October Issue 2015
Between Two Extremes
The flashbacks in Aliya’s mind continued non-stop. Her life flitted past; their first meeting, when both were eager, young, first year university students. They made a great pair. Each one had their mood swings, especially Tariq, but then, who doesn’t? Degrees in hand, they decided to get married before pursuing further studies. The wedding was wonderful, the new couple happily welcomed by the family.
A few years later, the problems began. Tariq hadn’t told Aliya when they married that he had been diagnosed as having bipolar affective disorder — she only learnt about it later into their marriage when she saw his medication. For a while, Tariq was regular about treatment and, overall, maintained an even temperament. Believing that he had been cured, however, he stopped going to the doctor and began to be neglectful of his medical regimen. Around this time, Aliya noticed that his moods were swinging out of control. On top of the world one day, he would be low and depressed the other. Often, in a hyped up state, he would be impatient and lose his temper with her. For the sake of the marriage, she tried to tolerate the ups and downs and persuade him to get medical help, but Tariq refused to believe there was anything wrong and turned on her instead.
Once Tariq insisted that Aliya leave the house along with their children — later, he was tearful and begged them to return. Aliya couldn’t cope with this see-saw existence. In addition to being the sole breadwinner, she was the one holding the marriage together. Then, one night, Tariq kicked Aliya out of the house again. Unable to reason with him, this time she left with no hope of saving their marriage.Tariq’s is a typical case of bipolar affective disorder, which is characterised by periods of elevated mood (mania or hypomania) alternating with depression. The mood may swing to extreme irritability, fast talking, jumping from one idea to another, racing thoughts, or being easily distracted. At times, there is enthusiasm for taking on new projects, accompanied by restlessness, overly high energy levels, often resulting in sleeplessness. At that stage, an individual with bipolar affective disorder may feel invincible, able to accomplish almost anything. At times, the individual may indulge in highly risky, impulsive behaviour, like substance abuse, just because it feels pleasurable. Periods of depression may be accompanied by crying and a negative outlook on life.
The risk of suicide among those with the disorder is high: more than 6 per cent die through suicide in the two decades after diagnosis. Often, it becomes impossible for the affected person to carry out day-to-day tasks. The changes in mood can be very different from the normal ups and downs that most people experience. This is the challenge of identifying and diagnosing someone who suffers from bipolar affective disorder.
According to the Diagnostic and Statistical Manual of Mental Disorders, (DSM), bipolar affective disorder I is defined by severe manic symptoms or by manic or mixed episodes lasting at least a week. There are depressive episodes as well, often lasting two weeks or more. In bipolar affective disorder II, on the other hand, there are no full-blown manic or mixed episodes, although there is a pattern of depressive and hypomanic episodes.
Despite extensive research, the causes of bipolar disorder are not yet clearly understood, but both genetic and environmental factors are believed to be involved. In a study conducted at the Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, it was found that children of parents with bipolar affective disorder had an increased risk of having a bipolar spectrum disorder (10.6 per cent vs. 0.8 per cent) and having any mood or anxiety disorder.
However, children with a family history of bipolar affective disorder are not bound to develop it, and in most cases will not manifest the disorder. Even in the case of identical twins who share the same genes, one twin may have the disorder while the other is free of it.
For a parent who may be bipolar, doctors advise that it is important to watch out for intense mood and behavioural swings in their children, and seek immediate treatment should that happen. Such a situation makes it critical for parents to provide the best possible environment for their children.
Bipolar affective disorder is one of the most heritable disorders. If a child has one parent with bipolar affective disorder, he/she is 9 times as likely to also be bipolar, compared to a child whose parents are not bipolar.
However, studies have shown that despite the genetic predisposition, the rate of bipolar affective disorder in children with one bipolar parent is 10 per cent. If both parents are bipolar, there is a 40 per cent chance of the child developing the disorder. While hereditary factors do play a part, if most people on both sides of the family are mentally healthy, then there is relatively little chance of a child developing the disorder.
Globally, bipolar affective disorder is estimated to occur in one to three per cent of the population — one per cent may be indicative of paucity of data in some countries, and rates of this illness appear to be similar in men and women. The most common age at which the symptoms begin to show is 25 years, though earlier episodes of bipolar affective disorder can also occur, and the disorder may also manifest later in life.
The economic cost of the disorder is substantial. According to a report by the British Journal of Psychiatry in 2002, bipolar affective disorder cost the National Health Service in England 199 million pounds a year. Moreover, the disorder’s indirect cost to society stood at 1,770 million pounds a year. A large proportion of this was related to a higher number of missed work days, estimated at 50 per year.
Bipolar affective disorder is treated by providing relief for its clinical symptoms. For adults suffering from bipolar affective disorder, treatment commonly includes mood stabilisers or antipsychotics and medication may be combined with psychotherapy. In periods of mania, doctors recommend that antidepressants be stopped, or be used with mood stabilisers, but only after careful consideration. At times, hospital treatment may become essential, even though the patient may refuse it. This step is critically important, however, because the patient may be at risk to himself/herself, and to others. Electroconvulsive therapy may be helpful for those who do not respond to other treatments. Medical supervision is necessary at all times.
Most people have social, financial, or work-related problems due to the disorder. Side effects of medication may cause or exacerbate other health problems.
