9.27 Manic Depressive Bipolar Disorder - Good Advices

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27. Manic Depression, Bipolar Disorder

Note this and the next chapter should be read together as part of my Mood Disorders section. 

Disorder (BPD); Update in progress 16 Septr 2021.  The descending column of headings in order as in text may be used to scroll down to or search & find.

Introduction to Mood Disorders
Bipolar Disorder (BPD) is 

BPD with Psychotic Mania, A Case Described
The symptoms of BPD

3 Types: BP 1, BP  II and Cyclothymia

Medication for BPD
Rapid Tryptophan Depletion (Treat mania)

Advice for Life 

 Introduction to Mood Disorders  Today in 2021, what psychiatry used to speak of as Depression is now diagnostically, Mood Disorders, with 2 major subcategories: Major Depressive Disorder (Previously Unipolar Depression) and Bipolar (Previously MDD or depression with mania, which is the worst part of MDD, with psychosis). In this chapter I write about the psychotic part, with mania, and in the next chapter I write about Major Depressive Disorder, or depression without mania.  From a practical (reader`s) standpoint they strikingly differentiate themselves by the presence  or absence of psychotic manic episodes.  As a generalization, Bipolar Depression is more genetic, more endogenous, more seriously allied with psychosis than the more common (10% lifetime world prevalence compared to 1% for Bipolar) Major Depressive Disorder.

Bipolar Disorder (BPD) is episodes of MANIC behavior, meaning acting in state of excited euphoria divorced from reality, followed by DEPRESSION, and, between psychotic episodes of mania, occurring as a DISORDER of the normal personality. Typically, BPD is cyclic with manic episode changing to depression, or more rarely opposite but it may be a single serious attack in life, the one manic episode in sea of depression. It may be due to overdose of anti-depression pill or to recreational (amphetamine) drug; or to event in life (unwanted promotion and new responsibility, winning lottery) that releases euphoria and then stresses one out.

BPD with Psychotic Mania, a Case Described: Imagine yourself a 28-year-old woman, slightly brilliant, with interests in creative writing, acting, and singing, but have not lit a fire with your talent so you teach high school. Always a mood-swing person, you recently heard yourself described by a friend as ‘cyclothymic’, which, he explains, is from the ancient Greeks’ believing the thymus, a gland in mid upper chest, to be the seat of emotion, and which describes a person who cycles through high-low emotional periods. Just last week, the high-school principal asked you to produce the yearly student show and you have been depressed for days by the responsibility. But this morning you awake with the sun's rays streaming in your window and a May breeze on your face. Your skin is tingling and breasts bursting with pleasure. Energy and happiness bubble within. Clock says six, an hour before anyone's up but you rush into your mother's room and shake her awake, finding yourself irritated when she fails to respond with enthusiasm. In the next hour you clean house, cook breakfast, shower and make yourself up as never before. And looking in mirror after donning sweater and shoving-in balled-up socks to improve figure, you say to self "I feel lovely!" It's Friday and you are supposed to present the high-school principal, Mr. Murgatroyd, a plan for the student show. You spray on puffs of French perfume – Circe – that you'd bought at New York City's Bloomingdale's, and you head for the meeting with Mr M, a married man in his 50's. You have no plan for the show but do have one for Mr. M. The interview ends with M topping U. You get rest of day off and Mr M says he will be pleased in your doing whatever you please as long as you please.

Outside everyone you pass is smiling and opportunities abound in your mind. You decide you had it with being a Preachy Teachy: you're too talented. Why not sing in a nightclub? But first you need to stop off at Tiffany's to buy jewelry and at Bergdorf Goodman's for the latest dress. No matter you've only 500 dollars in bank; you do have credit cards. Several hours later, after lunch with 2 martinis at expensive tea room with 50-dollar tip – you are out on street in newly acquired diamonds and pearls and a Paris fashion combination that set your credit card back $5,000, and you head for The New Copa Nightclub off 5^th Avenue.

You manage to sweet talk your way past a dour door guard, and here you are in the office of Mr. Feldman, the plump immigrant Israeli, age sixty-ish rich owner.

  “A job ya vant? My chantoozee?” He laughs and asks about experience and references and singing school. In answer you plump yourself down onto  his lap, place his right hand under your dress against your inner thigh, and let chemistry have do. Yeah, Chemistry! 

Fifteen minutes later, after intercourse, of course he’s willing to alter course and give you an audition. The club trio is tuning up and nobody's in the main lounge as you step out on stage and belt out the song “You do somepin’ t’me” ala famous American singer Bette Midler, accompanied by sexy wiggles.

Thirty minutes later, out on street again, with contract for a week's appearance, you are feeling irrepressibly good as you stride down 5^th Avenue. At 34^th St, you are attracted to Woolworth's Five-and-Ten-Cents Store. (It is 1996) Inside you stock up on low-cost goodies. Everyone seems to be approving of you and you know, just know, you are crème de la crème. At Tiffany's and Bergdorf Goodman's you paid by credit card – but those were expensive joints and not for the hoi-polloi. At Woolworth's everything ought to be free for one like me, you think. Besides, no one could catch me; I'm too smart. So you walk by, shoplifting as you please, and head out to the street and an alarm goes off. When two sales clerks come out to ask Hey! No pay?, your good humor turns violent and you fling the goods in their faces and kick them and start trying to scratch their eyes out but your fake fingernails prevent it. 

