Under- Standing Bipolar Disorder - SAMH

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understandingbipolardisordersamh.org.uk

contentsWhat is bipolar disorder? 04What types of bipolar are there?06What are bipolar mood states?08What causes bipolar disorder?12How does a diagnosis get made?14What treatments can help? 16What medication is available? 20This resource explains whatbipolar disorder is, what kindsof treatment are available,and how you can help yourselfcope. It also provides guidanceon what friends and familycan do to help.How can I help myself cope?24How can friends and family help?28Useful contacts 32Further informationTo read or print SAMH’s information booklets visit samh.org.uk.If you require this information in word document format for compatibilitywith screen readers, please email [email protected] more information visit: samh.org.uk3

Bipolar DisorderWhat is bipolar disoreder?What is bipolar disorder?Bipolar disorder is a mental health problem that mainly affectsyour mood. If you have bipolar disorder, you are likely to havetimes where you experience: manic or hypomanic episodes(feeling high) depressive episodes (feeling low) potentially some psychotic symptomsduring manic or depressed episodesYou might hear these different experiencesreferred to as mood states, and you canread more about them in our page onbipolar moods and symptoms.Everyone has variations in their mood, butin bipolar disorder these changes can bevery distressing and have a big impact onyour life. You may feel that your high and lowmoods are extreme, and that swings in yourmood are overwhelming.Depending on the way you experiencethese mood states, and how severely theyaffect you, your doctor may diagnose youwith a particular type of bipolar disorder.Bipolar disorder and stigmaMany people have heard of bipolardisorder, but this doesn’t mean theyunderstand the diagnosis fully. You mightfind that some people havemisconceptions about you or have anegative or inaccurate image of bipolardisorder. This can be very upsetting,especially if someone who feels this wayis a friend, colleague, family member ora health care professional.But it’s important to remember that youaren’t alone, and you don’t have to put upwith people treating you badly.Here are some options for you to thinkabout: Show people this information to helpthem understand more about what yourdiagnosis really means. Know your rights. Our pages on legalrights provide more information.‘What helps me themost is the ongoingrealisation andacceptance that theway in which mybipolar disordermanifests itself, andthe symptoms Idisplay, are notpersonality traits or‘bad behaviour.’Bipolar disorder or manic depression?The term ‘bipolar’ refers to the way your mood can change between two verydifferent states – mania and depression. In the past, bipolar disorder was referredto as manic depression, so you might still hear people use this term. Some health careprofessionals may also use the term bipolar affective disorder (‘affective’ meansthe disorder relates to mood or emotions).‘It’s an emotional amplifier: whenmy mood is high I feel far quicker,funnier, smarter and livelier thananyone; when my mood is low I takeon the suffering of the wholeworld.’4For more information visit: samh.org.uk5

Bipolar DisorderWhat type of bipolar is there?What types of bipolar are there?Depending on the way you experience different bipolar moods andsymptoms, and how severely they affect you, your doctor may diagnoseyou with a particular type of bipolar disorder. The table below explains someterms your doctor might use.DiagnosisWhat it meansBipolar IYou may be told you have bipolar I if you have experienced: at least one episode of mania which has lasted longerthan a weekYou might also have experienced depressive episodes,although not everyone does.Bipolar IICyclothymiaYou may get a diagnosis of bipolar II if you have experienced both: at least one episode of severe depression symptoms of hypomaniaYou may get a diagnosis of cyclothymia if: you have experienced both hypomanic and depressivemood states over the course of two years or more your symptoms aren’t severe enough to meet the criteriafor a diagnosis of bipolar I or bipolar IIThis can be a difficult diagnosis to receive, because you mayfeel that you are being told your symptoms are ‘not seriousenough’, but this is not the case. Mental health is a spectrum thatencompasses lots of different experiences and cyclothymiacan have a serious impact on your life.Using these terms can help both you and health professionals discuss your diagnosisand treatment more specifically. If your doctor ever uses words or phrases you don’tunderstand, you can ask them to explain.6How often do bipolar episodes occur?This can depend on a lot of things, such as: your exact diagnosis how well you’re able to manage yoursymptoms whether certain situations orexperiences can trigger your episodes(for example, you might find that gettingvery little sleep while going through astressful life event could trigger anepisode of mania) how you define an episode personallyWhat’s normal for you can also change overtime. However, many people find that: mania can start suddenly and lastbetween two weeks and four or fivemonths depressive episodes can lastlonger – sometimes for several monthsRapid cyclingYou may be told your bipolar is rapidcycling if you have experienced four ormore depressive, manic, hypomanicor mixed episodes within a year.This might mean you feel stable for a fewweeks between episodes, or that yourmood can change as quickly as within thesame day, or even the same hour.Currently, rapid cycling is not officiallyconsidered a separate type of bipolardisorder, but more research is needed toknow for sure or to better understand it.(For more information on rapid cycling,see the Bipolar Scotland website.)It’s also common to have stable or neutral periods in between episodes. This doesn’tmean that you have no emotions during this time – just that you’re not currentlyexperiencing mania, hypomania or depression, or that you’re managing your symptomseffectively. You might find you feel stable for years in between episodes, although forsome people periods of stability can be much shorter.‘It’s a lot harder coming to terms withbeing stable [.] than I could haveimagined. I’ve had to struggle with a ‘new’identity and way of life after spendingso many years thinking the ups and downsof bipolar are ‘normal.’For more information visit: samh.org.uk7

