As a psychiatry intern at a Mumbai hospital, I evaluated a middle-aged man who wore a red hat, Hawaiian print shirt and gold chains. Armed with enthusiasm, curiosity and a little theoretical knowledge of the subject, I sat down for what was to become one of the most interesting interviews of my training.
He greeted me cheerfully and talked about his appointment with the Prime Minister, his successful business ventures and the half-done film he was directing. He said he had a scheme to discuss with the PM that would end poverty and corruption in our country . He said he had been granted special powers by the universe for this mission. He also said that he did not need much sleep, was feeling very energetic and had many ideas to improve the world.
On speaking with his wife, I found following a setback in business, he had become irritable and then euphoric. He hardly slept but continued feeling very energetic, took up new projects, but did not complete them. He became more irritable, angry and even abusive , as 'people did not believe him' and started neglecting his family, work and health; this was interspersed with periods of euphoria and a sense of extreme well-being . This is when he was brought to the hospital.
Even to my relatively untrained mind, it was not very difficult to make a diagnosis: bipolar mood disorder (previously known as 'manic depression' ), in which a person goes through cyclical periods of feeling euphoric, energetic, grandiose, expansive or irritable (read manic episode) with periods of sadness of mood, low energy, lack of enthusiasm and low self-esteem (read depressive episode). It is like being on a thrilling high and then in a state of extreme gloom.
Bipolar disorder is characterised by a distinct period of abnormal mood, which could be either euphoric, expansive or irritable, accompanied by symptoms such as easy distractibility , inflated self-esteem , grandiose ideas, excessive talkativeness, racing thoughts, need for less sleep than usual and increase in goal-directed activity. For example , taking on too many projects at the same time; poor judgement leading to reckless behavior, such as spending sprees, reckless driving or promiscuity and denial that anything is wrong. When this lasts for at least a week and affects the person's day to day functioning, it is called a manic episode.
What causes bipolar disorder ? Why is it that some individuals suffer these extreme ups and downs during their lives? We are far from having all the answers.
Research suggests that bipolar disorder can be inherited . Excessively high or low levels of neurotransmitters (chemicals produced by brain cells or neurons) such as serotonin , norepinephrine and dopamine , an imbalance in neurotransmitter levels, or a change in the sensitivity of receptors on the nerve cells can cause bipolar disorder.
Acommon misconception is that stress or environmental factors cause the illness. Stressful life events (such as a death in the family, loss of a job, relationship difficulties , child birth, etc.) can certainly trigger the onset of bipolar disorder. But once the illness begins, it is the underlying biological and psychological processes which keep it active and are the cause of the illness.
My first patient with bipolar disorder responded well to medication and counselling sessions. Over time, he developed awareness regarding his illness (often absent during the 'high' phase). He visited the clinic every fortnight with afamily member for follow-up sessions and did progressively better over the following year. He later resumed running his business, which continued to be fairly successful . A fascinating aspect about bipolar disorder is its association with creativity.
Research has shown that individuals with bipolar are as likely to be creative and function exceptionally well, as they are likely to be dysfunctional . News channel CNN founder Ted Turner, psychologist Kay Jamison and actress Catherine Zeta Jones have talked openly about being bipolar. Picasso's 'pink' and 'blue' periods are well known. While one should refrain from romanticizing an illness that involves immense suffering, it is evident that some individuals with bipolar disorder can lead extraordinarily productive and creative (if trying) lives.
If you are reading this and wondering if you have bipolar disorder, please note that (thankfully) not everyone who is energetic, creative and takes up many projects is bipolar ! Bipolar disorder spans a wide range of symptoms and needs a thorough assessment for a diagnosis.
I find it heartening to see family members often bring printed information on the subject with a set of questions to be answered. Research on mood disorders across various cultures shows that a supportive family environment significantly improves the outcome in bipolar disorder.
(Dr Shamsah B Sonawalla is a consultant psychiatrist and a former faculty of Harvard Medical School, US)