Bipolar Disorder: Signs and Symptoms
Guest: Dr. Linda Austin - Psychiatry
Host: Dr. Pam Morris - Cardiology
Dr. Pam Morris: Hi. I’m Dr. Pam Morris. I’m talking, today, with Dr. Linda Austin. We’re talking, today, about bipolar disorder. Dr. Austin, how do you recognize bipolar disorder from regular depression?
Dr. Linda Austin: Well, first, the depressive episodes in both disorders may be identical. In fact, you may have an individual who goes along in life having depression from time to time. And when that depression hits, that person will have low energy. They may feel numb or empty. They may have changes in their sleep, either decreased or increased, changes in their appetite, decreased or increased. Those episodes may last anywhere from a few days to a few weeks, or a few months, or sometimes even longer. The disorders are actually identical, whether it’s garden variety depression or bipolar disorder.
Dr. Pam Morris: Now, I would think it’s very easy to recognize, in some ways, the symptoms of depression. But I would think that the symptoms of bipolar disorder would be a little more subtle, or difficult to recognize.
Dr. Linda Austin: They can be. And what can be very tricky is sometimes they only last for a few days, sometimes only a few hours, in which case it’s really difficult to make the diagnosis. It’s important to make the diagnosis, for reasons we can talk about later. But what happens, basically, is that the person will have episodes of normal mood. Probably, at some point, they will tell you they’ve had some episodes of depression. But they will have a third kind of mood that is distinctly different, Pam. And in that third kind of mood, which we call either hypomanic or manic, they have extra energy.
We classically think of it as an elated or happy mood. Actually, it’s more common for it to be an irritable, agitated, pressured kind of mood so that the person may have a ton of energy. They may talk, talk, talk, and you can’t get a word in edgewise. They may be up all night and yet have plenty of energy the next day, or just sleep a few hours and still have energy. I’ve heard of people going two weeks without sleep. They may actually do very impulsive behaviors that are out of character, like suddenly spending too much money, or having sex with a stranger, or taking a trip in a very impulsive way. What’s important is that there’s a cluster of these behaviors that occur in the face of this hyper energized mood. So, in other words, somebody who spends too much money shopping once in awhile, that’s not necessarily bipolar.
Dr. Pam Morris: I’m very relieved to hear that.
Dr. Linda Austin: I have no doubt you are, Dr. Morris. Or, somebody who talks a lot every once in awhile, that’s not bipolar either. But, to underline, it’s a distinctly different mood in which you have periods of this hyper energy that manifests itself with verbal behaviors, not sleeping, pacing, motor behaviors, poor decisions.
Dr. Pam Morris: How would you recognize the difference between regular depression and bipolar disorder? How would you diagnose it, for example, if you’re seeing a patient at a stage where they’re in the depressed stage, how would you then know that this may actually be part of the bipolar disorder?
Dr. Linda Austin: Well, the only way you can really know is by history, by talking to the person. And, actually, if I have one quibble with non-psychiatrists treating depression, and of course that happens a lot, and that should happen a lot, often times the full history isn’t taken. It’s important to ask these questions: Have you ever had a period of time in which you’ve had heightened energy, talking a mile a minute, not sleeping at night? That’s one set of questions.
Family history is another way of getting at it. Oftentimes talking with a family member can be very useful because people may not recognize the hypomanic episodes in themselves. They may feel great. They may be, actually, very productive, or very happy, or having a blast. But they’re driving everybody else crazy. So that’s why family can be important to talk to.
Dr. Pam Morris: You did mention that the heightened irritability can be an important part of the hypomanic stage. Now, I’ve oftentimes heard that irritability can also be an important symptom of the depressive stage. So, again, that must be difficult sometimes to distinguish.
Dr. Linda Austin: The irritability in depression is often kind of a grouchy irritability, whereas the irritability in bipolar is a pressure, talking a mile a minute, for example. If you’ve ever been on a city street and you see some homeless person across the street, and they’re talking at the top of their lungs in a very pressured kind of way, probably, that person is in a manic episode. Now, that’s an extreme example of what I’m talking about. But there’s often a belligerence to it, or a pushiness to it that is different from kind of the crankiness or the grouchiness of depression.
Dr. Pam Morris: Does the treatment differ for the two disorders?
Dr. Linda Austin: Absolutely. And that’s why it’s so important to get the diagnosis right. And it’s really important to ask the questions. The issue, Pam, is that regular antidepressants given to a bipolar person may actually trigger a manic episode. And that’s where we often see problems. Somebody will go to their well meaning and generally competent OBGYN or family practice doctor, or ophthalmologist, or whatever, and say, you know, I’m depressed. Can I have some Prozac or Zoloft? And they get a prescription without realizing that they may have a manic depressive vulnerability, and then, bingo, the antidepressant itself triggers a manic episode, which can be very severe.
I mean it really can be disastrous to somebody’s life. If they become severely manic, they may walk down the street naked. I know of one case where a very well known person was giving a speech and he had to be pulled off the podium because he was having a manic episode that was triggered by an antidepressant. Or, a person may go out and spend a huge amount of money because they become very manic. So these can be severe episodes. That’s why it’s important to make the diagnosis correctly. We treat bipolar disorder with mood stabilizers, like lithium or Depakote; there are a number of them, and we treat regular depression with antidepressants, like Prozac, Zoloft, Cymbalta, those sorts of meds.
Dr. Pam Morris: Does that mean that the typical antidepressants are actually not used for the depressive component of the bipolar disorder?
Dr. Linda Austin: If they’re used, they’re used very carefully. If they are used, it’s in the setting that you first use the mood stabilizer, for example, the lithium or the Abilify. And, then, if you still have some depression left over and you can’t rid of it using a mood stabilizer, you may very slowly and carefully add an antidepressant. But you always use the mood stabilizer first.
Dr. Pam Morris: One final question: In going to my physician, let’s say I tell my physician I’ve been having some episodes of sadness or unexplained tearfulness, or some irritability, or grouchiness, my physician wants to start me on an antidepressant. Should I be reluctant to begin the therapy without seeing a psychiatrist?
Dr. Linda Austin: You know, as a psychiatrist, obviously, I’m biased towards psychiatrists. The reality is there are many parts of the country where there just are not enough psychiatrists, so I think it’s fine for non-psychiatrists to treat depression. But, I think that both the physician, let’s say, the family practice doctor, or the OBGYN, and the patient really need to talk about whether there is any vulnerability to bipolar disorder. Here’s an example. Early in my career, I treated a young woman who had a very strong history of bipolar disorder. She had several brothers and sisters who had been manic. She had never been manic, but she was very depressed.
I was in a quandary. Do I assume that this is bipolar disorder, I mean, never having seen a manic episode. What do I do? So I said to her, “Okay. We are going to start the antidepressant very slowly; teeny, tiny, little itty bitty dose. Here’s my home telephone number. Call me if you have any of the symptoms of mania that you have seen over and over again in your brothers and sisters.” She said, “Fine.” She went three days on a very low dose, bingo, she had a manic episode. She ended up, this was in a big city, in the red light district, doing some behaviors that were incredibly out of character for her, and then, from there, went straight to the psychiatric unit. You know, clearly, it was a tough call and, clearly, we made the wrong decision. But it’s just an example of the kind of trouble you can get into if you don’t get a really careful history and work very closely with the patient around this problem.
Dr. Pam Morris: Well, as a cardiologist, I’ve found this discussion very helpful. I see quite a bit of depression. And, as we know, depression is closely linked with cardiovascular disease. And it really gives me some important information in chatting with patients in the future, so thank you for coming today.
Dr. Linda Austin: Thank you, Pam.
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