Bipolar DisorderWhat type of bipolar is there?What are bipolar mood states?This section provides information on: manic episodes (feeling high)hypomanic episodes (feeling high)depressive episodes (feeling low)mixed episodes (feeling high and low atthe same time) psychotic symptomsGoing through any of these experiencescan be extremely difficult to cope with,so it’s worth thinking about how you canlook after yourself, and what kind oftreatment could help. It’s also worthplanning ahead for a crisis. it lasts for a shorter time it doesn’t include any psychoticsymptomsWhile hypomania is less severe than mania,it can still have a disruptive effect on yourlife and people may notice a change in yourmood and behaviour.Symptoms of hypomania can include:About manic episodesMania can last for a week or more and has a severe negative impact on your abilityto do your usual day-to-day activities - often disrupting or stopping these completely.Severe mania is very serious and often needs to be treated in hospital.Here are some things you might experience during a manic episode:How you might feelHow you might behave happy, euphoric or a sense ofwellbeing uncontrollably excited, like you can’tget your words out fast enough irritable and agitated increased sexual energy easily distracted, like your thoughts areracing, or you can’t concentrate very confident or adventurous like you are untouchable or can’t beharmed like you can perform physical andmental tasks better than normal like you understand, see or hear thingsthat other people can’t more active than usual talking a lot, speaking very quickly,or not making sense to other people being very friendly saying or doing things that areinappropriate and out of character sleeping very little or not at all being rude or aggressive misusing drugs or alcohol spending money excessively or ina way that is unusual for you losing social inhibitions taking serious risks with your safety8About hypomanic episodesHypomania is similar to mania, but has afew key differences: it can feel more manageable –for example, you might feel able to goto work and socialise without anymajor problemsHow you might feelHow you might behave happy, euphoric or a sense of wellbeing very excited, like you can’t get yourwords out fast enough irritable and agitated increased sexual energy easily distracted, like your thoughts areracing, or you can’t concentrate confident or adventurous After a manic or hypomanic episode youmight: feel very unhappy or ashamed abouthow you behaved have made commitments or taken onresponsibilities that now feelunmanageable have only a few clear memories ofwhat happened while you were manic,or none at all feel very tired and need a lot of sleepand restFor more information visit: samh.org.ukmore active than usualtalking a lot or speaking very quicklybeing very friendlysleeping very littlespending money excessivelylosing social inhibitions or taking risks‘The hardest thingto explain is theracing thoughtswhen I’m manic. It’slike I’ve got fourbrains and they’reall on overdrive.it can be scary butalso euphoric at thesame time.’9

