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Mental Illness Fellowship Victoria. (n.d.). Factsheet – Understanding bipolar disorder. http://www.mifellowship.org/sites/default/files/styles/Fact%20Sheets/Understanding%20Bipolar%20Disorder.pdf

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Bipolar disorder is a mental illness that was previously referred to as manic depression. It affects the normal functioning of the brain so that the person experiences extreme moods – mania and depression.

People may also experience psychosis in the manic and/or depressed phase. A variety of types of bipolar disorder exists. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), the following are the distinct types:

Bipolar 1 disorder – characterised by one or more major manic or mixed episodes, usually accompanied by major depressive episodes
Bipolar 2 disorder – characterised by one or more major depressive episodes accompanied by at least one hypomanic episode
Cyclothymic disorder – characterised by at least two years of numerous periods of hypomanic symptoms (that do not meet criteria for a manic episode) and numerous periods of depressive symptoms (that do not meet criteria for a major depressive episode)
Bipolar disorder not otherwise specified – where bipolar features exist but do not meet any of the criteria for any of the specific diagnoses above. DSM (IV) further divides these distinct types into many subcategories.

1.6 percent of the population will develop bipolar disorder at some time in their lives.

The causes are not fully understood, but a genetic predisposition to the development of the illness has been clearly established.

While there is no cure for this illness it is highly treatable and manageable and 80–90 percent of people recover.

Community management of acute episodes of mania or depression depends on the degree of risk associated with the behaviours and mood. People will be hospitalised if their mania causes them to engage in life threatening, risk-taking behaviours and if their depression causes suicidal ideation or similar.

A biopsychosocial approach that includes attending to the biological need (chemical imbalance), as well as the psychological and social aspects of life is the most effective method in the treatment of, and recovery from, bipolar disorder.

Medication helps the brain to restore its usual chemical balance. Medications commonly used for bipolar include:

Antipsychotic medication, used to control psychotic symptoms and severe agitation
Mood stabilisers, which are the mainstay of maintenance therapy and improve symptoms during acute manic episodes
Lithium is the most commonly used mood stabiliser

Verbal therapies are a very useful adjunct to medication for the management of bipolar disorder. The therapy of choice for bipolar is Cognitive Behavioural Therapy (CBT), but family therapy and other therapies can also be helpful. Improving coping mechanisms and identifying triggers to episodes can be achieved in this context. The development of and adherence to a Wellness Recovery Action Plan can be a very useful strategy for prevention of relapse for people experiencing bipolar disorder.

People with bipolar disorder have a great need to maintain a healthy and balanced lifestyle to reduce stresses that may trigger episodes. Social support and meaningful occupation all support the recovery process from bipolar disorder.

Recognising that someone is displaying symptoms of bipolar disorder is the first step to offering helpful interventions. Overleaf [below] are behaviours common to the experiences of depression and mania, with suggestions for helpful interventions.

