Bipolar affective disorder: the facts not the fictions

Bipolar affective disorder (BPAD) describes a collection of diseases characterised by alternating mood. 'Bipolar' means at either end of the spectrum, representing the 'highs and lows' often seen in this condition. What causes BPAD is debated, but its effects on long-term quality of life cannot be ignored. A BPAD diagnosis seems to have become a trend with celebrities, with potential over-diagnosis trivialising and sensationalising what can be a severe and limiting disease. This article lays bare the facts about the forms of BPAD and who it commonly affects, without the Hollywood gloss.

What is BPAD?

There are five distinct types of recognised BPAD:

1. BPAD 1 (mania with or without depression)

2. BPAD 2 (hypomania with or without depression)

3. Cyclothymia (Rapid cycling BPAD)

4. Rapid cycling BPAD

5. Mixed state

BPAD 1 denotes 'mania' with or without depression and BPAD 2 comprises 'hypomania' with severe depression. 'Cyclothymia' describes hypomania with a relatively mild depression. 'Rapid Cycling' BPAD refer to states where mood changes occur over periods as short as days. Mixed BPAD means that the patient exhibits both mania and depression simultaneously. Other forms of drug-induced or disease-related mania exist, but we will focus primarily on BPAD1 and BPAD2.

What is mania?

Mania can be understood as an 'expansive mood, activity and ideas'. Patients may be irritable or euphoric. They may appear 'hyperactive', with rapid and hard-to-follow speech, hyper sexuality, reduced need for sleep and extravagant behaviour. They may have grand ideas, be overly optimistic and incongruently passionate in the face of adversity. Patients may not be aware they are acting inappropriately.

In rare cases, psychotic symptoms such as delusions of wealth, power, influence and religious significance may shape behaviour. Patients may be convinced that they are of special significance. Hypomania is a less severe form of the symptoms found in mania, where function is preserved and psychosis is absent. The main difference between BPAD1 and BPAD2 is that the symptoms in BPDA2 can permit day-to-day function. That is not to say that they are more tolerable to the patient.

During depressive episodes patients may experience a low mood, low energy, pervasive sadness, pessimism, social withdrawal and many other symptoms. Severe depression may include psychotic beliefs of guilt, pointlessness or fear, and can be an increased risk for suicide.

Distinguishing between the five forms is difficult. Often BPAD is diagnosed late. In these cases, the hypomania encountered in BPAD2 can be part of individual success stories, giving the person the energy and divergent thinking patterns to succeed in more creative circles such as film, music and comedy. It is only when depression sets in that people begin to notice problems.

Who does it affect?

BPAD affects young adults, and is equally prevalent between men and women regardless of socio-economic class. There is a public belief that 'creative types' are more likely to have BPAD. It is worth noting that, although increased creativity within manic states may explain the increased diagnosis in these groups, celebrity status is likely to attract more attention than the quietly manic man in his bedroom.

Many celebrities, such as Stephen Fry, have spoken openly about the 'good' and 'bad' of the disorder, but we must remember that these people represent a tiny proportion of the overall burden of disease. Although their engagement is honest and useful, we must remember their stories are often sensationalised by the news. We only see what the media shows, which is no way to frame a disease or decide on treatment.

Any opinions above are the author's alone. Guidance is based the best available evidence at the time of writing. Online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice. There are no conflicts of interest.
Ben is a young NHS doctor in the Southwest. His interests include neurology, health communication, and medical ethics. He is also an avid advocate of compassionate care and quality improvement, running a project in the Southwest around medical humanities. Please follow and support: Dr Janaway on Facebook Dr Janaway on Twitter


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