Manic depression

Manic-depressive illness, clinically called bipolar disorder, is a major mental illness belonging to the category of illnesses designated as mood disorders. It is estimated that as many as two million Americans suffer from this illness and many more may go undiagnosed or underdiagnosed. Approximately one in five families will be confronted with a family member who may experience a manic episode or an episode of clinical depression . As the term bipolar suggests, there are two extreme moods in manic depression: one is depression and the other is mania , where behavior and irritability or anger become extreme.

Manic depression is characterized by drastic emotional changes and extreme mood swings. The mood may be one of an emotional high where a person has excessive energy , may feel exuberant, creative, and ready to take on the world. This is characteristic of a manic episode. The person may feel that he or she needs little sleep and may even get only three or four hours of sleep during the manic episode. People in this mode of the illness may have racing thoughts, may have auditory hallucinations, and may suffer from delusions of grandeur. The person often exhibits a great deal of irritability and can become quite argumentative.

The other side of manic-depressive illness is a state of depression during which the person feels that everything is hopeless. The mood in the depressed state is flat. The person may have a poor appetite, may sleep too much or too little, feel tired, lose interest in otherwise pleasurable activities, experience difficulty in concentrating, may feel worthless or extremely guilty, and may have thoughts of suicide.

Diagnosis

Like the range of colors seen in a prism , manic depression or bipolar disorder has a spectrum from which psychiatrists make their diagnosis . One of the factors they examine is whether the person is in a depressed, manic, or hypomanic state. A hypomanic state is one in which a person experiences a more controlled mania. The person may become excessively active and feel elated, but does not become disorganized or delusional. People with these symptoms may be cyclothymic, that is they exhibit periods of depression and mania, but for shorter and less intense durations.

While there is no known single cause of manic depression, there appears to be some genetic predisposition, although no specific genetic defect has yet been detected. It usually appears in late adolescence or early adulthood and continues throughout life. Potential causes, such as increased stress or a traumatic emotional event, are many and varied; experts believe a combination of factors may act as a trigger.

In bipolar disorder, the person who experiences periods of depression that alternate with periods of mania is said to have bipolar disorder I, while the person who suffers mild hypomanic periods alternating with periods of depression is classified as having bipolar disorder II. In both illnesses, episodes are limited in time , lasting from several weeks to several months, although depression can last for more than a year without going into remission. If manic depression/bipolar disorder is not treated, however, recurrences tend to become more severe over time.

Emil Kraepelin

Since the 1950s, the psychiatric community has had the benefit of antimanic and antidepressant medications to treat manic-depressive illnesses. These medications were developed using the work of Emil Kraepelin, a German physician who wrote about mental illness in the late nineteenth century and early part of the twentieth century. Kraepelin had carefully noted distinguishing symptoms among mental patients and had followed the course of the various illnesses in many of them. He was the first to distinguish what he called dementia praecox, now called schizophrenia , and was able to differentiate this illness from manic depression.

During the 1950s and 1960s, a group at Washington University in St. Louis applied Kraepelin's method and began a classification system that led to the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM), which was published in 1952. In 1994, the DSM-IV was published. As of 2003, text revision in the DSM-IV-TR ("TR" for "text revision") made it the most current DSM available. The DSM presents a standard set of definitions for psychiatric illnesses. It also presents the symptoms and the number of them that must be present to diagnosis a particular psychiatric illness, such as manic depression.

Another problem facing the diagnosis of depression or mania is the fact that other medical conditions can cause similar symptoms. Among them are illnesses such as thyroid diseases, infectious diseases (the flu), cancers of the central nervous system , neurological disorders (multiple sclerosis), blood diseases, and even some reactions to metal toxicity.

Treatments for manic-depressive illness

Lithium has been the treatment of choice for manic-depressive illness for several decades. Lithium is a trace element found in plants and in mineral rocks . While there has been a great deal of success in treating manic-depressive patients with lithium and returning them to a relatively normal life, researchers are not sure how it works. It is a nonaddictive and nonsedating medication, but it must be carefully monitored for possibly dangerous side effects.

More recently, newer medicines have been used to treat bipolar manic depression disorder. Carbamazepine and valproate are two anticonvulsants that have been particularly useful with patients who do not respond to lithium. These medications also have to be monitored for proper dosages. Antidepressants may be necessary during severe depressive episodes but may push a patient into the manic state. In severe cases, hospitalization and even electroconvulsive therapy (ECT) may be necessary.

