Bipolar and mood swings

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Bipolar Disorder Signs and Symptoms

Is it bipolar disorder? Here’s how to recognize the signs and symptoms and get help for mania, hypomania, and bipolar depression.

We all have our ups and downs, but with bipolar disorder (once known as manic depression or manic-depressive disorder) these peaks and valleys are more severe. Bipolar disorder causes serious shifts in mood, energy, thinking, and behavior—from the highs of mania on one extreme, to the lows of depression on the other. More than just a fleeting good or bad mood, the cycles of bipolar disorder last for days, weeks, or months. And unlike ordinary mood swings, the mood changes of bipolar disorder are so intense that they can interfere with your job or school performance, damage your relationships, and disrupt your ability to function in daily life.

During a manic episode, you might impulsively quit your job, charge up huge amounts on credit cards, or feel rested after sleeping two hours. During a depressive episode, you might be too tired to get out of bed, and full of self-loathing and hopelessness over being unemployed and in debt.

The causes of bipolar disorder aren’t completely understood, but it often appears to be hereditary. The first manic or depressive episode of bipolar disorder usually occurs in the teenage years or early adulthood. The symptoms can be subtle and confusing; many people with bipolar disorder are overlooked or misdiagnosed—resulting in unnecessary suffering. Since bipolar disorder tends to worsen without treatment, it’s important to learn what the symptoms look like. Recognizing the problem is the first step to feeling better and getting your life back on track.

Myths and facts about bipolar disorder

Myth: People with bipolar disorder can’t get better or lead a normal life.
Fact: Many people with bipolar disorder have successful careers, happy family lives, and satisfying relationships. Living with bipolar disorder is challenging, but with treatment, healthy coping skills, and a solid support system, you can live fully while managing your symptoms.

Myth: People with bipolar disorder swing back and forth between mania and depression.
Fact: Some people alternate between extreme episodes of mania and depression, but most are depressed more often than they are manic. Mania may also be so mild that it goes unrecognized. People with bipolar disorder can also go for long stretches without symptoms.

Myth: Bipolar disorder only affects mood.

Fact: Bipolar disorder also affects your energy level, judgment, memory, concentration, appetite, sleep patterns, sex drive, and self-esteem. Additionally, bipolar disorder has been linked to anxiety, substance abuse, and health problems such as diabetes, heart disease, migraines, and high blood pressure.

Myth: Aside from taking medication, there is nothing you can do to control bipolar disorder.

Fact: While medication is the foundation of bipolar disorder treatment, therapy and self-help strategies also play important roles. You can help control your symptoms by exercising regularly, getting enough sleep, eating right, monitoring your moods, keeping stress to a minimum, and surrounding yourself with supportive people.

Signs and symptoms of bipolar disorder

Bipolar disorder can look very different in different people. The symptoms vary widely in their pattern, severity, and frequency. Some people are more prone to either mania or depression, while others alternate equally between the two types of episodes. Some have frequent mood disruptions, while others experience only a few over a lifetime.
There are four types of mood episodes in bipolar disorder: mania, hypomania, depression, and mixed episodes. Each type of bipolar disorder mood episode has a unique set of symptoms.

Mania symptoms

In the manic phase of bipolar disorder, it’s common to experience feelings of heightened energy, creativity, and euphoria. If you’re experiencing a manic episode, you may talk a mile a minute, sleep very little, and be hyperactive. You may also feel like you’re all-powerful, invincible, or destined for greatness.

But while mania feels good at first, it has a tendency to spiral out of control. You may behave recklessly during a manic episode: gambling away your savings, engaging in inappropriate sexual activity, or making foolish business investments, for example. You may also become angry, irritable, and aggressive—picking fights, lashing out when others don’t go along with your plans, and blaming anyone who criticizes your behavior. Some people even become delusional or start hearing voices.

Common signs and symptoms of mania include:

  • Feeling unusually “high” and optimistic OR extremely irritable
  • Unrealistic, grandiose beliefs about one’s abilities or powers
  • Sleeping very little, but feeling extremely energetic
  • Talking so rapidly that others can’t keep up
  • Racing thoughts; jumping quickly from one idea to the next
  • Highly distractible, unable to concentrate
  • Impaired judgment and impulsiveness
  • Acting recklessly without thinking about the consequences
  • Delusions and hallucinations (in severe cases)

Hypomania symptoms

Hypomania is a less severe form of mania. In a hypomanic state, you’ll likely feel euphoric, energetic, and productive, but will still be able to carry on with your day-to-day life without losing touch with reality. To others, it may seem as if you’re merely in an unusually good mood. However, hypomania can result in bad decisions that harm your relationships, career, and reputation. In addition, hypomania often escalates to full-blown mania or is followed by a major depressive episode.

Symptoms of bipolar depression

In the past, bipolar depression was lumped in with regular depression, but a growing body of research suggests that there are significant differences between the two, especially when it comes to recommended treatments. Most people with bipolar depression are not helped by antidepressants. In fact, there is a risk that antidepressants can make bipolar disorder worse—triggering mania or hypomania, causing rapid cycling between mood states, or interfering with other mood stabilizing drugs.

Despite many similarities, certain symptoms are more common in bipolar depression than in regular depression. For example, bipolar depression is more likely to involve irritability, guilt, unpredictable mood swings, and feelings of restlessness. With bipolar depression, you may move and speak slowly, sleep a lot, and gain weight. In addition, you’re more likely to develop psychotic depression—a condition in which you lose contact with reality—and to experience major problems in work and social functioning.

