Bipolar Disorder: Overview
Bipolar Disorder: Overview
— Leslie E. Packer, PhD
YOU MAY NEED MORE THAN ONE PLAN
Bipolar Disorder is a condition in which the student “swings” between different types of mood episodes: depression and mania or depression and hypomania. Bipolar Disorder used to be called “Manic-Depression.”
WHAT ARE HYPOMANIA AND MANIA?
The prefix “hypo” means “under,” so “hypomania” actually translates into “under mania,” or just below the level of (full) mania. An individual who is hypomanic will be sleeping less (or may not sleep at all), will have a burst of energy, feel heightened focus or creativity, a sense of increased confidence, and may be able to accomplish a lot and tackle a number of meaningful and organized projects.
If the individual is able to control the hypomania, it is a state that may actually be very positive and pleasurable. Some of the impulsivity and increased energy may result in spending sprees or other activities that, while not bizarre, are not what the individual would normally do. While some aspects of hypomania are experienced as positive, the individual’s impulsivity can pose genuine problems. Distractibility is often present, and as in mania, speech may be very rapid as the person responds to everything going on around them. All too often, hypomania progresses into full-blown mania. While some people think of mania as the opposite of depression, i.e., as a “high,” it is not really that way, although hypomania (and early stages of mania) are associated with feelings of euphoria or exuberance. The evolution of a hypomanic episode into mania might look like this:
- Manic episodes generally begin with what is experienced as an improvement or upward shift in mood. This initially euphoric or elated mood, accompanied by decreased need for sleep is usually experienced as an initially increased sense of energy and confidence. This is the hypomanic state.
- As the hypomania progresses into mania, thoughts begin to race and speech becomes rapid (pressured).
- The euphoria is replaced by irritability, and in some cases, assaultiveness.
- The individual becomes more impulsive, disinhibited, and takes more risks.
- Thoughts become more disorganized, and in severe cases, delusional or psychotic.
A student in a severely manic state is in as much (or even more?) danger as an individual in a major depressive episode.
COURSE OF BIPOLAR DISORDER AND SUBTYPES
Any two students with Bipolar Disorder may look and function quite differently. Indeed, any one student with Bipolar Disorder may look and function quite differently at different times, depending on their mood state. For some students with Bipolar Disorder, there may be long periods of relative wellness between the different mood cycles. Some students will cycle very rapidly, and other students with Bipolar may appear to be “chronically irritable” or in a chronic “mixed” state that has both manicky features and some depressive features. Indeed, if the predominant symptom is irritability, it may be difficult to know whether it is from depression or mania. An individual in a mixed episode may exhibit signs of agitation, suffer from insomnia, experience changes in appetite, have some psychotic features, and experience suicidal thinking. A student in a mixed mood episode may be in serious danger if they have the suicidal thoughts of depression and the energy of mania to complete the suicide.
There are different subtypes of Bipolar Disorder (although the following may change when the DSM-V is released in a few years):
- Bipolar Disorder Type I is characterized by at least one manic episode, with or without major depression. With mania, either euphoria or irritability may mark the phase, and there are significant negative effects.
- Bipolar Disorder type II is characterized by at least one episode of hypomania and at least one episode of major depression. With hypomania the symptoms of mania (euphoria or irritability) appear in milder forms and are of shorter duration. They do not affect social or school functioning as dramatically.
- Cyclothymic Disorder is not as severe as either Bipolar Disorder II or I, but the condition is more chronic. The disorder lasts at least two years, with single episodes persisting for more than two months. Cyclothymic disorder may be a precursor to full-blown bipolar disorder in some people or it may continue as a low-grade chronic condition. Some people refer to Cyclothymic Disorder as Bipolar III.
MAIN IMPACT OF BIPOLAR DISORDER IN SCHOOL
While elevated mood may be the symptom most often associated with mania, irritable mood may actually be the most prominent symptom and the individual may appear very labile (or quick-changing) in their moods — expansive at one moment and irritable when thwarted.
Sleep disorders associated with both depression and Bipolar Disorder will impact the student’s ability to wake up in the morning, get to school on time, and concentrate (particularly in the morning).
Medications used to treat Bipolar Disorder may produce increased thirst, lethargy, tremors, appetite change, diarrhea, nausea, and vomiting, among other side effects.
Panic Disorder has also been found to be comorbid with Bipolar Disorder in almost 1 in 5 cases. Students who have both Panic Disorder and Bipolar Disorder are more likely to have psychotic symptoms and suicidal thinking.
Obsessive-Compulsive Disorder is often comorbid with Bipolar Disorder and may complicate treatment.
Memory functions and processing speed are often impaired. Medications may also impair memory due to side effects. Many students with Bipolar Disorder will require accommodations for memory problems and retrieval issues.
Math is often impaired, even when the student is in a euthymic (“normal”) mood state.
Peer relationships and socialization are often impaired due to the symptoms of the disorder being unacceptable to peers and/or due to deficits in the ability to accurately interpret facial expressions of others during mood episodes. Many students with Bipolar Disorder have difficulty with this and may misinterpret peers’ facial expressions as indicating anger.
Bipolar Disorder seldom occurs by itself. The most common comorbid condition is ADHD, which comes with a whole host of problems. School personnel need to screen for other conditions if a student is diagnosed with Bipolar Disorder.
On a positive note, some students with mood disorders will be highly creative and the “exuberance” of a hypomanic episode may be associated with even greater
WHAT TO DO
If you have a student who is diagnosed with Bipolar, talk with the parents and ask them to let you know when their child seems to be starting a new cycle. With teenagers, you can ask the student to let you know themselves, but some teenagers may not recognize when they are going into depression or mania and other teenagers may just be in denial and refuse to admit (to themselves or you) that they are in a mood swing. Teenagers who have been in psychotherapy may be more likely to recognize and acknowledge when they are starting a mood swing.
Your support and empathy are crucial to how the student will fare in school. It may be very difficult to cope with a student who seems “mean as a snake,” or who seems calculating and manipulative, but remind yourself that the student is a victim of their own neurochemical turmoil. Although they may appear to relish being nasty or they may appear to be trying to manipulate you, there are reasons for their behavior. They may be manicky and are just covering up their confusion over why they are saying and doing things that they know are inappropriate.
Unlike other conditions or disorders that are variable but predictable on some level, with Bipolar Disorder, you may need to have a “Plan A” and a “Plan B” for the student, depending on what type of episode (if any) they are experiencing.