The psychiatric community generally favors a combined treatment of medicine, along with an educational program for the patient and family, and psychological counseling to help the patient adjust to the medication and learn how to deal with the illness. Because this disorder can be debilitating and deadly (suicide risk is 30 times greater), recognition and accurate diagnosis is essential. Sufferers often "need help to get help," and observant family and friends can play an important role in this area.

Resources

books

Amchin, Jess. Psychiatric Diagnosis: A Biopsychosocial Approach Using DSM-III-R. Washington, DC: Psychiatric Press, 1991.

Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Washington, DC: American Psychiatric Association, 1994.

Diagnostic and Statistical Manual of Mental Disorders: DSM IV-TR. 4th ed., text revision. Washington, DC: American Psychiatric Association, 2000.

Goodwin, Frederick K., and Kay Redfield Jamison. Manic-Depressive Illness. New York: Oxford University Press, 1990.

Jamison, Kay Redfield. Touched with Fire. New York: Free Press, 1993.

Jefferson, James W., and John H. Greist. Lithium and ManicDepression: A Guide. Madison, WI: Madison Institute of Medicine, 1999.

Maj, Mario. Bipolar Disorders. New York: John Wiley & Sons, 2002.

Papolos, Demitri F., and Janice Papolos. Overcoming Depression. New York: Harper & Row, 1987.

Torrey, E. Fuller, and Michael B. Knable. Surviving Manic Depression: A Manual on Bipolar Disorder for Patients, Families, and Providers. New York: Basic Books, 2002.

periodicals

Carroll, B.J. "Brain Mechanisms In Manic Depression." Clinical Chemistry: International Journal of Laboratory 40, no. 2 (1994): 303-308.

Hyman, S.E. "The Genetics of Mental Illness: Implications for Practice." Bulletin of the World Health Organization 78 (April 2000): 455-463.

Sajatovic, M. "Treatment of Bipolar Disorder in Older Adults." International Journal of Geriatric Psychiatry 17, no. 9 (2002): 865-873.

Vita Richman

KEY TERMS

Bipolar I disorder

—A manic-depressive illness characterized by one or more manic episodes, along with a depressive episode.

Bipolar II disorder

—A manic-depressive illness characterized by a depressive episode and a hypo-manic episode.

Cyclothymic disorder

—An illness in which there are many hypomanic episodes and many periods of depression during a period of time lasting at least two years.

Depression

—A mood disorder where the predominant symptoms are apathy, hopelessness, sleeping too little or too much, loss of pleasure, self-blame, and possibly suicidal thoughts.

Hypomania

—A condition in which a person is in an elevated mood and exhibits manic behavior that is not as severe as full-blown mania.

Mania

—A condition in which the person's mood is elevated, is hyperactive, and has racing thoughts.

Mood disorder

—An illness that is characterized by a disturbance of mood, which may be depressed or elevated and must be of a significant duration.

Manic Depression

BIBLIOGRAPHY

Many lay people use the name manic depression to refer to a disorder that is more formally called bipolar disorder within the diagnostic system of the American Psychiatric Association. In this formal diagnostic system, there are three forms of bipolar disorder. Bipolar I disorder, the most severe form, is defined by a single episode of mania. Manic episodes are characterized by a period of expansive, elevated, or irritable moods, along with such symptoms as diminished need for sleep, rapid speech, grandiosity, agitation or increased activity, racing thoughts, and increased engagement in pleasurable activities that have potential to cause trouble. The symptoms must last for at least one week and create severe impairment. Bipolar II disorder is a milder form of the disorder, defined on the basis of hypomania and recurrent depression. Hypomania is characterized by the same set of symptoms as mania, but symptoms must only last for four days and do not create severe impairment. Cyclothymia is defined by frequent ups and downs that are not severe enough to meet the criteria for hypomania or mania.

Two measures commonly used to verify diagnoses within research studies include Michael B. First and M. Gibbons’s 2004 Structured Clinical Interview for DSM -IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.), and Jean Endicott and Robert L. Spitzer’s 1978 Schedule for Affective Disorders and Schizophrenia. No biological markers are available to aid with diagnosis.

About 1 percent of the population experiences bipolar I disorder; it was estimated in 2005 by Ronald C. Kessler et al. that bipolar II disorder also affects approximately 1 percent of the population. Cyclothymia may affect 4 percent of the population, according to a 2004 study by E. J. Regeer et al. The vast majority of people with a single episode of mania will experience another episode during their lifetime, many within five years, reported Michael J. Gitlin et al. in 1995. A 2002 report by Lewis L. Judd et al. said that mild symptoms lingering between episodes are common. The median time of onset for this disorder has been estimated at twenty-five years of age, according to the report by Kessler et al., but at least 25 percent of affected people report that episodes began by age seventeen.