Common symptoms of bipolar depression include:

  • Feeling hopeless, sad, or empty
  • Irritability
  • Inability to experience pleasure
  • Fatigue or loss of energy
  • Physical and mental sluggishness
  • Appetite or weight changes
  • Sleep problems
  • Concentration and memory problems
  • Feelings of worthlessness or guilt
  • Thoughts of death or suicide

Symptoms of a mixed episode

A mixed episode of bipolar disorder features symptoms of both mania or hypomania and depression. Common signs of a mixed episode include depression combined with agitation, irritability, anxiety, insomnia, distractibility, and racing thoughts. This combination of high energy and low mood makes for a particularly high risk of suicide.

What is rapid cycling?

Some people with bipolar disorder develop “rapid cycling” where they experience four or more episodes of mania or depression within a 12-month period. Mood swings can occur very quickly, like a rollercoaster randomly moving from high to low and back again over a period of days or even hours. Rapid cycling can leave you feeling dangerously out of control and most commonly occurs if your bipolar disorder symptoms are not being adequately treated.

The different faces of bipolar disorder

Bipolar I Disorder (mania or a mixed episode) – This is the classic manic-depressive form of the illness, characterized by at least one manic episode or mixed episode. Usually—but not always—Bipolar I Disorder also involves at least one episode of depression.

Bipolar II Disorder (hypomania and depression) – In Bipolar II disorder, you don’t experience full-blown manic episodes. Instead, the illness involves episodes of hypomania and severe depression.

Cyclothymia (hypomania and mild depression) – Cyclothymia is a milder form of bipolar disorder that consists of cyclical mood swings. However, the symptoms are less severe than full-blown mania or depression.

Treatment for bipolar disorder

If you spot the symptoms of bipolar disorder in yourself or someone else, don’t wait to get help. Ignoring the problem won’t make it go away; in fact, it will almost certainly get worse. Living with untreated bipolar disorder can lead to problems in everything from your career to your relationships to your health. But bipolar disorder is highly treatable, so diagnosing the problem and starting treatment as early as possible can help prevent these complications.

If you’re reluctant to seek treatment because you like the way you feel when you’re manic, remember that the energy and euphoria come with a price. Mania and hypomania often turn destructive, hurting you and the people around you.

Treatment basics

Bipolar disorder requires long-term treatment. Since bipolar disorder is a chronic, relapsing illness, it’s important to continue treatment even when you’re feeling better. Most people with bipolar disorder need medication to prevent new episodes and stay symptom-free.

There is more to treatment than medication. Medication alone is usually not enough to fully control the symptoms of bipolar disorder. The most effective treatment strategy for bipolar disorder involves a combination of medication, therapy, lifestyle changes, and social support.

Self-help for bipolar disorder

While dealing with bipolar disorder isn’t always easy, it doesn’t have to run your life. But in order to successfully manage bipolar disorder, you have to make smart choices. Your lifestyle and daily habits can have a significant impact on your moods and may even lessen your need for medication..

The keys to bipolar disorder self-help

Get educated. Learn as much as you can about bipolar disorder. The more you know, the better you’ll be at assisting your own recovery.

Get moving. Exercise has a beneficial impact on mood and may reduce the number of bipolar episodes you experience. Aerobic exercise that activates arm and leg movement such as running, walking, swimming, dancing, climbing or drumming may be especially beneficial to your brain and nervous system.

Keep stress in check. Avoid high-stress situations, maintain a healthy work-life balance, and try relaxation techniques such as meditation, yoga, or deep breathing.

Seek support. It’s important to have people you can turn to for help and encouragement. Try joining a support group or talking to a trusted friend. Reaching out is not a sign of weakness and it won’t mean you’re a burden to others. In fact, most friends will be flattered that you trust them enough to confide in them, and it will only strengthen your relationship.

Stay closely connected to friends and family. Nothing is as calming to the nervous system as face-to-face contact with caring supportive people who can just listen to you talk about what you’re experiencing.

Make healthy choices. Healthy sleeping and eating habits can help stabilize your moods. Keeping a regular sleep schedule is particularly important.

Monitor your moods. Keep track of your symptoms and watch for signs that your moods are swinging out of control so you can stop the problem before it starts.

Bipolar disorder and suicide

The depressive phase of bipolar disorder is often very severe, and suicide is a major risk factor. In fact, people suffering from bipolar disorder are more likely to attempt suicide than those suffering from regular depression. Furthermore, their suicide attempts tend to be more lethal.

The risk of suicide is even higher in people with bipolar disorder who have frequent depressive episodes, mixed episodes, a history of alcohol or drug abuse, a family history of suicide, or an early onset of the disease.

Suicide warning signs include:

  • Talking about death, self-harm, or suicide
  • Feeling hopeless or helpless
  • Feeling worthless or like a burden to others
  • Acting recklessly, as if one has a “death wish”
  • Putting affairs in order or saying goodbye
  • Seeking out weapons or pills that could be used to commit suicide

Take any thoughts or talk of suicide seriously

If you or someone you care about is suicidal, call the National Suicide Prevention Lifeline in the U.S. at 1-800-273-TALK or visit IASP or Suicide.org to find a helpline in your country. You can also read Suicide Prevention.

Causes and triggers

Bipolar disorder has no single cause. It appears that certain people are genetically predisposed to bipolar disorder, yet not everyone with an inherited vulnerability develops the illness, indicating that genes are not the only cause. Some brain imaging studies show physical changes in the brains of people with bipolar disorder. Other research points to neurotransmitter imbalances, abnormal thyroid function, circadian rhythm disturbances, and high levels of the stress hormone cortisol.

External environmental and psychological factors are also believed to be involved in the development of bipolar disorder. These external factors are called triggers. Triggers can set off new episodes of mania or depression or make existing symptoms worse. However, many bipolar disorder episodes occur without an obvious trigger.

Stress – Stressful life events can trigger bipolar disorder in someone with a genetic vulnerability. These events tend to involve drastic or sudden changes—either good or bad—such as getting married, going away to college, losing a loved one, getting fired, or moving.