Bipolar DisorderWhat type of bipolar is there?About depressive episodesHere are some things you might experience during a depressive episode:How you might feelHow you might behave down, upset or tearful tired or sluggish not being interested in or findingenjoyment in things you used to low self-esteem and lacking inconfidence guilty, worthless or hopeless agitated and tense suicidal not doing things you normally enjoy having trouble sleeping, or sleepingtoo much eating too little or too much misusing drugs or alcohol being withdrawn or avoiding people being less physically active than usual self-harming, or attempting suicideMany people find that a depressive episode can feel harder to deal with than manicor hypomanic episodes. The contrast between your high and low moods may make yourdepression seem even deeper.(See our pages on depression for more information.)‘The lows can be flat anddevoid of colour, or intenseand torturous. Sometimes it’sfull of demons, and paininside so bad nothing physicalcould hurt you.’10About mixed episodesMixed episodes (also called ‘mixed states’)are when you experience symptoms ofdepression and mania or hypomania at thesame time or quickly one after the other.This can be particularly difficult to copewith, as: it can be harder to work out whatyou’re feeling it can be harder to identify what helpyou need it might feel even more challengingand exhausting to manage youremotions you may be more likely to act onsuicidal thoughts and feelings your friends, family or doctor mightstruggle to know how they cansupport you bestAbout psychotic symptomsPsychotic symptoms can include: delusions, such as paranoia hallucinations, such as hearing voicesNot everyone with a diagnosis of bipolardisorder experiences psychosis, but somepeople do. It’s more common duringmanic episodes, but can happen duringdepressive episodes too. These kinds ofexperiences can feel very real to you atthe time, which may make it hard tounderstand other people’s concernsabout you.(See our pages on psychosis formore information.)‘Then [with mania]comes the paranoia,the shadows, thevoices, the thoughtsomeone is behindme following meeverywhere I go,ready to get me.’For more information visit: samh.org.uk11

Bipolar DisorderWhat causes bipolar disorder?What causes bipolar disorder?No one knows exactly what causes bipolar disorder. Researchers suggest that acombination of different factors, including physical, environmental and social,increase your chance of developing the condition.On this page you can find information on: childhood trauma stressful life events brain chemistryChildhood traumaSome experts believe that experiencinga lot of emotional distress as a child cancause you to develop bipolar disorder.This can include experiences like: sexual or physical abuse neglect traumatic events losing someone very close to you,such as a parent or carerThis could be because experiencingtrauma and distress as a child can have abig effect on your ability to regulate youremotions.Stressful life eventsYou may be able to link the start of yoursymptoms to a very stressful period in yourlife, such as: a relationship breakdown money worries and poverty experiencing a traumatic lossAlthough lower levels of stress are unlikelyto cause bipolar disorder, for some peoplethey can trigger an episode of mania ordepression.12Brain chemistryEvidence shows that bipolar symptomscan be treated with certain psychiatricmedications, which are known to act on theneurotransmitters (messenger chemicals)in your brain.This suggests that bipolar disorder maybe related to problems with the functionof these neurotransmitters – and this issupported by some research. However, noone knows for certain exactly how theseneurotransmitters work and whetherproblems with these are a cause or a resultof bipolar disorder.Genetic inheritanceIf you experience bipolar disorder, youare more likely to have a family memberwho also experiences bipolar moods andsymptoms (though they might not have adiagnosis). This suggests that bipolardisorder might be passed on throughfamilies.However, this does not necessarily meanthat there is a ‘bipolar gene’ – family links arelikely to be much more complex.For example, researchers think thatenvironmental factors can also be triggersfor experiencing symptoms of bipolardisorder. And for most people, familymembers are an influential part of yourenvironment as you grow up.‘The biggestthing for me ismaking time formyself; it is veryeasy to feelguilty aboutmaking time, andvery difficultto do on apractical level.’Can drugs cause bipolar disorder?Medication, drugs or alcohol can’t cause you to develop bipolar disorder, but they cancause you to experience some bipolar moods and symptoms. For example: Some antidepressants can cause mania or hypomania as a side effect when youare taking them or as a withdrawal effect when you are coming off them. If you beginto experience mania after taking or after coming off antidepressants for depression,this might lead your doctor to give you an incorrect diagnosis of bipolar disorder,or prescribe you more medication. But in this case it’s usually worth waiting to seeif your symptoms pass without treatment first. Alcohol or street drugs can cause you to experience symptoms similar toboth mania and depression. It can often be difficult to distinguish the effects ofalcohol and drugs from your mental health symptoms.If you’re concerned about the effects of medication, alcohol or street drugs on yourmental health, it’s important to discuss it with your doctor.For more information visit: samh.org.uk13