It is well established that bipolar disorder is biologically based: heritability accounts for as much as 85 percent of whether people develop mania, according to a 2003 report from Peter McGuffin et al. Neurobiological research in 2003 by Craig A. Stockmeier suggests that a set of brain regions, modulated by dopamine and serotonin, are involved in the disorder. Psychosocial variables, including negative life events, negative cognition, and family hostility and criticism can increase the risk of depressive episodes within this disorder, per several reports (Butzlaff and Hooley 1998; Monroe et al. 2001; Alloy et al. 2000). Sleep loss and events involving goal attainment can predict increases in mania over time (Johnson 2005a, 2005b; Malkoff-Schwartz et al. 1998, 2000).

Historically, treatments for this disorder, including psychotherapy alone or hospitalization, were not very effective. The discovery of lithium’s mood-stabilizing effects led to dramatic gains in outcome. The dominant treatment approach is mood-stabilizing medication. The first-line treatment recommendation remains lithium, but if side effects are difficult to tolerate, anticonvulsant medications are also useful mood stabilizers. Antidepressants are often added to combat depression, but not without a mood stabilizer because antidepressants can provoke manic symptoms when administered alone (Altshuler et al. 1995; Goldberg and Whiteside 2002). Antipsychotic medications can address psychotic or agitation symptoms. Research in 2004 by Sheri L. Johnson and Robert L. Leahy indicates that family or individual talk therapy can be helpful supplements to medication.

SEE ALSO Depression, Psychological; Manias

BIBLIOGRAPHY

Alloy, Lauren B., Lyn Y. Abramson, Michael E. Hogan, et al. 2000. The Temple-Wisconsin Cognitive Vulnerability to Depression Project: Lifetime History of Axis I Psychopathology in Individuals at High and Low Cognitive Risk for Depression. Journal of Abnormal Psychology 109: 403-418.

Altshuler, Lori L., Robert M. Post, Gabriele S. Leverich, et al. 1995. Antidepressant-induced Mania and Cycle Acceleration: A Controversy Revisited. American Journal of Psychiatry 152: 1130-1138.

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders (DSM -IV-TR). 4th ed., text rev. Washington, DC: Author.

Butzlaff, Ronald L., and Jill M. Hooley. 1998. Expressed Emotion and Psychiatric Relapse: A Meta-analysis. Archives of General Psychiatry 55: 547-552.

Endicott, Jean, and Robert L. Spitzer. 1978. A Diagnostic Interview: The Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry 35 (7): 837-844.

First, Michael B., and M. Gibbon. 2004. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). In Comprehensive Handbook of Psychological Assessment. Vol. 2: Personality Assessment, eds. Mark J. Hilsenroth and Daniel L. Segal, 134-143. Hoboken, NJ: Wiley.

Gitlin, Michael J., Joel Swendsen, Tracy L. Heller, and Constance Hammen. 1995. Relapse and Impairment in Bipolar Disorder. American Journal of Psychiatry 152: 1635-1640.

Goldberg, Joseph F., and Joyce E. Whiteside. 2002. The Association between Substance Abuse and Antidepressant-induced Mania in Bipolar Disorder: A Preliminary Study. Journal of Clinical Psychiatry 63: 791-795.

Johnson, Sheri L. 2005a. Life Events in Bipolar Disorder: Towards More Specific Models. Clinical Psychology Review 25: 1008-1027.

Johnson, Sheri L. 2005b. Mania and Dysregulation in Goal Pursuit. Clinical Psychology Review 25: 241-262.

Johnson, Sheri L., and Robert L. Leahy, eds. 2004. Psychological Treatment of Bipolar Disorder. New York: Guilford.

Judd, Lewis L., Hagop S. Akiskal, Pamela J. Schettler, et al. 2002. The Long-Term Natural History of the Weekly Symptomatic Status of Bipolar I Disorder. Archives of General Psychiatry 59: 530-537.

Kessler, Ronald C., Wai Tat Chiu, Olga Demler, and Ellen E. Walters. 2005. Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62 (6): 617-627.

Malkoff-Schwartz, Susan, Ellen Frank, Barbara Anderson, et al. 1998. Stressful Life Events and Social Rhythm Disruption in the Onset of Manic and Depressive Bipolar Episodes: A Preliminary Investigation. Archives of General Psychiatry 55: 702-707.