Substance Abuse – While substance abuse doesn’t cause bipolar disorder, it can bring on an episode and worsen the course of the disease. Drugs such as cocaine, ecstasy, and amphetamines can trigger mania, while alcohol and tranquilizers can trigger depression.

Medication – Certain medications, most notably antidepressant drugs, can trigger mania. Other drugs that can cause mania include over-the-counter cold medicine, appetite suppressants, caffeine, corticosteroids, and thyroid medication.

Seasonal Changes – Episodes of mania and depression often follow a seasonal pattern. Manic episodes are more common during the summer, and depressive episodes more common during the fall, winter, and spring.

Sleep Deprivation – Loss of sleep—even as little as skipping a few hours of rest—can trigger an episode of mania.

9 Most Common Triggers for Bipolar Mood Episodes

Bipolar disorder is characterized by symptoms including unusual shifts in mood and energy. These mood shifts or episodes last at least a week in the case of mania, and at least two weeks in the case of depression, according to psychiatrist Jeffrey Bennett, MD, an associate professor of psychiatry at the Southern Illinois University School of Medicine in Springfield.

There are several types of bipolar and related disorders. In order to be diagnosed with bipolar I, you must have had at least one manic episode that may have been preceded or followed by hypomanic or depressive episodes. In the case of bipolar II, you must have had at least one major depressive episode and at least one hypomanic episode, but never experienced a manic episode.

Both mania and hypomania share the same symptoms, which include feeling unusually upbeat, euphoric, or irritable, with increased energy, mood elevation, a decreased need for sleep, racing thoughts, trouble concentrating, and poor judgment. In cases of mania, these symptoms are severe enough to be causing significant problems in your day-to-day life.

For example, you might be unable to go to work or school, or you may be compulsively spending money. Hypomania is considered a less severe form of mania. In cases of hypomania, your daily functioning isn’t significantly impacted. For example, you are able to work and socialize.

When mood shifts are severe enough, they can have a profound effect on your life. Some episodes of depression and mania are accompanied by loss of reality or psychosis, characterized by hallucinations or delusions. “And unfortunately, suicide is common, with some sources estimating it to be as high as 10 to 15 percent,” explains Dr. Bennett.

Can these episodes be avoided? Perhaps not. But understanding certain triggers can help you better manage bipolar disorder.

One of the most common bipolar triggers is stress. In a study published in June 2014 in the Journal of Affective Disorders, negative or stressful life events were associated with subsequent mood swings. Earlier in their course, episodes of depression or mania in bipolar disorder appear to be triggered more often by stressful life events.

In addition, with recurrent episodes, some people with bipolar disorder may experience less complete periods of remission and a greater likelihood of relapse, either to depression or mania, according to Bennett.

While causes of stress are highly individual, certain life events and lifestyle patterns may act as triggers. Watch out for these common culprits.

Coping with Mania

Manic episodes can vary from person to person. Some people can recognize they’re heading toward a manic episode, while others may deny the seriousness of their symptoms.

If you experience mania, in the heat of the moment, you probably won’t realize you’re having a manic episode. So, perhaps the best way to cope with mania is to plan ahead. Here are some steps you can take to prepare.

Reach out to your healthcare team

The first and most important thing to do if you think you have manic episodes, is to reach out to your mental health provider. This could include a psychiatrist, psychiatric nurse practitioner, counselor, social worker, or other mental health professional. If you’re worried that you’re close to the onset of a manic episode, contact your mental health provider as soon as possible to discuss your symptoms.

If you have a loved one or family member who is familiar with your illness, they may also help you receive support.

Identify medications that help

Healthcare providers typically treat acute manic episodes with medications known as antipsychotics. These drugs can reduce manic symptoms more quickly than mood stabilizers. However, long-term treatment with mood stabilizers can help prevent future manic episodes.

Examples of antipsychotics include:

  • olanzapine (Zyprexa)
  • risperidone (Risperdal
  • quetiapine (Seroquel)

Examples of mood stabilizers include:

  • lithium (Eskalith)
  • divalproex sodium (Depakote
  • carbamazepine (Tegretol)

If you’ve taken these medications in the past and have some understanding of how they work for you, you may want to write down that information in a medication card. Or you could have it added to your medical record.

Avoid triggers that worsen your mania

Alcohol, illegal drugs, and mood-altering prescription drugs can all contribute to a manic episode and affect your ability to recover. Avoiding these substances can help you maintain your emotional balance. It may also help make recovery easier.

Maintain a regular eating and sleeping schedule

When you’re living with bipolar disorder, having structure in your daily life is vital. This includes following a healthy diet and avoiding caffeine and sugary foods that could affect your mood.

Getting enough regular sleep can also help you avoid manic or depressive episodes. In addition, it can help reduce the severity of any episodes that do occur.

Watch your finances

Going on spending sprees can be one of the major symptoms of mania. You can cope with this by limiting how easily you can access your finances. For example, keep enough cash to maintain your everyday lifestyle around your home, but do not have extra cash readily available.

You also may want to keep credit cards and other spending methods in places where they’re more difficult to use. Some people find it helpful to give their credit cards to a trusted friend or family member, while others avoid obtaining credit cards altogether.

Set up daily reminders

Create reminders for taking your medications and maintaining a regular bedtime. Also, consider using phone or computer notifications to help you keep your schedule.

Her worst hypomanic episode was the summer before her senior year of high school, she recalls. “I was out of the house, on my feet, in rehearsal for 16 hours a day,” Emma says. “I got three hours of sleep on that schedule for two months. But I felt euphoric.”

Mike, 66, who has symptoms of bipolar I, describes mania as feeling like you’re on top of the world. “You feel like Superman. Nothing is impossible. Even the most unrealistic goal seems easy and attainable,” he tells SELF.