Bipolar DisorderHow do you get a diagnosis get made?How does a diagnosis get made?To make a diagnosis your doctor will ask you about: how many symptoms you experience how long your manic or depressiveepisodes last how many episodes you’ve had, and howfrequently they occur the impact your symptoms have onyour life your family historyThey may also: ask you to keep a diary of your moods tohelp them assess you check for any physical health problems,such as thyroid problems which cancause mania-like symptomsYou can only be diagnosed with bipolardisorder by a mental health professional,such as a psychiatrist – not by your GP.However, if you’re experiencing bipolarmoods and symptoms, discussing it withyour GP can be a good first step. They canrefer you to a psychiatrist, who will beable to assess you.‘Once properlydiagnosed,I knew thecause.I understoodthat I wassomeone withan illness. I wasnot a failure,not a badperson.’14How long will diagnosis take?Because bipolar disorder involveschanges in your moods over time, yourdoctor may want to observe you for a whilebefore making a diagnosis. Bipolar disorderalso has some symptoms in common withother mental health diagnoses (such asdepression, personality disorders ,schizoaffective disorder andschizophrenia), so your doctor maywant to take care that they diagnose youcorrectly.Because of this it might take a long timeto get a correct diagnosis – sometimes itcan take years.What can I do if I disagree withmy diagnosis?If you feel the diagnosis you’ve been givendoesn’t fit the way you feel, it’s importantto discuss it with your doctor. You can seeka second opinion and take action if you’renot happy with your doctor. Advocacyorganisations can provide advice andsupport on how you can do this.‘I was diagnosedwith BPD firstbecause of theoverlap insymptomsbetween bipolar IIand BPD.’For more information visit: samh.org.uk15

Bipolar DisorderWhat treatments can help?What treatments can help?The National Institute for Health and Care Excellence (NICE) –the organisation that produces guidelines on best practice in healthcare – suggests that treatment for bipolar disorder should includeboth talking therapies and medication.This section covers: What treatment could I get to managea current episode? What can I do in thelonger term? Which talking therapies might I beoffered? How can talking therapies help in thelong term? What treatment can I get in a crisis?The exact combination of treatmentsyou’re offered will depend on whetheryou’re managing a current bipolar episode,or managing your mental health in thelong term.What treatment could I get to managea current episode?This will usually depend on what kind ofepisode you’re experiencing.During depressive episodes You’re likely to be offeredmedication – this might be newmedication or adjusting your currentmedication. You might also be offered a structuredpsychological treatment that’s provento help with depression, such asCognitive Behavioural Therapy (CBT).(See our pages on depression for moreinformation on treatments and self-caretips for depression.)‘I find thebiggest step isaccepting thatis who you are.Changing yourways with medsand therapy is ahard slog.’16During manic or hypomanic episodes You’re likely to be offeredmedication – this might be newmedication or adjusting your currentmedication. You’re unlikely to be offered a talkingtherapy if you are currentlyexperiencing a manic or hypomanicepisode.What can I do in the longer term?The aim of treatment should be to help youmaintain stable moods and manage yoursymptoms well. As you start to feel morestable, the majority of your support couldcome from a Community Mental HealthTeam (CMHT) or your GP, although your GPshould arrange for you to still be in touchwith a mental health specialist.If you are receiving a talking therapy, youmight set some of these goals with yourtherapist. You should share these goals withyour GP. You may also want to share themwith your family, friends and carer if youhave one.Your health professionals should work withyou to help you identify: Clear emotional and social recoverygoals for you to work towards andregularly reflect on and revise with yourdoctor. A crisis plan, so you know what to do ifyou experience any of your early warningsigns or triggers, or begin to feel verydistressed. How you feel day-to-day, so you canbe aware of how best to manage yourmood and notice any changes. A medication plan, including dates whereyou can review your dose, how well themedication is working and any sideeffects that you experience.‘It has been 13 years sinceI was Hospitalised orsectioned, and [I’ve] doneso well. My medicationis working.’For more information visit: samh.org.uk17

