Bipolar Disorder

Living at the Edge of Experience

By Ruth Werner
[Pathology Perspectives]

Bipolar disorder, sometimes called manic depression, is a common, severe, and progressive mood disorder. It appears in several subtypes, but the unifying factor is fluctuation between depression and mania: the two extreme ends of the arc of human moods, with minimal time spent between them in the “normal” zone. People with bipolar disorder live at the edges of human experience.
Bipolar disorder, sometimes called manic depression, is a common, severe, and progressive mood disorder. It appears in several subtypes, but the unifying factor is fluctuation between depression and mania: the two extreme ends of the arc of human moods, with minimal time spent between them in the “normal” zone. People with bipolar disorder live at the edges of human experience.
Bipolar disorder affects about 2.6 percent of the US adult population—about 2.3 million people. Of those, 83 percent have a severe form of the condition. Bipolar disorder can be diagnosed at almost any age, but it usually appears between late adolescence and early adulthood. About half of all patients are diagnosed by age 25, but symptoms often appear years before an accurate diagnosis is made.
Men and women are affected about equally by bipolar disorder, but this condition is often misdiagnosed in its early manifestations. Consequently, women are far more likely to be originally diagnosed with major depressive disorder (also called unipolar depression), while men are most likely to be initially diagnosed with schizophrenia.
Arc of the Experience
Imagine an arc that represents a range of moods, with balance and high function at the highest point. On the left-hand side of the arc, visualize severe depression. In this morass, pleasure does not exist. Never has, and never will. Voices whisper to you about your worthlessness. Others are plotting against you. You can’t sleep, but you can’t get out of bed. You can’t concentrate or remember anything. The only thing that absorbs you is the increasingly attractive thought of ending it all. Oblivion beckons.
Climbing out of the muck of severe depression we find moderate depression: less debilitating, but you’re still not able to function at your best.
At the highest part of the arc we find normal, balanced function. Color returns to the world. Normal hiccups of everyday life do not break your stride. Successes are celebrated, but they don’t lead you to take unhealthy risks. You are functioning at, or close to, your peak capacity. Most of us, thankfully, live the majority of our lives in this middle section of the mood range.
Now, slipping down toward the right side, we find hypomania: a state of elevated or irritable mood, often connected to a creative pursuit, or a strongly—even obsessively—driven activity. Your self-esteem is soaring. In this state, you begin to ignore things you don’t consider relevant, so you can focus on whatever catches your attention.
And, at the far right side of the arc, we find mania: the drive that pushes hypomania to pathological levels. High confidence in your work gives way to grandiose psychedelic fantasy. You are ecstatic, and furious at anyone who questions your actions. Failure is not an option; failure is simply impossible. You believe you can fly.
Types Of Bipolar Disorder
Bipolar disorder is often categorized by severity or by the frequency of mood swings. The majority of people diagnosed with this disorder experience bipolar type I.
Bipolar Type I
This condition is diagnosed when a person experiences a manic episode that lasts at least a week and involves hospitalization, or if the person experiences significant impairment in occupational or social function. Within the manic episode, the person exhibits signs of grandiosity, little need for sleep, racing thoughts, rapid speech, impulsiveness, irritability, and extreme pleasure in various activities, up to the point of self-injury and high-risk behaviors. The depressive phase involves an episode lasting at least two weeks, with five or more of the following symptoms: a severely depressed mood and total loss of pleasure or interest in activities; weight and sleep changes; and fatigue, poor concentration, lack of decisiveness, and preoccupation with suicide. Psychotic delusions and hallucinations can occur at both the manic and depressive phases of type I bipolar disorder.
Bipolar Type II
This is a milder form of the condition, involving swings from moderate depression to hypomania. Type II bipolar disorder does not involve symptoms of psychosis, and while it can feel extreme, it typically does not lead to major impairment of the ability to function in social or job-related settings.
Mixed Bipolar Disorder
This describes a condition with aspects of both mania and depression occurring simultaneously or in rapid succession. It can be highly disruptive to the individual’s ability to maintain jobs or relationships.
Bipolar NOS (“not otherwise specified”)
This designation is given to people whose symptoms are outside the normal range of function, but the duration of symptoms is too short or their onset is too new for an official diagnosis.
Cyclothymic disorder describes mood swings from hypomania to mild depression that persist for two years or more. Like bipolar type II, it severely impacts quality of life, but it is not completely debilitating.
Rapid-Cycling Bipolar Disorder
This is a severe form of bipolar disorder with a minimum of four episodes per year. It tends to have a younger onset than other types of bipolar disorder, and it is more common in women than it is in men.