On the more extreme end of the spectrum, a person may completely lose touch with reality during a manic episode. Bradley, 54, who was diagnosed with bipolar I when he was 48 years old, remembers a few distinct examples of extremely out-of-character behavior during mania. During one episode, “I thought I was teaching English to millions of Chinese people telepathically,” he tells SELF. “How did that feel at the time? Normal.” During another, “I thought I was being watched by everyone on the planet when I showered took a bath. Initially, I felt shy, then I got over it,” he says.

Manic episodes can also make someone act impulsively or carelessly even if they feel “up” or euphoric, and as a result, can lead to serious consequences.

“It’s a common experience for people with bipolar disorder to spend a ton of money during manic episodes. I’ve had patients waste their fortunes or go into debt,” Dr. Galynker says. Mania may also lead someone to become very sexual and behave sexually in ways that may be totally out of character for them. “These are classic examples of risky behaviors associated with mania in bipolar disorder,” Dr. Marsh adds.

Sarah*, 25, who was diagnosed with bipolar II last year, has felt these types of urges during hypomanic episodes: “You feel like you want to spend money and have as much sex as possible,” she says. “It feels almost as if you have taken Adderall or cocaine. You feel confident, like anything you do is right, and there will be no consequences for your behavior.”

Gracie, 30, has experienced these issues firsthand during hypomania. “When I was manic I thought I could take on the world. I craved attention from anyone. I was unfaithful to my live-in boyfriend whom I love beyond words and never wanted to hurt. what I was doing would destroy him, but unable to stop myself from doing it,” she recalls.

Gracie also says she made poor choices with money, by “spending on things I didn’t need and could not afford.” In the back of her mind she knew she was making poor decisions, she says, but she couldn’t get herself to stop.

But Gracie does acknowledge that there are aspects of mania that can feel quite positive in the moment: “I love the amount of energy I have and my ability to multitask, talk fast, keep up with jokes and sarcasm, and be the life of the party without a care in the world while manic,” she says.

Andrea, 46, says that the bursts of energy she gets during a hypomanic episode can “lead to lots of creativity.” (She was diagnosed with bipolar II in 2010.) “When I was younger, I could get by on less sleep and be active all day long,” she tells SELF. “Even now, people call me energetic, though I don’t see myself that way at all.”

Dr. Marsh agrees that hypomania or mania can bring on periods of great creativity or confidence for a person with bipolar disorder. “Mania can feel like a wonderful, exciting, productive place to be when it is going on, that absolutely does happen” she says. “But it can also be extremely disconcerting or even dangerous for a person when they still feel this sense that something is not right, that they are not fully in control of themself.”

Prevention and management of bipolar episodes almost always involves medication, but therapy can also be incredibly beneficial.

Treatment for bipolar disorder in general involves medication to help stabilize the individual’s mood, and landing on the right combination of drugs can take some amount of trial and error.

Energy States: Mania and Manic Episodes

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Depression: Depression & Related Conditions
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Addictions: Alcohol and Substance Abuse

Rashmi Nemade, Ph.D. & Mark Dombeck, Ph.D., edited by Kathryn Patricelli, MA

Bipolar Disorder involves a swing between high and low energy states. When in a high-energy state, people appear happy because they are motivated and excitable. In a low energy state, people feel sad, and lack motivation and enthusiasm. As the energy level of a manic episode increases, the early happy mood tends to change into a more agitated and psychotic state. The person may feel more terrified than happy, but still has a high energy level. As a depressive mood state increases, people may go from just feeling badly about themselves to actually not being able to leave their bed. Therefore, the happy and sad moods that are thought to make up mania and depression are results of different energy states. They are not necessarily primary features of the disorder.

These high and low energy states are often thought of as places that exist upon a scale of energy levels. Manic moods are characterized by high energy states, while depressive moods are characterized by low energy states. Bipolar moods may shift from depressed to manic and back to depressed again. When looking at this on the energy level scale, there is a smooth shifting of the person’s energy state moving up and down the energy scale. Each end of this energy scale can be considered to be a pole, or end point (in the same way that the North and South Poles are the end points of the earth). This is where the term “Bipolar” came from as it means involving movement between two poles.

Mania and Manic Episodes

Because high-energy manic states exist on a scale, it is possible for someone to be a little manic or very manic. People who are very manic are said to be experiencing a manic episode. People who are only a little manic are said to be experiencing a hypomanic episode. The term ‘hypo’ means “under”, so the term “hypomanic” means “less than fully manic.”

There are defined criteria (in the Diagnostic and Statistical Manual (DSM)) that must be met to say that someone is experiencing a full manic episode. For example, manic episodes must be present for at least one week long before they can be diagnosed. Manic episodes lasting up to several months are possible.

A variety of symptoms are possible during a manic episode. At least three of the following need to be present before the diagnosis can be made:

  • an increased sense of self (the person believes they are much better, smarter or more powerful than anyone else around them). This can also happen as a delusional sense of self (the person truly believes they are the president/king/leader in charge of others)
  • decreased need for sleep (for example, feeling fully rested after 3 hours of sleep)
  • more talkative than usual or pressure to keep talking
  • the person feels a sensation of racing thoughts (often called a “flight of ideas”)
  • distractibility (for example, the person’s attention is too easily drawn to unimportant or irrelevant activity happening around them). This can be reported by the person or observed by others around them
  • an increase in goal-directed activities (purposeful behavior that happens either socially, at work or school, or sexually), or physical agitation
  • excessive involvement in activities that have a high potential for painful consequences (for example, going on a shopping spree, unprotected sex, gambling, poor business investments, etc.)