Bipolar DisorderWhich talking therapies mightI be offered?There are several talking therapies youmight be offered to help you manage yourbipolar disorder in the long term. These area few that have been tested and shown towork well for some people, although othertherapies may work too: Cognitive behavioural therapy(CBT) – looks at how your feelings,thoughts and behaviour influenceeach other and how you can changethese patterns. Interpersonal therapy – focuses onyour relationships with other people andhow your thoughts, feelings andbehaviour are affected by yourrelationships, and how they affect yourrelationships in turn. Behavioural couples therapy focuses on recognising and trying toresolve the emotional problems thatcan happen between partners.What treatments can help?Other types of talking therapiesyou may be offered are: Enhanced relapse prevention/ individualpsychoeducation – this is a briefintervention to help you learn copingstrategies. Group psychoeducation – this involvesworking in a group of people with sharedexperiences, led by a trained therapist,to build up knowledge about bipolardisorder and self-management. Family-focused therapy – this involvesworking as a family to look at behaviouraltraits, identify risks and buildcommunication and problem-solvingskills.Some of these treatments are more widelyavailable than others. What you are offeredcan also depend on what you and yourdoctor agree would be most useful for you.How can talking therapies helpin the long term?Talking therapies can help you: understand or make sense or meaningout of your bipolar disorder, and reflecton the impact it has had throughoutyour life identify early warning signs andsymptoms develop strategies to cope withearly symptoms, triggers and episodes make a crisis plan set goals and plans for staying wellWhat treatment can I getin a crisis?If you start to feel very unwell, or if anepisode of depression or mania is lastingfor a long time and your regular treatmentisn’t working, you may need to access crisisservices to help you get through it.This may include: emergency support, such as going to A&E getting support from a crisis resolutionand home treatment (CRHT) team hospital admissionIs ECT ever used to treat bipolar disorder?Electroconvulsive therapy (ECT) should only be considered a treatment option forbipolar disorder in extreme circumstances. According to NICE guidelines, this couldbe if: you’re experiencing a long and severe period of depression, or a long periodof mania, AND other treatments have not worked, or the situation is life-threatening.If you feel like you’re in this situation, your doctor should discuss this option with youin a clear and accessible way before you make any decisions.‘Bipolar disorder is one of thosethings that if you have it and it’s wellcontrolled, you can use it productively.it’s in [my] best interest to take [my]meds, see [my] shrink regularly and staywell.’18For more information visit: samh.org.uk19

Bipolar DisorderWhat medication is available?What medication is available?If you are diagnosed with bipolar disorder, it’s likely thatyour psychiatrist or GP will offer to prescribe medication.This might include: antipsychotics lithium anticonvulsants antidepressants20Which medication you are offered willdepend on: Your current symptoms, for example,if you are currently experiencing amanic or depressive episode. Your past symptoms, such aswhether you are mainly manic or mainlydepressed, and how long the episodeshave lasted. How you have responded totreatments in the past. The risk of another episode, and whathas triggered episodes in the past. Your physical health, in particular whetheryou have kidney problems, weightproblems or diabetes. How likely you are to take the medicationconsistently. Your sex and age (for example, if youcould become pregnant your doctorshouldn’t offer you valproate, as it carriessignificant risks to your baby). In older people, a test of mentalprocesses such as the one used todiagnose dementia.Before you take any medicationBefore you decide to take any medication,you should make sure you have all the factsyou need to feel confident about yourdecision.Antipsychotics for bipolar disorderYou are most likely to be prescribed anantipsychotic if you have an episode ofmania or severe depression in which youexperience psychotic symptoms, suchas hearing voices. However, someantipsychotics are increasingly prescribedeven if you haven’t had psychoticsymptoms, as their side effects might beless unpleasant, and they’re safer inpregnancy.For more information visit: samh.org.ukThe National Institute for Health and CareExcellence (NICE) treatment guidelinesrecommend the following antipsychotics: Haloperidol (Dozic, Haldol, Haldoldecanoate, Serenace) Olanzapine (Zalasta, Zyprexa,ZypAdhera) Quetiapine (Atrolak, Biquelle, Ebesque,Seroquel, Tenprolide, Zaluron) Risperidone (Risperdal, RisperdalConsta)If your first antipsychotic doesn’t work,you should be offered a different one fromthe list above. If the second antipsychoticdoesn’t work you may be offered lithium totake together with an antipsychotic.If you’re prescribed an antipsychotic, you’llneed to have regular health checks withyour doctor.21