It is difficult to overstate the impact of bipolar disorder on the quality of life of the patient and people close to the patient. Up to 80 percent of bipolar individuals report suicidal ideation; 25–50 percent eventually attempt or succeed.
Bipolar disorder is often seen alongside other problems. Substance abuse, including alcoholism, is an extremely common complication of this condition. Many bipolar patients also struggle with anxiety disorders, especially panic disorder, posttraumatic stress disorder, and social anxiety.

These illnesses are serious on their own, but they can also make standard bipolar treatment less effective.
Bipolar Treatment
One of the most challenging aspects of bipolar disorder is treating it in such a way that the patient is neither manic nor depressive, but spends the majority of his or her time in a range of normal functioning. Successfully treating only manic symptoms can throw a person into a deep depression. Treating only the depressive symptoms can throw a person into dangerous levels of mania. Treatment goals are therefore designed to reduce the severity and frequency of mood swings: to tamp down the mania, and to lift up the depression. A variety of pharmaceutical interventions may be used in this context.
Mood Stabilizers
These include varieties of lithium, including Eskalith and Lithobid. Valproic acid (Depakote) is another mood stabilizer. These drugs are effective at tamping down manic symptoms, but they usually don’t address depression.
Lamictal, Neurontin, Topamax, and other anticonvulsant drugs are sometimes used to limit manic symptoms.
Abilify, Risperdal, Seroquel, and Zyprexa are some of the drugs that are used to manage the hallucinations or delusions that can occur at the opposite extremes of bipolar disorder.
Severe depression is often the trigger that leads individuals to seek medical help. But taking only antidepressants can precipitate a manic episode, or rapid cycling symptoms. Consequently, antidepressants are typically only prescribed when antipsychotic and/or mood-stabilizing drugs are also being used. The most commonly prescribed antidepressants for bipolar disorder include Paxil, Prozac, Wellbutrin, and Zoloft.

The medications that treat bipolar disorder are not gentle, and they almost always have to be used in combinations. Some of these drugs can have dangerous interactions with other common medications, including hormone supplements and oral contraceptives. Consequently, many patients find themselves bouncing back and forth between the mood states that are connected to their own internal chemistry and those that are externally imposed by the medications they take. In addition, medications for bipolar disorder carry a host of unpleasant side effects, including irritability, weight gain, and a general sense of lethargy. Finally, lithium and its analogues can impair thyroid function. This can cause fluctuations between high energy and low energy states, much like bipolar disorder—so in this case the medication’s side effects may mimic or exacerbate the symptoms it is intended to subdue. It is not difficult to understand why many bipolar patients are resistant to taking their medication.
All that said, it is vital that a bipolar disorder patient does not suddenly change his or her drug regimen. This can lead to dangerous rebound effects, and a sudden and extreme exacerbation of symptoms.
Electroshock therapy is sometimes used to treat bipolar disorder, but it is usually reserved for cases when medications don’t work, or when a patient wishes to avoid drugs for other reasons, such as pregnancy.
Experts agree that, in addition to medication, psychotherapy and education of the patient and the patient’s loved ones are important parts of managing this challenging disorder. Knowing how this condition affects function, and having a predetermined plan for emergency situations, can help the patient and his or her supporters cope.
Where Does Massage Fit?
No studies examining the interactions between massage therapy and bipolar disorder have been published. Consequently, to determine whether massage is appropriate in this situation, we have to look at other considerations.
Persons with bipolar disorder are strongly advised to keep a reliable and consistent schedule, to maintain good social connections, to get quality sleep, and to eat well. In short, they are counseled to engage actively in their own self-care. Clearly, massage therapy can play a part in this self-care effort.
The accumulated evidence for massage in the context of major depressive disorder and anxiety disorders is fairly strong. Many bipolar patients initially seek medical attention because their depressive symptoms can be alarming. It seems reasonable, therefore, that massage therapy might be a strategy to pursue, at least during the depressive phase. Further, the self-awareness that massage therapy can promote may be helpful to bipolar patients. Many specialists suggest that mindfulness—the practice of increasing awareness of one’s mood and physical state—can help bipolar patients determine whether their mood shifts are within a healthy range or not.
It is important to point out massage does not have the power to “fix” bipolar disorder. People who have bipolar tendencies will probably find that massage alone is not capable of smoothing out their mood shifts. Massage is not a substitute for the careful combination of psychotherapy, medication, and education that a person with bipolar disorder needs to successfully manage this condition. In this situation, massage may be helpful, but it is not the answer.
It is possible that people with bipolar disorder could derive great benefits from massage, but we won’t really know this until someone writes it down. Do you have clients with this condition? For the sake of your profession, please consider writing a case report that tracks your client’s symptoms and goals. Then share the report with the rest of us—we are eager to learn from your experiences.

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