Malkoff-Schwartz, Susan, Ellen Frank, Barbara Anderson, et al. 2000. Social Rhythm Disruption and Stressful Life Events in the Onset of Bipolar and Unipolar Episodes. Psychological Medicine 30: 1005-1016.

McGuffin, Peter, Fruhling Rijsdijk, Martin Andrew, et al. 2003. The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression. Archives of General Psychiatry 60: 497-502.

Monroe, Scott M., Kate Harkness, Anne D. Simons, and Michael E. Thase. 2001. Life Stress and the Symptoms of Major Depression. Journal of Nervous and Mental Disease 189: 168-175.

Regeer, E. J., M. ten Have, M. L. Rosso, et al. 2004. Prevalence of Bipolar Disorder in the General Population: A Reappraisal Study of the Netherlands Mental Health Survey and Incidence Study. Acta Psychiatrica Scandinavica 110 (5): 374-382.

Stockmeier, Craig A. 2003. Involvement of Serotonin in Depression: Evidence from Postmortem and Imaging Studies of Serotonin Receptors and the Serotonin Transporter. Journal of Psychiatric Research 37: 357-373.

Sheri L. Johnson

Christopher Miller

Manic Episode

Definition

Description

Resources

Definition

A manic episode is a discrete period lasting at least a week during which a person experiences abnormally elevated, expansive, or irritable mood.

Description

A person experiencing a manic episode shows persistent and often inappropriate enthusiasm which may involve taking on new projects for which he or she

KAY REDFIELD JAMISON (1946–)

Kay Redfield Jamison is a psychologist and educator who is considered an authority on manic-depressive illness. Her volume Manic-Depressive Illness, compiled with Frederick K. Goodwin, is regarded as a key contribution to the study of manic-depressive illness, a biochemical disorder which results in periods of mania alternating with bouts of depression. The book encompasses a range of issues and subjects, including diagnosis, clinical studies, psychological ramifications, and patho-physiological elements. Larry S. Goldman, reviewing the work in the New England Journal of Medicine, acknowledged Jamison and Goodwin as “two highly regarded senior clinicians and researchers” and proclaimed their book “thorough and most readable.” Goldman concluded, “It is hard to imagine a clinician working with patients with the illness… or a researcher in any part of the field of mood disorders who should not have this tour de force available.”

Jamison followed Manic-Depressive Illness with Touched with Fire: Manic-Depressive Illness and the Creative Temperament, a detailed account of the ties between artistic sensibilities and manic-depressive illness. While conceding that not all artists are manic-depressive, Jamison argues that a significant association exists between the

artistic and manic-depressive temperaments. There is, for example, a high rate of suicide among both types. In her analysis, Jamison incorporates scientific and medical data, including diagnostic methods and genetic information, and she applies this data to a host of creative individuals, including the composer Robert Schumann, the painter Vincent Van Gogh, and such American writers as Ernest Hemingway, John Berryman, and Hart Crane. Jamison notes that many of the creative individuals considered in Touched with Fire had little recourse to any suitable psycho-medical care.

In 1995 Jamison published An Unquiet Mind, a memoir of her own experiences with manic depression. In this volume Jamison recounts her extreme moodiness as a child and relates her first, exhilarating experience of mania when she was in her mid-teens. She notes that mania and depression sometimes exist simultaneously. It is during these periods, when the depths of despair are coupled with the impulsiveness characteristic of mania, that sufferers, according to Jamison, are more likely to consider suicide. Jamison discloses in An Unquiet Mind that she attempted to take her own life, and she credits psychotherapy with helping her realize greater acceptance and stability.

is ill suited. It might also involve engaging strangers in detailed conversations, acting without concern for consequences of one’s actions, or increased sexual activities. Less commonly, a person may be abnormally irritable during a manic episode. On average, the episodes begin before age 25. This means that some individuals experience their first episode while in their teens and others during middle age.

Psychiatrists use five criteria to identify someone in the midst of a manic episode. First, the period of abnormal behavior must persist for at least one week unless the person is admitted to a hospital. Typically, the episodes last from a few weeks to a few months. Second, the diagnosis requires three additional symptoms if the mood change results in expansive behavior, or four if it results in unnatural irritability. These symptoms include an unwarranted sense of self-importance, a tendency to be easily distracted, a decreased need for sleep, a rapid flow of ideas with one replacing another before the first is acted upon, an inability to sit still or increased activity directed at achieving some goal, an irrepressible need to talk, and finally, a devotion to some activity the patient finds pleasurable but could be harmful (e.g., buying sprees, reckless driving). The third criterion is that the symptoms do not qualify the patient for a diagnosis of mixed episode, which involves elements of depression. Fourth, the patient can not function normally at home or at work, or shows signs of psychosis. The fifth and last criterion is that the cause of the episode can not be attributed to side effects from any drug abuse, medication, medical treatment, or medical condition.