Bipolar DisorderLithium for bipolar disorderLithium can be effective for reducing thelikelihood of: mania recurrent depression further mood episodes suicidal feelingsIt is typically a long-term method oftreatment, usually prescribed for at leastsix months. For lithium to be effective, thedosage must be correct. You’ll needregular blood and health checks whiletaking lithium, to make sure your lithiumlevels are right for you.What medication is available?Anticonvulsants for bipolar disorderThere are three anticonvulsant drugs usedas mood stabilisers which are licensed totreat bipolar disorder: Carbamazepine Valproate LamotrigineCarbamazepine (Tegretol) is alsosometimes prescribed to treat episodesof mania. It can be prescribed if lithium isineffective or unsuitable for you.Valproate (Depakote, Epilim) can be usedto treat episodes of mania and is typically along- term method of treatment. It can beprescribed if lithium is ineffective orunsuitable for you. However, if you couldbecome pregnant your doctor shouldn’toffer you Valproate unless there is apregnancy prevention programme in place,as it carries significant risks to your baby.Lamotrigine (Lamictal) hasantidepressant effects and is licensed totreat severe depression in bipolar disorder.NICE guidelines recommend that it is notused to treat mania. If you are pregnant andtaking Lamotrigine, NICE recommendsyou are checked regularly.22Antidepressants for bipolar disorderIn some circumstances you might also beoffered antidepressant medication, suchas selective serotonin reuptake inhibitors(SSRIs) – a commonly prescribed type ofantidepressant. You might be offeredantidepressants in combination with oneof the medications described above.Remember: You should always checkwith your doctor or pharmacist beforetaking any drugs together, or closelyfollowing one another, in case they couldinteract with each other badly. For example,combining lithium with SSRIantidepressants can increase the risk ofserotonin syndrome (a serious side effect).‘Lithium helps [me cope]and I just have to keepreminding myself thatwhichever feeling I’mgoing through won’tlast forever.’For more information visit: samh.org.uk23

Bipolar DisorderHow can I help myself cope?How can I help myself cope?Bipolar disorder can make you feel like you have little control.However, there are lots of things you can do to manage yoursymptoms and increase your wellbeing: get to know your moodstake practical stepslook after your physical healthbuild a support networkGet to know your moodsMonitor your mood. It can be helpful tokeep track of your moods over a periodof time. You could try using a mood diary(there are many freely available, such asthe one from Bipolar Scotland). Understand your triggers. For example,if you often feel high after a late night orlow when facing a deadline, it can helpto recognise these patterns. Then youcan take action to avoid the trigger,or minimise its impact. Learn your warning signs. You maystart to notice that there is a pattern tohow you feel before an episode.24This could be: changes in your sleeping pattern changes in your eating patterns orappetite changes in your behaviourBeing aware that you are about to have achange in mood can help you make sureyou have support systems in place and thatyou can focus on looking after yourself.It can also help to discuss any warning signswith family and friends, so they canhelp you.‘have to becareful howmuch socialcontact I have– too much cansend me high.I have to startsaying ‘no’ todemands.’Take practical steps Stick to a routine. Having a routine canhelp you feel calmer if your mood is high,motivated if your mood is low, and morestable in general.Your routine could include: day-to-day activities, such as whenyou eat meals and go to sleep time for relaxation or mindfulness time for hobbies and social plans taking any medication at the same timeeach day – this can also help you manageside effects and make sure that youhave a consistent level of medicationin your system: Manage stress. Stress can trigger bothmanic and depressive episodes.There are lots of things you can do tomake sure you don’t get stressed orlook after yourself when you doencounter stress. Manage your finances. You can contactNational Debtline for free, impartialfinancial advice. Plan ahead for a crisis. When you’re inthe middle of a crisis it can be difficult tolet others know what kind of help youwould find most helpful, so it can beuseful to make a plan while you arewell for how you want to be treated whenyou are unwell.‘I have an alarmset on my phoneso I take my medsat the same timeevery day.’For more information visit: samh.org.uk25

Bipolar DisorderLook after your physical health Get enough sleep

What is bipolar disorder? Bipolar disorder is a mental health problem that mainly affects your mood. If you have bipolar disorder, you are likely to have times where you experience: manic or hypomanic episodes (feeling high) depressive episodes (feeling low) potentially some psychotic symptoms during manic or depressed episodes