A Primer on Depression and Bipolar Disorder

II. Mood Disorders As Physical Illness

B.  Bipolar Signs and Symptoms

In medical parlance a "symptom" is a description of how the illness feels to the person experiencing it ("the view from the inside''), and a "sign'' is a result of the illness that a physician can see or measure ("the view from the outside''). Both are important in discussions of mental illness because the person with a mental illness often has a seriously impaired ability to notice and assess the significance of the symptoms he/she experiences.

Good descriptions of the signs and symptoms of mood disorders can be found in the books listed in the Bibliography at the end of this essay. I will quote briefly from the book Moodswing, using the mood scale given on p. 203. On this scale one assigns an index of 45 - 55 to ``normal moods''. Depression ranges downward to 0, and mania ranges upward to 100. Consider depression first:

• At 40 the victim's mood is mildly depressed. He/she feels "bad'', lacks energy and motivation, feels slowed down, lacks optimism, gets little pleasure, and has decreased sex drive.
• At 30 the victim is moderately depressed. Has severe loss of energy, takes little or no interest in events or other people. Has difficulty leaving bed, but can function with considerable effort. Typically doesn't want to go to work, but can force him/herself to do so. Feels life is not worthwhile. Little sexual interest.
• At 20 the victim has severe depression. Can take care of daily routine, but only with constant prodding and reminding. Very withdrawn. Shows significant gain or loss of weight. Has a serious sleep disorder. Volunteers suicidal feelings. May be unreasonably suspicious.
• At 10 the victim has extreme depression. Actively suicidal. Typically totally withdrawn, but may also be extremely agitated. Has difficulty rating self on the mood scale.
• Level 0 is a medical emergency. Victim is suicidal. Stuporous, stares into space, gives little or no response to questioning, delusional. Unable to take medication or eat; may require tube feeding. Requires immediate hospitalization.

The descriptions given are comprehensive in the sense that one or more of the symptoms will be experienced by most depressed people, but typically not all of them will be experienced by any one person. From 30 on downward the victim absolutely needs treatment by a psychiatrist or a physician familiar with mental illness. Before 1985, my worst depressions were about 35 on this scale. At the bottom of my 1985/86 crash I got down to about 10 or 15. There is a huge difference in how one feels at 35 and at 10 or 15. Depressed people are often extremely dependent. In some cases, they become quite narcissistic; that is, they focus only on their own needs, and can be quite demanding that they get met. If one has been in a depressive state for a long time, then moving beyond this tendency towards narcissism becomes a major goal in the healing process after the basic chemical imbalance in the brain is corrected.

Now consider mania. Mania often goes unrecognized by its victims, who generally "feel good", indeed often very good, and therefore may not accept that they have an illness. They will often attribute its symptoms to other causes, and deny that they have a problem.

• At 60 the victim experiences a mildly elevated mood, feels wonderful, has an increased sexual drive, wants to spend money and travel. Is hyperperceptive, mentally agile, verbally fluent. Has a flood of creative ideas for new projects. May be mildly obtrusive. At this level, treatment may not be necessary or desirable unless the negative aspects are troublesome to the victim or his/her companions.
• At 70, one feels moderate mania. Excessive talkativeness and noticeable overactivity and restlessness. Victim is socially inappropriate, and typically wants to control people and events around him/her. Often irritable and annoyed. Needs only 4 - 6 hours of sleep, sometimes skips a night's sleep altogether. Treatment is needed.
• At 80, severe mania. Victim is sleeping very little, acts out of control, can be hostile when crossed. Treatment is needed, but will be resisted. Should be hospitalized, but when in hospital wants to sign out of the ward.
• At 90, extreme mania. Victim is out of control, can't rate self on mood disorder scale, totally uncooperative. Urgently needs medication and controlled environment.
• At 100, medical emergency. Victim is wildly overactive, may be psychotic ("crazy"). Can't stop talking, incoherent, belligerent. Not sleeping at all. May be hallucinating and delusional. May be paranoid (inappropriately suspicious) or violent. Hospitalization is mandatory.

One aspect of mania is that the victim can be extremely egocentric, again to the point of narcissism, but unlike a depressed person, may actively, indeed even violently, seek control. It is then that they are likely to create severe problems for those around them, and even become dangerous. Giving up this need for control is one of the major problems faced, by people who have been manic, in their process of psychic healing, after their medical condition has successfully been dealt with.

It is an astonishing fact that the totally opposite feelings of mania and depression result from the same underlying biochemical disorder in the brain. Yet the clinical evidence is compelling, because it is found that the same medication, lithium, that controls mania will sometimes control depression in people suffering from bipolar affective disorder. It is also interesting that mania, at least hypomania or very moderate mania, is likely to be untreated because the victim seemingly feels good. Indeed, most mildly manic people will strongly resist treatment; the problems they encounter from bad judgment or financial indiscretions (expenditures far beyond the victim's total assets) seem to be outweighed by the pleasant experience of elevated energy, feelings of well being, enhanced mental capacity, and feelings of omnipotence or of being God. Whereas a severely depressed person is typically passive, quiet, and relatively undemanding, a manic person can be a constant source of disturbance, and a severely manic person can even be physically dangerous. Before 1996, I never got above 70 on the above scale. But in 1996-1997 I was up to 90; I urgently belonged in a hospital!

Whereas almost everyone has at least a notion of what depression is, fewer people are familiar with mania. Whether by design or by coincidence, a very good description of what bipolar disorder feels like from the inside is given in the remarkable book Zen and the Art of Motorcycle Maintenance by Robert Pirsig. This bestseller accurately describes both extreme depression, and moderate mania. Anyone who has experienced mania will recognize the obsessive thought patterns of the character Phaedrus ("the wolf"), and in the fluent mental discourses of the narrator in his "Chautauquas".

Someone suffering from bipolar affective disorder swings back and forth between mania and depression, sometimes with intervening periods of normality, sometimes not. In some cases people experience fairly regular swings up and down; in others they seem to be random. Likewise the intervals between swings, and the amplitudes of the swings may be very irregular, may or show a recognizable pattern. There are no general rules of thumb that one can rely upon. However, in the case of unipolar depression it seems that as the victim's age increases, the time interval between successive episodes of depression tends to decrease, each episode tends to lengthen, and the depth of the depression increases. This is not a pretty picture for it implies that without treatment there is a chance of slipping into a more or less permanent state of depression later in life.

Indeed, this is what happened to my father. We had no knowledge about clinical depression and its treatment at the time, but in retrospect it is clear that he became chronically depressed at about age 50, and for the remaining 20 years of his life slowly sunk deeper and deeper into the morass of serious depression. At the time, relatively little was known about treating depression, so it is uncertain how much he might have improved with the treatment available then. As it was, during the last 20 years of his life he was miserable. I strongly suspect that if he could have had access to present-day treatment his misery could have been avoided. The ultimate danger to severely depressed people is that there comes a day when they can't bear the "pain" any more, and they commit suicide. We will discuss suicide more fully later on.

next: Treatment of Depression and Bipolar Disorder