But it is important to remember that bipolar affective disorder can be treated, and people with this illness can lead full and productive lives. It is equally important to remember, as stated in the respected medical journal The Lancet, that bipolar affective disorder is not only about the extremes of emotion — it’s also about the individual who exists at and in between those extremes. Such individuals can be talented, creative, often artistic. Two famous examples are renowned artist Vincent van Gogh, and equally renowned writer Virginia Woolf.
Technological advances are aiding genetic research on bipolar affective disorder, enabling better predictability. One example is the Bipolar Disorder Phenome Database, with which scientists will be able to link visible signs of the disorder with the genes that may influence them. Researchers are also excited about the outcome of stem cell research, because there is hope that in the near future skin cells will help detect the possibility of bipolar affective disorder.
There are studies in progress focusing on genetic factors in diseases with similar symptoms such as depression and schizophrenia that may also provide clues about risk factors in the development of bipolar affective disorder.
Imaging studies of the brain reveal characteristic differences in the brains of people with bipolar affective disorder. One study found that the pattern of brain development of children with bipolar affective disorder was similar to that of children with “multi-dimensional impairment,” a disorder that causes symptoms somewhat similar to bipolar affective disorder and schizophrenia. There may be, therefore, a common pattern of brain development linked to unstable moods.
An MRI study also found that the brain’s prefrontal cortex — a region of the brain involved in problem solving and decision making — is often smaller in adults with bipolar affective disorder and does not function as well. The prefrontal cortex matures during adolescence and that could be the reason why the disorder is often detected in the teenage years. These findings could enable early detection and intervention.
Learning more about the connections between brain regions, and gathering information from genetic studies will help scientists better understand bipolar affective disorder. This in turn will help to fine tune treatment options.
Bipolar affective disorder is a deeply troubling, emotionally scarring illness, particularly when it affects a beloved family member, or when a loving married couple is torn apart by the trauma of living with bipolar illness. The best answer is to consistently provide a wealth of understanding and sympathy, love and support — that can make all the difference in treatment and recovery.
Family members can help by learning about the illness, offering hope and encouragement, keeping track of symptoms, and being a partner in treatment. However, many caregivers may feel that this is easier said than done, because caring for a person with bipolar affective disorder can take an incredibly high toll on the caregiver’s own physical and emotional health. Young children, in particular, are vulnerable to thinking they somehow caused their parent to become ill. Striking a balance between supporting the loved one and taking care of oneself is difficult, but critically important.
When bipolar affective disorder is not properly controlled with medical treatment, the family may experience emotional distress such as guilt and worry and face financial stress as a result of reduced income. The good news is that most people with bipolar affective disorder can stabilise their moods with proper treatment, medication, and support. And when they are stable, most bipolar individuals can function and contribute to society the same as anyone else. It is important to understand that people with bipolar affective disorder cannot control their moods. But accepting bipolar affective disorder involves acknowledging that things may never again be totally ‘normal.’ Expecting too much of them is a recipe for failure. On the other hand, expecting too little can also hinder recovery, so it is important to strike a balance between encouraging independence and providing support.
References: Nature (volume 325, Feb-Mar 1987, pp. 783-787); The Lancet (volume 311, May 2012, pp. 11-17); Journal of the American Medical Association (Global Incidence: Cross sectional Epidemiology of Major Depression & Bipolar Disorder: MM Weisman et al.); Psychiatric Services (volume 55, issue 9, pp. 1029-1035); The British Medical Journal, December 2012, pp.345; http://psychcentral.com/news/2009/03/03/children-at-risk-if-parents-bipolar/4497.html.
Interview: Dr Tania Nadeem, Child and adolescent psychiatrist, Agha Khan Hospital
Can you describe the behaviour patterns that help to identify a case of bipolar affective disorder?
In bipolar affective disorder, there are fluctuations in mood, ranging from depression to mania. When in depression, people feel sad, tired, tearful, hopeless with a loss of interest in life, and at times suicidal. During a manic episode, individuals are full of energy and extremely active with too many thoughts [racing through] their head, and are therefore unable to focus on one thing.
How common is bipolar affective disorder among the general population in Pakistan or among the patients who check in for treatment at your hospital?
I am not aware of any research on the incidence of bipolar affective disorder in Pakistan. In the US, however, it has a prevalence of two to three per cent in adults. I’d say 20-30 per cent of the people I see at my clinic in Karachi have bipolar affective disorder.
In your experience, how agreeable are patients in Pakistan to medical treatment for bipolar affective disorder?
All psychiatric disorders have a stigma associated with them and this prevents people from seeking help. I’ve seen people suffering from depression for years without seeking help. They mostly do so when the symptoms have become so great that families find it very difficult to cope. However, manic patients are usually so troublesome that families bring them in, despite the stigma.
How long does treatment last on the average?
Bipolar affective disorder is a lifelong illness, just like diabetes or hypertension. Medication can be used to control it, but it does not cure the disorder.
Is there awareness in Pakistan about this disorder?
There is limited awareness of all psychiatric disorders in Pakistan. The notion that a psychiatric disease is just like any other medical disease is very difficult for people here to swallow.
One cause of bipolar affective disorder is stress. Given the insecure environment in Pakistan — both literally and financially — has the incidence of bipolar affective disorder increased significantly in recent years?
Most psychiatric disorders have a major biological component to them. However, stress can definitely exacerbate a disease or cause the first breakdown for those who are biologically predisposed.
Is medication and psychotherapy for bipolar affective disorder easily available to the common man in Pakistan?
Medication is available for those who can afford it. However, at the present time, there is a very limited number of therapists in Karachi.
This article was originally published in Newsline’s October 2015 issue.