Insight into the Experience of Depression
Symptom	Associated behaviour Remember, these behaviours are out of keeping with the person’s normal value system	Helpful interventions
Depressed mood, loss of interest or pleasure in nearly all activities	Characterised by expressions of helplessness and hopelessness Depressed most of the day Loss of interest or pleasure in activities, the person may not move much or may just stare into space Skin may become coarse and dry, and hair lank and greasy or sparse Sometimes a person can articulate having no feelings, but a depressed mood can be inferred from the person’s facial expression or demeanour Sometimes, depressive mood can be exhibited in irritability rather than sadness, including persistent anger, overreaction to events, angry outbursts and blaming others Social withdrawal Sometimes a significant reduction from previous levels of sexual interest or desire	Be aware you cannot jolly the person out of this state Connect with the emotion of the experience rather than try to change someone’s mind eg. ‘It must be very hard to feel so low’ Reinforce your love for the person Try to sit beside and be in the person’s space – often people who are depressed do not like to make demands on others but they appreciate company. Likewise, you will need to do the talking rather than expecting the person to do so Keep up good levels of communication even when not reciprocated eg Let the person know where you are going even if there is no response
Inability to concentrate	Poor concentration and poverty of thought, where the person has difficulty putting sentences and thoughts together, may give monosyllabic responses, and need prompting May appear easily distracted or complain of memory difficulties A reduction in ability to achieve intellectually demanding tasks	Attend to safety issues that poor concentration can cause eg if someone works with knives or drives a vehicle Set realistic tasks Have realistic expectations
Suicidal ideation	Recurrent thoughts of death May talk about death or suicide May attempt suicide	Always treat talk of suicide seriously Be aware of suicide risk. Ask the appropriate questions and communicate with treating team about this issue. This issue may be a reason for hospitalisation If the person expresses unexpected happiness and begins to give possessions away, seek assistance immediately
Decreased energy, tiredness and fatigue	A person may report sustained fatigue without physical exertion Smallest tasks seem to require substantial effort May take twice as long as usual to do things eg washing and dressing in the morning	Avoid placing unrealistic demands on the person Be patient Affirm small achievements
Sense of worthlessness or guilt	May translate into belief that the person has done something terrible and needs to be punished for it May include unrealistic negative evaluation or self worth Guilty about preoccupations over minor past failings Misinterprets neutral or trivial day-to-day events as evidence of personal defects Exaggerated sense of responsibility for untoward events	Connect with the emotion of the experience rather than try to change someone’s mind eg ‘It must be very hard to feel so low’ Affirm small achievements Avoid too much attempt at problem-solving. The person probably will not be ready Avoid long self-effacing, self-defeating talk from the person
Changes in appetite	Most commonly, reduced appetite Sometimes an increase in appetite but usually cravings for particular foods, eg sweets or carbohydrates Significant loss or gain in weight	Be aware of hydration and nutrition issues. Again, these issues may need to be attended to in hospital
Changes in sleep patterns	Most commonly insomnia Not sleeping at all or waking early in the morning, (usually between 2am and 4am) when normally the person does not have trouble sleeping Less frequently, over-sleeping	Try to do some exercise like walking around the block Medications can certainly assist
Insight into the experience of mania
Elevation in affect (mood)	Increased confidence Inflated self esteem Distractibility May be described as euphoric, unusually good, cheerful or high May also alternate between euphoria and irritability. Note: It is important to remember that the person’s mood is very infectious. They can get everyone contributing. However, when others participate in the fun it can escalate the situation. Others can be presumed to be able to control their excitement. The person in this state cannot, and the situation can get out of hand, which may result in some combativeness and conflict.	Be calm Do not participate in the escalation of excitement Use simple, clear communications, and make sure the message has been understood. You may need to repeat, but do not push Make sure that you move away from potential conflictual situations. Use their distractibility to come back again When the person is able to take feedback, provide something like ‘You are a little high at the moment, what about listening to some music’, in a gentle way
Thoughts racing	Flight of ideas shown by continuous flow of accelerated speech, with sudden changes from one topic to another When this is severe, speech may become disorganized and incoherent	Do not make too many demands Reduce stimulation and loud noises
Inflated self-esteem	Uncritical self-confidence or, sometimes, marked grandiosity. These can be delusional May give advice on matters about which they have no special knowledge Despite lack of any particular experience or talent, person may embark on writing a novel or composing a symphony	Avoid conflict Keep the person’s real level of expertise in mind. Do not allow yourself to be overly influenced by their persuasive presentation of advice Remember that this is the illness speaking
Manic speech	Typically, manic speech is pressured, loud, rapid and difficult to interrupt May talk non-stop sometimes for hours on end and without regard for others’ wishes to communicate Sometimes joking, punning and amusing irrelevancies Person may become theatrical, with dramatic mannerisms and singing Sounds rather than meaningful sentences may govern word choice	This is very tiring so make sure that you get some space, which you will need to regulate for yourself – the other person will not recognize your need When you want space, try to manage your emotional state as the individual will pick up on your distress and you may have to defend yourself, as the person will not see themselves as unreasonable Be genuine, try not to turn off. When something is funny enjoy it
Increased physical mobility and energy	Restlessness Can set out on tasks that take great physical exertion eg walking a long way Unaware of thirst, hunger, heat or cold Increase in goal-directed activity, often excessive planning, and participation in multiple activities Increased sexual drive, fantasies and behaviour May simultaneously take on new business ventures without regard for risk or satisfactory outcomes Increased sociability – renewing old acquaintances, ringing friends (or even strangers) any time of day or night with no regard to the intrusive, domineering and demanding character of the interactions May write a torrent of letters/emails on many topics to friends, public figures or media	Be conscious of the safety factor. The danger of physical complications may be one of the trigger factors to indicate the need for hospitalisation If you can, help the person to use some of their energy on a walk or helping in the garden Remember it is very easy for this person to end up with disturbed sleep patterns, sleep late and spend half the evening ringing people. You may need to seek advice about medication for sleep In hot weather, fluid replacement is important, particularly when the person is on lithium People can become so dehydrated that the blood concentration of lithium increases to such an extent that the person can go into a hepatic coma. Lithium also increases sensitivity to sun Encourage the person to drink small amounts regularly. Consider what the person likes to drink and make it easily available. Address nutrition in the same way, thinking of high-energy food
Decreased need for sleep	Person can be most active at night when every one else is sleeping Increasing stimulation – radio, television Person awakens earlier than usual, feeling full of energy Person may go for days without sleep and yet not feel tired	Encourage the person to have a bath or a shower Some people suggest warm drinks, but not coffee or tea. This helps the person feel looked after
Expansiveness and recklessness	Unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions May start extensive conversations with complete strangers Intrusive behaviour eg overly enquiring Crosses personal boundaries Spending sprees Risk taking eg driving fast, walking on roads, jumping distances Increase in goal directed activity eg composing a musical, solving a technical problem Imprudent involvement in pleasurable activities such as buying sprees, foolish business investments, indiscriminate sexual encounters with strangers, or sexual infidelity when this is not characteristic	Be assertive about your own boundaries in a friendly manner Take action to protect assets where necessary Reduce access to dangerous situations eg put car keys in a safe spot Try to support the person in managing their sexual urges. If a young girl (in particular), try to organise a friend to accompany her on her outings Remember, in partner relationships intimacy demands may increase substantially. You will need to work out your own limits
Delusions and hallucinations, especially of a grandiose nature	Delusions of grandeur eg ‘I am Jesus Christ’ Hallucinations	Do not argue about the reality Connect with the emotion of the delusion or hallucination eg ‘It must be frightening to believe that you are Jesus Christ

