, faith in God will help a lot in treatment and enable family members to better understand and provide support.
- If you are at one pole, understand the other pole can appear at any time. When you understand this, ask for help.
- This disease has treatment, so do not lose hope.