Manic depressive disorder (bipolar disorder)

  Modern psychiatry owes its intellectual framework to Kraepelin’s distinction between schizophrenia and manic depressive illness. This is now renamed bipolar disorder, the term used from here on. During Kraepelin’s time mental hospitals took whoever was sent to them; some got better but most didn’t. There was not that much attention to diagnosis other than perhaps distinguishing the learning disabled from the psychotic. Kraepelin noted that one group of patients alternated through several periods of profound disturbances – sometimes agitated and sometimes withdrawn and depressed. What distinguished them most from the schizophrenia patients (which he called ‘dementia praecox’) was that they made full recoveries between episodes and more of them eventually left hospital. It was the course of the illness rather than its symptoms that impressed him (see Chapter 2).

  Bipolar patients can have all the same symptoms as in schizophrenia (hallucinations, delusions, thought disorder, etc.) although these occur only in the most severe forms of mania and depression. However these symptoms are accompanied by a profound disturbance of mood – either depression or elation. It is this elation that is called mania (or often hypomania). The change in mood overshadows all else in this condition. In the depressed phase the patient suffers from severe depression and may be suicidal. In the elated phase the patient is overactive and bursting with confidence and energy. Hypomanic patients can be very destructive to themselves – spending money they haven’t got and behaving in an uninhibited manner (drinking too much, being sexually overactive without thought for the consequences, driving too fast, etc.). The psychotic symptoms, where they occur, reflect the mood. If the patient is depressed hallucinations will be critical and persecuting, if elated the hallucinations praise and encourage. Depressive delusions are usually of guilt and worthlessness and hypomanic delusions are expansive and grandiose: ‘I’m going to be asked to advise the president about foreign policy’, ‘My paintings are worth millions’.

  In less extreme forms of hypomania patients can be very entertaining, often talking fast (‘pressure of speech’), punning and making humorous associations between ideas (‘flight of ideas’). Many famous entertainers and artists have suffered from bipolar disorder and acknowledge that they get their inspiration when they are ‘high’. It can be difficult to be certain about diagnosis in some of the milder forms of hypomania because it usually lacks the ‘strangeness’ of the schizophrenic episode. The main disturbance is one of judgement – we would all like to spend more money or hope that our paintings are worth more than they are. Often the diagnosis needs friends and family members to be able to confirm that this is not how the person usually is. A rather flamboyant, flirty TV executive was brought to the clinic by her worried mother. The story was not, in itself, that remarkable – some rather torrid love affairs with work colleagues, recreational drug use in night clubs, and some incidences of rudeness to her boss and absences from work. There are lots of media people who conduct their lives like this. What was decisive was her mother’s description of how normally she was an over-conscientious, rather anxious woman and that this was completely out of character. The mother was alert to the issue because her late husband had also suffered such episodes.

  Like schizophrenia, bipolar disorder also affects just under 1 per cent of the population, it runs in families, it starts in early adult life (though usually later than schizophrenia) and males and females are affected about equally. Although the elated phases are more dramatic depression is more frequent and persistent. The depressive phase of bipolar disorder is not easily distinguishable from the much more common disorder of clinical depression.