Note: Risk taking behaviour is often related to manic episodes and can alert families and individuals to the onset of such an episode. Mania may begin as pleasurable so that people will be reluctant to give it up, and develop into a state that is out of control and frightening.

In addition to the specific interventions previously mentioned, there are many things friends and family can do to help.

Always remember that bipolar disorder is a medical condition that requires medical treatment. Just as you cannot stop a person’s leg bleeding by talking to them, you cannot stop bipolar disorder without medical intervention. Treatment is effective.
Find out as much about the illness as you can. Knowledge is power and gives you a much better chance of developing good coping strategies.
Be patient. People experiencing bipolar disorder need to come to some insight regarding their illness. This is not always easy and takes time.
Know what to expect of the mental health system and be prepared to be assertive in seeking appropriate care.
Link in with community organisations that offer supports and services that complement the mental health system. They often provide educational programs, counselling and local support groups.
Remember to stay healthy yourself. Do not underestimate the impact of the illness on you. Acute episodes of depression or mania often involve trauma and grief and have an impact on whole families. Be prepared to seek support to develop strategies that keep you well.

Ask an expert – receive answers to questions about schizophrenia from consultants and professionals: SFNSW
www.sfnsw.org.au/questions/discussion.htm

Mental Illness Fellowship Victoria
www.mifellowship.org

Mental Health Services Website (Vic)
www.health.vic.gov.au/mentalhealth

National Alliance of the Mentally Ill (NAMI) (USA)
www.nami.org

Mental Health Council of Australia
www.mhca.com.au

SANE Australia
www.sane.org

Beyond Blue
www.beyondblue.org.au

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M00794A

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