Many of these symptoms are also present in a hypomanic episode. A hypomanic episode is similar to a manic episode, but the symptoms may be experienced to a lesser extent. The main differences between a manic and hypomanic episode are the following:

• A hypomanic episode may only last four days, whereas a manic episode, by definition, lasts one week.
• In a manic episode, psychotic features (hallucinations and delusions) may be present, but in a hypomanic episode, they cannot be.
• A manic episode significantly impairs the affected person’s functions, but a hypomanic episode does not.

Both of these kinds of episodes may be seen in patients with bipolar disorder.

Resources

BOOKS

Goodwin, Frederick K., and Kay Redfield Jamison. Manic-Depressive Illness. New York: Oxford University Press, 2007.

VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington D.C.: American Psychological Association, 2007.

PERIODICALS

Frey, Benício Noronha, and others. “Increased Oxidative Stress After Repeated Amphetamine Exposure: Possible Relevance as a Model of Mania. Bipolar Disorders,” Bipolar Disorders 8.3, Jun. 2006: 275–80.

Keck, Paul E., Jr., and others. “A Randomized, Double-Blind, Placebo-Controlled 26-Week TrialofAripiprazole in Recently Manic Patients With Bipolar I Disorder.” Journal of Clinical Psychiatry 67.4, Apr. 2006: 626–37.

Lin, Daniel, Hiram Mok, and Lakshmi N. Yatham. “Poly-therapy in Bipolar Disorder.”CNS Drugs” 20.1, 2006: 29–42.

Michalopoulou, Panayiota G., and Lefteris Lykouras. “Manic/Hypomanic Symptoms Induced by Atypical Antipsychotics: A Review of the Reported Cases.” Progress in Neuro-Psychopharmacology & Biological Psychiatry 30.4, May 2006: 549–64.

Dean A. Haycock, Ph.D.

Manic episode

Definition

A discrete period lasting a week or more during which a person experiences mania, an abnormally elevated, cheerful, or euphoric mood.

Description

A person experiencing a manic episode shows persistent and often inappropriate enthusiasm which may involve taking on new projects for which he or she is ill suited. It might also involve engaging strangers in detailed conversations, acting without concern for consequences of one's actions, or increased sexual activities. Less commonly, a person may be abnormally irritable during a manic episode. On average, the episodes begin before age 25. This means that some individuals experience their first episode while in their teens and others during middle age.

Psychiatrists use five criteria to identify someone in the midst of this type of mood episode. First, the period of abnormal behavior must persist for at least one week unless the person is admitted to a hospital. Typically, the episodes last from a few weeks to a few months. Second, the diagnosis requires three additional symptoms if the mood change results in expansive behavior, or four if it results in unnatural irritability. These symptoms include an unwarranted sense of self-importance, a tendency to be easily distracted, a decreased need for sleep, a rapid flow of ideas with one replacing another before the first is acted upon, an inability to sit still or increased activity directed at achieving some goal, an irrepressible need to talk, and finally, a devotion to some activity the patient finds pleasurable but could be harmful. The third criterion is that the symptoms do not qualify the patient for a diagnosis of mixed episode . Fourth, the patient can not function normally at home or at work, or shows signs of psychosis . The fifth and last criterion is that the cause of the episode can not be attributed to side effects from any drug abuse, medication, medical treatment, or medical condition.

Many of these symptoms are also present in a hypomanic episode. A hypomanic episode is similar to a manic episode, but the symptoms may be experienced to a lesser extent. The main differences between a manic and hypomanic episode are the following:

• A hypomanic episode may only last four days, whereas a manic episode, by definition, lasts one week.
• In a manic episode, psychotic features (hallucinations and delusions ) may be present, but in a hypomanic episode, they cannot be.
• A manic episode significantly impairs the affected person's functions, but a hypomanic episode does not.

Both of these kinds of episodes may be seen in patients with bipolar disorder .

Dean A. Haycock, Ph.D.

man·ic de·pres·sion • n. another term, esp. formerly, for bipolar disorder.DERIVATIVES: man·ic-de·pres·sive adj. & n.