Manic episodes typically do not come on all at once. Instead, there is a progression of manic symptoms that happen over a period of time. During the early manic phase of a bipolar condition, a person may become highly energetic, have a million ideas, become very talkative, stay up all night, feel sexually and generally potent, and become very productive. As the manic episode progresses and gains in strength, individuals tend to lose their inhibitions and whatever judgment they might normally have, and pursue one or more risky, but immediately pleasurable behaviors. For example, people in a severe manic episode may become sexually promiscuous., leading to becoming pregnant (or getting someone else pregnant) or becoming infected with a sexually transmitted disease. They may spend impulsively on shopping, travel, gambling, or drugs. This can cause massive credit card debts or a trail of bounced checks and large cash withdrawals from the ATM afterwards. In their enthusiasm to socialize, people with mania may chatter on and on about things that are inappropriate to share with strangers, (personal beliefs, sexual experiences, etc.) They may also display inappropriate anger, or agitation, and even lash out and become violent in some cases. For example, a person with mania in a bar might pick a fight for no reason. In the most severe cases of mania, hallucinations, delusions, and psychosis occur, further complicating the situation. The inappropriate and out-of-control behavior of people experiencing a manic episode makes the costs associated with mania sometimes devastatingly high.

Bipolar Disorder: Preventing Manic Episodes

How do I manage a manic episode?

Know the warning signs

Learn to recognize your early warning signs. One of the most important ways to avoid a manic episode is to identify early signs and seek treatment.

Common early warning signs of a manic episode include:

  • Needing less sleep.
  • Being more active.
  • Feeling unusually happy, irritable, or energetic.
  • Making unrealistic plans or focusing intensely on a goal.
  • Being easily distracted and having racing thoughts.
  • Having unrealistic feelings of self-importance.
  • Becoming more talkative.

The best way to manage bipolar disorder is to prevent manic episodes. Although that is not always possible, you can identify and try to avoid the triggers that may lead to a mood swing. One of the most important aspects of managing your illness is to stay on a routine, particularly keeping a stable sleep pattern.

Managing a manic episode

  • Maintain a stable sleep pattern. Go to bed about the same time each night, and wake up around the same time each morning. Too much or too little sleep or changes in your normal sleep patterns can alter the chemicals in your body. And this can trigger mood changes or make your symptoms worse.
  • Stay on a daily routine. Plan your day around a fairly predictable routine. For example, eat meals at regular times, and make exercise or other physical activity a part of your daily schedule. You might also practice meditation or another relaxation technique each night before bed.
  • Set realistic goals. Having unrealistic goals can set you up for disappointment and frustration, which can trigger a manic episode. Do the best you can to manage your illness. But expect and be prepared for occasional setbacks.
  • Do not use alcohol or illegal drugs. It may be tempting to use alcohol or drugs to help you get through a manic episode. But this can make symptoms worse. Even one drink can interfere with sleep, mood, or medicines used to treat bipolar disorder.
  • Get help from family and friends. You may need help from your family or friends during a manic episode, especially if you have trouble telling the difference between what is real and what is not real (psychosis). Having a plan in place before any mood changes occur will help your support network help you make good decisions.
  • Reduce stress at home and at work. Try to keep regular hours at work or at school. Doing a good job is important, but avoiding a depressive or manic mood episode is more important. If stress at work, school, or home is a problem, counseling may help improve the situation and decrease stress.
  • Keep track of your mood every day. After you know your early warning signs, check your mood daily to see whether you may be heading for a mood swing. Write down your symptoms in a journal. Or record them on a chart or a calendar. When you see a pattern or warning signs of a mood swing, seek treatment.
  • Continue treatment. It can be tempting to stop treatment during a manic episode because the symptoms feel good. But it is important to continue treatment as prescribed to avoid taking risks or having unpleasant consequences from a manic episode. If you have concerns about treatment or the side effects of medicines, talk with your doctor. Do not adjust the medicines on your own.

For When You Miss Your Bipolar Disorder Mania

By Laura Yeager

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    We may romanticize mania at times, but would you really will the extremes of your illness back into existence, even if you could?

    Photo: Pexels.com

    By Laura Yeager

    Everybody thinks relief from severe mood swings is a wonderful thing. It is, but sometimes, remission does have its drawbacks.

    People can be sick with bipolar disorder for years. Spending three years in a manic, delusional state, I thought people knew who I was everywhere I went. It was tremendously hard to go to places (even Kmart) because in my mind, people were tracking my every movement.

    I knew what Britney Spears feels like, and I’ve never made one record.

    As you can guess, when I finally got my mania under control (thanks to daily medication and time), I was free to go places “anonymously.” No one followed me any more. My life became that of a normal, middle-aged, Mid-western woman, who lived in the suburbs, and who could go to Kmart without thinking a thing of it. No one would know me there.

    I was a nobody again.

    This was marvelous for about two years. I relished my “normalcy.” I baked cakes. I changed diapers. I bought boxes of Clementines for $6.99 at the grocery store. I had little parties—barbecues and family dinners at Thanksgiving. I made my husband his favorite foods and graded papers from my teaching job at a local college. God, was I normal.

    But then, I started to notice the drawbacks of remission. They do exist. Here are a few of mine:

    Folding clothes is enjoyable.

    There’s nothing wrong with folding your clothes, but should one really enjoy it? Gone are the days of hopping a plane to New York City to eat bread sticks with butter and drink beer in bars. Now, it’s just me, the laundry, and my patio door window, looking out onto a world that I never anxiously venture into any more.

    I feel unpopular…

    Mania makes you feel like the “it” girl or boy. But in remission, you’re just another pudgy neighbor on a quiet cul-de-sac.

    Worse, since I’m not depressed anymore, every day I must put on shoes, makeup and clothes…

    It was so much easier staying in my nightgown. Life was uncomplicated. You get used to the sound of your own breathing. You almost like the smell of your dirty body. You’re in survival mode, no more, no less…how simple…

    I can no longer crank out three magazine articles a day.

