The Cruel Duality of Bipolar Disorder: Creativity and High Risk

Henry Nasrallah, MD

Henry Nasrallah, MD, Course Co-Director of the 3rd Annual
Mood Disorders Symposium. Photo by Cindy Starr / Mayfield Clinic.

What did Abraham Lincoln, Winston Churchill, Leo Tolstoy, Virginia Woolf and Jimi Hendrix have in common? And what condition do Judy Collins, James Taylor, Kitty Dukakis, Kay Jamison and Catherine  Zeta-Jones also share? The answer is bipolar disorder, a mood disorder characterized by periods of high energy, euphoria or irritability, and sleeplessness followed by periods of depression.

The condition was the topic of Saturday’s third annual Mood Disorders Symposium, a continuing education event that was held at UC Health Drake Center. The event was sponsored by the Mood Disorders Center at the UC Gardner Neuroscience Institute, one of four institutes of the UC College of Medicine and UC Health; the Department of Psychiatry and Behavioral Neuroscience; and the Center for Clinical & Translational Science & Training.

Henry Nasrallah, MD, Professor of Psychiatry and Behavioral Neuroscience and Vice Chair for Education and Training, said the topic was a fitting one for May, which is national Mental Health Awareness Month. April and May represent the peak suicide months of the year, and 15 to 18 percent of people with bipolar disorder will die of suicide if they go untreated. “Bipolar disorder can make a person more creative and productive, and there are many examples of high-achieving people with bipolar,” Dr. Nasrallah said. “Georg Friedrich Händel wrote the Messiah in two weeks during a manic episode. But the condition is also disabling. Bipolar disorder has one of highest associations with suicide in medicine.”

Stephen Strakowski, MD, explained the neurobiology of bipolar disorder.

Stephen Strakowski, MD, the Stanley and Mickey Kaplan Professor and Chair of the Department of Psychiatry and Behavioral Neuroscience and Vice President of Research for UC Health, said bipolar disorder is a brain disease. “It is not caused by bad parenting or the environment; it is caused by genetics,” he said.

Fortunately, many treatments for bipolar disorder exist, including longstanding medications (e.g., lithium), newer mood stabilizers and antipsychotics, various types of interpersonal and family-focused therapy, transcranial magnetic stimulation and electroconvulsive therapy.

Bipolar disorder exists on a spectrum, Dr. Nasrallah said, and a recent survey of 100,000 people suggests that it affects 3.7 percent of the population. People with bipolar I suffer severe depression and mania (disabling extreme moods) and may be hospitalized for both. People with bipolar II have less dramatic periods of “hypo-mania” and are hospitalized only for major depression. “Bipolar patients are the ones who are reading four or five books at the same time,” Dr. Nasrallah said. “They typically are not diagnosed until the mania interferes with their job or they are hospitalized.”

Treatment is vital because a brain bathed in cortisol – a stress hormone – can undergo serious changes. Although bipolar disorder cannot be diagnosed with brain imaging, brain imaging studies have revealed specific characteristics in the bipolar brain. Several imaging studies, but not all, have shown that the amygdala appears to develop abnormally in untreated patients with bipolar disorder.

“The amygdala, which processes our fight-or-flight reactions to fear, is smaller than normal in children and enlarged in adults with bipolar disorder,” Dr. Strakowski said. “The developmental process in the amygdala has gone awry.”

At the same time, the ventricles, reservoirs where fluids are exchanged, spread and grow larger, reflecting a loss of surrounding brain tissue. “These patients lose white-matter connections, the connecting neuronal pathways, in the brain,” Dr. Strakowski said. “We worry that the efficiency of these networks is degrading.”

Brain imaging of people with bipolar disorder reveals heightened activity in the amygdala and prefrontal cortex, where executive function resides. “Our hypothesis is that the prefrontal cortex is over-working to control an over-activated amygdala,” Dr. Strakowski said. “The brain is compensating at baseline, struggling to maintain a dysfunctional emotional regulatory system. During mania, the amygdala loses prefrontal control, which leads to wild emotional swings.” Glutamate, an  excitatory neurotransmitter, is elevated in people with bipolar disorder, as is lactate in the brain, reflecting abnormalities with energy management “at a very deep cellular level,” he said.

Other general points of interest from the symposium included:

Only 20 percent of people with bipolar disorder have been diagnosed, and the average person with the condition will suffer for eight years before receiving a correct diagnosis. The average age at onset is 18 to 24 years, although children have also been diagnosed with the condition. Sixty percent will initially be diagnosed with depression. Bipolar disorder is equally common in men and women, while unipolar depression is much more common in women.

In families with strong heredity, the onset of bipolar disorder may occur earlier with successive generations.

After April and May, October brings the second-highest wave of suicides. Researchers theorize that the light-dark change triggers mania, which leads to suicide. A lethal combination of “depressive thinking, combined with the energy to do something about it,” results in these tragedies, Dr. Strakowski said. “We need to keep a close eye on patients at those times.”

Medications for bipolar disorder can include a host of unpleasant side-effects and can be challenging for patients. A collaborative partnership among health care providers and caregivers and family can maximize the potential for recovery, said Caleb Adler, MD, Associate Professor of Psychiatry and Behavioral Neuroscience and Co-Medical Director of the UC Mood Disorders Center.

Catherine, a social worker, shared her story of recovery.

Catherine, a survivor of bipolar disorder who is now a social worker, said that therapy, medication, family support and a consistent work and sleep schedule were all part of her recovery.

Melissa DelBello, MD, Professor of Psychiatry and Behavioral Neuroscience and Co-Medical Director of the UC Mood Disorders Center, said some data suggest that omega 3’s will help some depressive symptoms. Even if they fail to do so, they can help counteract risk factors like weight gain, a side-effect of some medications.

When to switch doctors? A patient should switch if he or she does not like his or her physician and should not fear getting a second opinion. “Only a weak doctor would object to your getting a second opinion,” Dr. Strakowski said. “If your doctor objects to getting a second opinion, that alone suggests it’s time for a change.”

— Cindy Starr

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