You are booked at police station charged with shoplifting and assault. When your mother arrives, you're already in deep depression and have to be hospitalized because you use the detention cell to urinate and defecate.

The symptoms of BPD are seen in the above description: an increased self-esteem, high-touch energy, high endorphin pleasure output, obtrusive sexuality, excess of nerve and talk ( A lecturing-talk jag to an audience of astounded friends or neighbors); plus social unconventionality and an emotional brittleness that deteriorates into anger when thwarted. The behavior is goal-directed. Distinctive feature is the sudden turning on and off. An elevated state is followed by deep depression. Also the behavior is episodic,  i.e., not one's usual behavior but brought on by particular events.

3 Gradations: BP 1, BP  II and Cyclothymia:  The BP-I is as above, what I call crazy. It shows no insight, it cycles sharply, like a switch-on in the brain. And the manic phase may last for days and is terrifically talky, aggressive and when thwarted, variously violent. It is the kind of person that – if met in manic phase – appears driven by some hideous genie but when in depressive phase is mute and suicidal. No treatment is successful and best is to grab the person, using several strong men and get her into hospital where she may be quieted by high-dose strong anti-psychotic injections and gotten out of her spin by brain electroshock treatment.

  The BP-II, is what we are most familiar with and to which the term hypomania, or lesser mania, could apply. It is often charming, creative and highly successful but may be ticked off into mania by bad encounter, poor choice of anti-depression drug, or recreational cocaine or amphetamine; and then may get into trouble. It can be helped by keeping away from stimulant drugs and by directive psychotherapy that starts a non-Freudian psychoanalysis.

  Lastly, cyclothymia is a high-touch energy personality with up/down mood swing but is creative and constructive and almost always is found “top a the heap.” It is not an illness but a personality type that may become a disorder and a risk for a character BPD episode under stimulus of drug, bad environment or organic disease. Such person is often wrongly diagnosed as BPD 1 or 2 because of occasional lapse and it is important she or he receive good support from someone the person respects, who says “Feeling good about yourself is good.”

What is called BPD, I, may at times be a catch bag of differently caused conditions that resemble each other in having depression with manic phase. Further, keep in mind what we are presented with in medical book and clinical description is the pathological wing of these groups, which does not include the successful “man that got away”, i.e., has not gotten into trouble with Society. Some persons classified as BPD don't have a disorder at all – they are high creative and high-touch energy rich gifted ones that should be trained better to keep them out of harm's way.

  BPD cases will assort naturally. The crazy type (BPD-I) is self evident by its great talking jag, often before an amazed audience. Such person is removed from advice by forcible hospitalization. Psychotherapy is worth a good try by friendly authority figure and calmed down under anti-psychotic medication. BPD-II and cyclothymia can benefit by the non-Freudian psychoanalysis of this Notebook's Chapter 33. 

  Medication for BPD should: 1) blunt the acute psychotic symptoms and get the patient ready for psychotherapy; and 2) best be Lithium carbonate the mainstay for long term maintenance. But it takes at least 7 days to start its manic-deleting effect during which the patient may be creating havoc. Therefore the best treatment of an acute flaming manic episode is in- hospital electro-convulsive course of treatment (ECT). In the absence of ECT`s availability, the anti-psychotic Haloperidol (Haldol) can stop a manic phase in its tracks. Meanwhile, the patient in a calmed-down state may be helped much by non-Freudian, cognitive psychotherapy. 
Rapid Tryptophan Depletion is a dietary technique whereby a person is placed on a specially prepared diet containing high concentrations of all the dietary amino acids except tryptophan, which it lacks totally. Since dietary tryptophan is the sole source for brain tryptophan and 5-HT this dietary manipulation rapidly reduces blood brain tryptophan and is being used with Haldol injections as a successful acute treatment for the mania of bipolar depressive disease. In persons without mania it has cased episodes of major depression. To discover more about it, readers are referred  to the article Clinical and Physiological Consequences  of Rapid Tryptophan Depletion  by Moore, P., et al in Neuropsychopharmacology. 2000 Dec.;23(6): 601-22.  Also see Sadock & Sadock`s Comprehensive Textbook of Psychiatry, X ed 2017, Chapter 1.17 Serotonin Release, Synthesis, and Storage Capacity, pages 302/3.

Advice for Life:  Person with BPD-II and Cyclothymia should have an “edge” against feeling too good and against too high self-esteem. It means using humility, a self put-down habit every time you sense you are getting carried away by an idea of your own personal excellence. (Say to self: “Now stop that, you idiot!”) A Bipolar person should work on having a self-deprecating sense of humor. Also purposely delay acting out your decision whenever you have impulse. Also a potential BPD should try very hard to consider the opposing opinions of other persons and should always internally oppose his own decisions. And BPD ought to have one friendly, older respected mentor she can go to or call upon when about to get into an adventure. In addition, to rescue, the mentor will prevent a punctured self-esteem deteriorating into serious depression by analyzing the behavior in light of the hyper personality interacting with bad environment.

End Of Chapter but not of Mood Disorders. To read next click 9.28 Depression - A Cure