    Mania brings energy! I can’t stay up all night. I’m so sluggish when I’m in remission. It’s the sluggishness of the average man and/or woman. I’m Average.

    My psychiatrist is no longer a scintillating, love interest.

    When I’m sick, my doctor becomes so cute. He knows my deepest darkest secrets, and he likes me still, for who I am. When I’m in remission, it’s not as fun to go visit him. He’s just a guy who prescribes my meds and who is paid to watch over me. Not very romantic, is it?

    Sleep, sleep, sleep…8 hours a day is oh-so-predictable, and I miss the all-nighters when shut-eye was the last thing I wanted.

    Now, my sleep is like clockwork. There are no extremes anymore. Life is perfectly ho hum…

    The celebs on TV don’t send me secret messages.

    I especially miss Regis Philbin who told me his deepest, darkest secret. I was so proud of knowing that. But, Regis has stopped talking to me through the TV.

    I’m out of excuses. I can’t blame my mania.

    Yes, you’re well now. You must take care of business. Go out to lunch. Pay bills. Buy gas. Read the newspaper. It’s called living responsibly.

    When I take some time to think, I can only be so wistful about my mania; after all, it landed me in a psych ward.

    Being sick with bipolar disorder is a great leveler. It strips most everything away, leaving only the most primitive elements—fear, grief, anger, lust, euphoria, thoughts of genius. There’s something satisfying (in hindsight, maybe) about living life on the edge. We may romanticize at times, but ultimately we strive for health. Would you really will the extremes of your illness back into existence, even if you could?

    In the end, wellness is “where it’s at.” It’s peaceful and quenching and healing.

    I’m in remission.

    I pray you are, too.

    Printed as “Missing My Mania“, Spring 2008

    • Sibutramine-induced mania as the first manifestation of bipolar disorder

      The temporal relationship between sibutramine intake and onset of behavioral changes as well as the decrease in manic symptoms with cessation of sibutramine and initiation of anti-manic pharmacotherapy led us to suspect the role of sibutramine in the pathogenesis of manic episode. It could be hypothesized that sibutramine may induce mania in predisposed individuals by acting in a similar way with other selective serotonine reuptake inhibitors (SSRIs) . In the 1980s sibutramine was initially intended as an antidepressant drug . In the 2000s antidepressant-associated mania has been linked to all major antidepressant classes in a subgroup of 20-40 % of bipolar patients . Bipolar spectrum incorporates classic bipolar disorder (manic + depressive episode), bipolar II disorder (hypomanic + depressive episode), and bipolar III disorder that is not an official diagnosis recognized by psychiatric associations. Although we will not find bipolar III disorder mentioned in the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), psychiatric professionals use the unofficial diagnosis of bipolar III disorder to describe patients who have experienced manic or hypomanic episode due to antidepressant treatment . The serotonin transporter gene is a candidate to be associated with antidepressant-associated mania in some patients . The serotonin transporter gene demonstrates a polymorphism within the promoter region (5-HTTLPR) with two allelic forms -the long and the short variants. Since 5-HTTLPR polymorphism is considered as a predictor of abnormal response to antidepressants in vulnerable to bipolar disorder patients, a correct diagnosis of bipolarity and detailed family history for affective disorders should be done before the beginning of sibutramine treatment. It is essential mainly for short variant of 5-HTTLPR carriers . As chronic sleep deprivation can precipitate the manic episode, insomnia (a very common side-effect of sibutramine) might exacerbate manic symptoms in our vulnerable patient. It was also hypothesized that individuals can engage in overeating for the purpose of regulating their mood . Therefore, bipolar patients may overeat to “self medicate” their affective symptoms, and suppression of overeating and/or weight loss might therefore trigger the onset or exacerbation of the mood symptoms. It is also possible that the weight loss might also be associated with release of toxins, including drugs that might have mood destabilizing effects .

      Although the neuropsychiatric side effects of sibutramine have not yet been completely elucidated, there is accumulating literature on a variety of psychiatric disturbances caused by sibutramine. Further studies are required to clarify the relationship between sibutramine and episodes of psychiatric disorders including mania. Sibutramine, as an antiobesity drug was approved in the USA in 1997 and in the European Union in 1999, but recently followed the example of another antiobesity drug -rimonabant (an inverse agonist for the cannabinoid receptor CB1) that was removed from all markets in the European Union . There was concluded that the risks of cardiovascular complications of sibutramine were greater than its benefits. Potential risks associated with the sibutramine treatment of obesity warn physicians to be alert not only to cardiovascular events but also to psychiatric adverse effects. Therefore a careful assessment of patient’s mental state together with detailed family psychiatric history should be done before beginning sibutramine treatment. If patients present a first episode of psychosis, mania, or other psychiatric disorder, they should be investigated thoroughly while sibutramine is being withheld . It is important to obtain information about vulnerability of the patient to psychiatric disorders and whether eventual symptoms were due to a primary psychiatric disorder or to a drug-induced episode. In patients with weight gain while on antipsychotic medications (e.g. olanzapine treatment), sibutramine, if not managed appropriately, could conceivably exacerbate psychotic episode symptoms or trigger its relapse. Physicians should also remember that use of sibutramine is contraindicated not only in patients with a history of coronary artery disease, heart failure, arrhythmias, cerebrovascular disease, inadequately controlled hypertension, bulimia/anorexia nervosa, pregnancy, lactation, severe renal or liver dysfunction, narrow angle glaucoma, but also in patients treated with monoamineoxidase inhibitors (MAOIs), selective serotonine reuptake inhibitors (SSRIs) or certain migraine drugs as triptans, because of potential risk of serotonin syndrome. Thus, a 2-week interval is required after stopping MAIOs -before treatment with sibutramine, and after stopping sibutramine -before treatment with MAOIs .

