“I felt exhilarated, as if I were bursting with creativity, energy and euphoria.” That sounds like someone raring to go, fuelled by a creative high. Certainly nothing to complain about. As it turned out, it was an early warning sign that the person was heading for one of the most complex and challenging mental disorders that we know. In the course of therapy, this young man said, “For the longest time, I didn’t realize that this was mania.”
The early warning signs of Bipolar Disorder (BD) can be so misleading, sometimes so subtle – and sometimes so confusing, even – that they are often missed, even by mental-health professionals, unless the person has severe mania.
One of the so-called “mood disorders”, BD is marked by extreme mood swings from high to low, and from low to high. Highs are periods of mania, while lows are periods of depression. The mood swings may even be mixed, so you might feel elated and depressed at the same time or in rapid sequence.
Though BD doesn’t always arrive with a flashy calling card and can be hard to diagnose, there are certain red flags that it is well to be aware of, so that the possibility of BD can be considered.
Red flags of bipolar disorder
Long before they have an episode of either depression or mania, sufferers of bipolar disorder describe a phase during which they already felt “different” or “altered”. The symptoms experienced during this phase are the early warning signs of bipolar.
Although many of these signs are common to several sufferers, each bipolar sufferer tends to have his or her own unique set of early warning signs.
An additional point to note is that, in the early stage of bipolar, the symptoms may masquerade as a problem other than mental illness. For example, BD may make its first appearance as a drug or alcohol problem, or poor performance in school, college or at work. Children with BD often display hyperactive behavior, and may then be misdiagnosed with ADHD (Attention Deficit Hyperactivity Disorder).
The early warning signs will, of course, be different depending on which episode (depressive or manic) is in the formation stage. (In 60 to 70 per cent of sufferers, bipolar begins with a depressive episode).
Early warning signs of mania
If it is the manic phase that is emergent, the early warning signs may include these:
» Abnormally and persistently elevated mood – elation / euphoria; feeling overly happy or “high” for long periods of time.
(Sometimes, however, this high appears as greater irritability, rather than as an elevated mood).
» Excessive talking. You may feel a greater need or pressure to talk, or to speak at a faster pace than usual.
» Flight of ideas, racing thoughts. You may have a subjective experience that your thoughts are racing.
» Decreased need for sleep. Your sleep requirements may be lower (e.g., you may feel rested after only 3 hours of sleep).
» Increased activity and energy. You may feel you have a great deal more energy than normal and that you will be able to achieve more.
» Psychomotor agitation; restlessness. You may pace the floor impatiently.
» Concentration difficulties, distractibility. Your attention is too easily drawn to unimportant or irrelevant external stimuli, so that you are unable to concentrate.
» Increased self-confidence – a feeling of being able to manage everything that you intend to undertake (while actually finishing none of those tasks).
» A tendency to greater sociability than usual. You may have fewer social inhibitions (e.g., you may not think twice about phoning a friend in the middle of the night).
» Inflated self-esteem or grandiosity. The feeling of being important or at the center of interest.
» Impulsiveness, a reckless pursuit of gratification – unrestrained shopping sprees, impetuous travel, sexual indiscretions, foolish business investments, fast driving.
Early warning signs of depression
In the case of an oncoming depressive episode, the early signs in bipolar disorder are indistinguishable from those of major depression. Two hallmarks — the big red flags — are:
1. Depressed mood. You feel a persistent sadness or pessimism, helpless or hopeless, and may have crying spells, or excessive emotional sensitivity.
2. Loss of interest in normal daily activities. You lose interest in or pleasure from activities that you used to enjoy – eating, work, friends, hobbies, leisure activities and sex.
In addition to these core warning signs, in some (not all) persons, depression may also be marked by one or more of these signs and symptoms:
» Sleep disturbances. Either insomnia (having trouble sleeping), or over-sleeping can be a red flag for depression. Waking in the middle of the night or early in the morning and not being able to get back to sleep are typical.
» Impaired thinking or concentration. You may have trouble concentrating, remembering or making decisions.
» Appetite and weight changes. You may experience either reduced or increased appetite; or significant weight loss or gain.
» Agitation, Irritability. You may feel restless, agitated, irritable and easily annoyed.
This is more likely if you are male: men tend to deny having problems because they feel they have to “be strong”. So, they may show fewer of the “typical” signs of depression such as sadness or crying. But irritability, aggressiveness, anger, blame, lashing out – all these can be red flags of depression, especially in men.
» Fatigue or slowing of body movements. You feel weariness and lack of energy nearly every day. You may feel as tired in the morning as you did when you went to bed the night before. You may feel like you’re doing everything in slow motion: your movements and speech may be sluggish. You may speak in a slow, monotonous tone, or pause before answering questions or starting an action. You may speak so softly that you will not be able to be heard. You may not speak except in response to a direct question.
» Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders or chronic pain.
There could be a worsening of co-existing chronic disease, such as rheumatoid arthritis or diabetes.
» Low self-esteem. You may have feelings of worthlessness, self-reproach or excessive or inappropriate guilt.
Depression is experienced differently from one person to the next, so not all the red flags will be present in every case. One person may feel sad and “down”, unable to enjoy normal activities. Another may start eating more and sleeping all the time. A third may become angry or volatile and compulsively throw himself into his work or hobbies.
If the depressive symptoms are the first manifestation of BD in a person, as they are in the majority of cases, (s)he may – wrongly -- be diagnosed as suffering from clinical depression. Later, as symptoms of mania come on, the diagnosis will – or should -- change to bipolar disorder. Unfortunately, many of those who initially present with depressive symptoms may continue getting treatment for only depression for several years before the correct diagnosis of bipolar disorder is made.
Your action plan
One or two of the red flags of BD don’t generally predict this mood disorder. Nor should you arrive at a conclusion of bipolar if you have experienced any of these symptoms for a brief while and then they’re gone (e.g., most of us have the occasional experience of waking up in the night and finding it difficult to go back to sleep). Similarly, “mood swings” from day to day or moment to moment are not necessarily a pointer to bipolar disorder.
Instead, look for these three indicators:
» There are several red flags waving.
» The symptoms you are experiencing are persistent.
» The symptoms you are experiencing are causing serious problems in your ability to study, work, or relate to others.
Whatever the particular pattern of red flags you observe in yourself, if they persist for more than two weeks, you need to be evaluated by a health professional. The early warning signs provide an orientation, they do not constitute a diagnosis.
If you think a loved one is showing the warning signs of bipolar disorder, talk with the person about your concerns. Ask if you can make a doctor’s appointment and offer to accompany the person on the visit. Here are some suggestions:
» Have your concerns written down on a sheet of paper to make sure you cover all areas.
» Give specific details of mood symptoms and behaviors to the doctor.
» Describe any severe mood changes, especially anger, depression and aggressiveness.
» Describe personality changes, especially instances of elation, paranoia, delusions and hallucinations.
» Be sure to discuss any use of alcohol or mind-altering drugs that the person may be using since they can often cause changes in mood, which may be mistaken for the symptoms of bipolar disorder.
How early intervention can help
Untreated, the early symptoms of bipolar disorder may progress to a psychosis, where there is a loss of touch with reality. That is, the affected person may experience hallucinations (seeing or hearing things which are not there - such as hearing a voice telling him he is no good), may develop irrational beliefs (delusions - for example, intense feelings of having committed a sin), and disordered thought and speech.
Recognizing and acting upon the warning signs of bipolar disorder can often prevent the illness from becoming disabling and even life-threatening.
(The author is a former editor of 'Health & Nutrition' magazine, and now works as a counseling therapist)