      All of the abovementioned aspects of sibutramine treatment require careful weighting, and benefits of obesity pharmacotherapy must outweigh the risks and costs. Albert Einstein said: “The devil has put a penalty on all things we enjoy in life. Either we suffer in health or we suffer in soul or we get fat”, but patients do not have to suffer in health or soul when they try to lose fat. When the patient has a positive family history for bipolar disorder, a change to the other antiobesity drug than sibutramine may be required (e.g. to orlistat). The neurobiology of obesity is extremely complex and many novel potential antiobesity drugs and targets are identified including those acting on the central pathways as ciliary neurotrophic factor, melanocortin-4 receptor agonists, ghrelin, neuropeptide Y antagonists, melanin-concentrating hormone antagonists, or peptide Y . However, the most effective long-term weight loss still depends on motivation for permanent decrease in energy intake, improving dietary quality, and increase in physical activity. Further research should take into consideration the use of a mood stabilizers in prevention of mood changes in predisposed individuals, before sibutramine treatment. The main conclusion of our case is that the use of sibutramine (even in minimal recommended dose) should be contraindicated in patients with a family history for bipolar disorder.

      Ketamine-Induced Mania During Treatment for Complex Regional Pain Syndrome

      Dear Editor,

      Complex regional pain syndrome (CRPS) describes a disease of localized chronic pain that often occurs after preceding trauma, is out of proportion to its expected course, and includes other symptoms such as hair loss and allodynia . There are no known psychologic or personality factors associated with its development . Therapy is multimodal, and pharmacologic treatments include steroids, antiepileptics, antidepressants, opiates, and ketamine . Ketamine is mainly an N-methyl-D-aspartate (NMDA) receptor antagonist with known psychomimetic effects that are usually transient, mild, and tolerable . We describe a case of ketamine inducing a prolonged manic episode and potentially unmasking bipolar disorder in a young woman with depression and CRPS. Few other case reports have documented similar prolonged exacerbations of underlying mood disorders post–ketamine administration.

      Our patient is a 30-year-old female who was admitted to the inpatient pain service for ketamine infusion for right lower extremity CRPS. She sustained a right foot sprain during laser tag three years prior. She developed constant pain that was aggravated by touch, temperature changes, and humidity. She tried physical therapy, group psychotherapy, pregabalin, mexiletine, gabapentin, and an epidural injection with little effect. Intravenous (IV) lidocaine previously provided only temporary relief, and a spinal cord stimulator failed after six weeks. Opiates previously helped, but she developed opioid use disorder, for which she was undergoing treatment.

      Her psychiatric history included unipolar depression and anxiety involving three suicide attempts. Four months prior, during hospitalization for the most recent attempt, she underwent brief treatment for her CRPS with a ketamine infusion (20 mg/h titrated down to 10 mg/h) for two days, with no noticeable psychotic or manic symptoms, and in fact no effect on her depression. At the time of her current hospitalization, her opioid use disorder was in remission and being treated with buprenorphine/naloxone. She occasionally smoked cannabis. Additional home medications were hydroxyzine as needed for anxiety and duloxetine.

      She underwent a right superficial peroneal and sural nerve block 17 days prior to admission, with immediate yet incomplete improvement in pain. On the day of admission, her vital signs, mental status exam, and physical exam were normal except for the signs and symptoms described as related to her CRPS. On hospital day 1 (HD1), she was started on ketamine at 10 mg/h. Her approximate weight was 56 kg, translating to 0.18 mg/kg/h. Her pain improved from 6/10 to 2/10, and the infusion was increased to 15 mg/h. On HD2, the infusion was increased to 20 mg/h, and then further to 25 mg/h (0.45 mg/kg/h) on HD3. On HD4, the patient was able to touch her foot with minimal allodynia. Later that afternoon, she began “happily talking to herself” and having visual hallucinations of a baby in the room. The ketamine infusion was immediately stopped. The next day, she developed pressured speech and delusions of grandeur. Olanzapine was started for potential substance-induced psychosis/mania. She had persistent psychotic thoughts, and on HD7 the olanzapine was changed to quetiapine. The psychiatry team was concerned about ketamine-induced mania with psychotic features vs an underlying bipolar disorder unmasked by ketamine, and on HD8 her duloxetine was decreased from 60 mg to 20 mg daily. On HD9, labs were obtained and were within normal ranges (including thyroid-stimulating hormone). From HD9 through HD12, she continued to have delusions and euphoric mood, and her quetiapine was increased stepwise to 600 mg total daily dose. Her leg pain had completely resolved. Her mood began to improve, and she was discharged home on HD15. She was seen one week after discharge and still had mild euphoria. At her next follow-up, 57 days after discharge, her mood was normal. She still had no pain in her leg, though she noted occasional redness. She was started on memantine 5 mg nightly to prevent recurrence of her CRPS.

      To our knowledge, this is the third report of ketamine-induced mania occurring during the treatment of refractory pain. Ricke et al. described a 42-year-old woman with depression who was treated for gluteal CRPS with IV ketamine over a five-day period. She developed manic symptoms that resolved only after HD18 when quetiapine was started. Of note, she had self-administered opiates during the hospitalization. Nichols et al. previously described a 27-year-old man with multiple substance use disorder who underwent a leg fasciotomy for rhabdomyolysis and received IV ketamine on HD9 for postoperative pain. He developed manic symptoms on H12, which resolved only on HD30 after the initiation of olanzapine. Notably, he had used IV heroin the day prior to his admission. Our patient was undergoing treatment for a history of opioid use disorder. In the two previously described cases, concomitant opiate administration was present as well. We speculate whether opiate receptor activation, or even a prior history of substance use disorder, may play a role in the risk of developing ketamine-induced mania.

      Our patient’s initial ketamine infusion rate of 10 mg/h was a common starting rate noted in a large review of ketamine infusions for CRPS . The authors of this study recommended a duration of three to five days and a maximum infusion rate of 25 to 50 mg/h. The true optimal dose is unclear, and another well-studied initial rate is 0.07 mg/kg/h (5 mg/h for a 70 kg patient), titrated to a maximum of 0.43 mg/kg/h (30 mg/h for a 70 kg patient) for a total of five days . It is important to note that our patient’s ketamine dose as well as duration of treatment prior to the onset of psychiatric symptoms fell within these proposed ranges. Ketamine is being explored as a novel rapid-acting treatment for depression, with one common protocol being 0.5 mg/kg IV ketamine infusion given over 40 minutes . In this setting, there have also been case reports of ketamine inducing an affective switch .

      We described here the case of a woman with a history of depression and opioid use disorder in remission who received a ketamine infusion for treatment of CRPS and developed a prolonged manic episode. Further studies into risk factors for development of mania or psychosis are needed. In certain individuals, prophylactic use of neuroleptic medications to prevent such symptoms may be beneficial .

      1 Harden RN , Bruehl S , Stanton-Hicks M , Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8 4:326–31. 2 Beerthuizen A , Stronks DL , Huygen FJ , et al. The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1)—a prospective multicenter study. Eur J Pain 2011;15 9:971–5. 3 Bussa M , Guttilla D , Lucia M , Mascaro A , Rinaldi S. Complex regional pain syndrome type I: A comprehensive review. Acta Anaesthesiol Scand 2015;59 6:685–97. 4 Sigtermans MJ , van Hilten JJ , Bauer MC , et al. Ketamine produces effective and long-term pain relief in patients with complex regional pain syndrome type 1. Pain 2009;145 3:304–11. 5 Ricke AK , Snook RJ , Anand A. Induction of prolonged mania during ketamine therapy for reflex sympathetic dystrophy. Biol Psychiatry 2011;70 4:e13–4. 6 Nichols SD , Bulman M , Tisher A , Campbell JJ 3rd. A case of possible iatrogenic ketamine-induced mania in a patient being treated for postoperative pain. Psychosomatics 2016;57 5:543–6. 7 Correll GE , Maleki J , Gracely EJ , Muir JJ , Harbut RE. Subanesthetic ketamine infusion therapy: A retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Med 2004;5 3:263–75. 8 McGirr A , Berlim MT , Bond DJ , et al. A systematic review and meta-analysis of randomized, double-blind, placebo-controlled trials of ketamine in the rapid treatment of major depressive episodes. Psychol Med 2015;45 4:693–704. 9 Banwari G , Desai P , Patidar P. Ketamine-induced affective switch in a patient with treatment-resistant depression. Indian J Pharmacol 2015;47 4:454–5. 10 Alison McInnes L , James-Myers MB , Turner MS. Possible affective switch associated with intravenous ketamine treatment in a patient with bipolar I disorder. Biol Psychiatry 2016;79 9:e71–2. © 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]

      9 Triggers of Mania in Bipolar Disorder

      Mood swings are the mainstays of bipolar disorder. There are small ones like everyone has, but there are also swings that go over the top or right to the bottom. The lightweight mood swings can be dealt with, most of the time. You work it out and move on with life. For full episodes of depression and mania, however, treatment gets difficult. It can take years for a patient and their doctor(s) to find the right treatment. Even then there may need to be tweaks or even overhauls. One way to help yourself out in this process is to watch your behaviors and take note of what may be triggering episodes. Here are 10 common triggers for manic episodes:

      1 Changing sleep patterns
      Both too little sleep and too much sleep can trigger episodes. The best idea is keeping a tight sleep schedule. Go to bed and get up at the same time, every day.

      2 Having a baby
      Postpartum depression is a widely-known illness. However, between 20-30% of women with bipolar I disorder experience manic episodes postpartum, especially within the first 2-3 weeks.

      3 Alcohol or drug use
      You don’t have to abuse alcohol or drugs for them to affect your mental health. It makes sense that stimulants like meth and cocaine could induce mania, but depressants like alcohol and marijuana can too.

      4 Antidepressants
      While antidepressants are often effective when used to treat unipolar depression, they can trigger manic episodes. If they are used to treat bipolar disorder at all, they are typically used along with a mood stimulator.

      5 Overstimulation
      Noise, lights and odors can be overstimulating but social situations can as well.

      6 Illness
      Physical illness causes emotional stress. It also causes inflammation to occur in the body and in the brain. Any inflammation in the brain can seriously affect the areas that control mood.

      7 Season changes
      While the lack of sunlight during the winter can worsen depression, the increase of sunlight can induce mania. Allergens can also cause inflammation (see #6).

      8 Social conflict
      Relationships play a big role in managing bipolar disorder. Our friends and family can be our biggest supporters, but it’s difficult. Because of the intensity of these relationships, when something goes wrong, it can be a stressor.

      9 Really anything that throws off your groove
      Okay, not anything. Not getting your usual parking space is probably not going to trigger a manic episode. Travel, a new job, a new relationship- these are all examples of changes that can affect your normal behavior patterns. The more your normal patterns are thrown off, the more you can be affected biologically and the higher your chances are of a manic episode.

      Bonus: Not taking your medication
      This is fairly straightforward. If you don’t take the medication that is intended to prevent mood swings, you are more likely to experience those episodes. More urgently, discontinuing your medication can send you into withdrawal which can lead not only to mania, but also other severe, physical symptoms.

      You can find me on Twitter @LaRaeRLaBouff

      Photo credit: Kelly Sikkema

      9 Triggers of Mania in Bipolar Disorder

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