Bipolar disorder: More than a punchline

For a recent "Tonight Show" skit, Jay Leno held up a bag of "Nutty" brand pancake mix. That's not truth in labeling, the comedian said, turning the package around. On that side the brand name was "Bipolar."

At least people who have bipolar disorder weren't laughing.

A powerful stigma is attached to being bipolar. "The stigma is that everybody who's bipolar could go wild," said Sue Floyd, a board member of the Depression Bipolar Support Alliance in Cape Gir?ardeau.

Many people don't understand the disorder and its varying severity. Their first impulse is to stay away from someone who's bipolar. People who have the disorder fear that reaction. That's one of the problems with Leno's joke.

"If people are laughed at, it's just going to drive them back in their shell," said Dr. Kishore Khot, a psychiatrist at the Community Counseling Center in Cape Girardeau.

An estimated 3 percent of the U.S. population has bipolar disorder, and the diagnoses numbers are increasing, especially among children. Adult cases doubled between 1994 and 2003. In the past decade the diagnosis of bipolar disorder among children in the U.S. has increased 40-fold.

According to a report recently published in the Archives of General Psychiatry, "Either bipolar disorder was historically underdiagnosed in children and adolescents and that problem has now been rectified, or bipolar disorder is currently being overdiagnosed in this age group."

Missouri's Department of Mental Health saw 3,227 people whose diagnosis included bipolar disorder in 1995. In 2006, the number had more than doubled to 7,243. Part of the increase could be due to the expansion of community outreach services that has accompanied the shrinkage of the state hospital system during that period, but the numbers are in line with national statistics.

In famous company

Long known as manic depression, the disorder remains misunderstood outside the mental health community. Many who have bipolar disorder can be treated with medication and psychotherapy and can hold jobs. They're in famous company. Ted Turner, Dick Cavett, Peter Gabriel, Charley Pride and Patty Duke have talked about their bipolar disorder. In an analysis of the lives of artists and manic-depression, psychologist Kay Jamison counts George Frederick Handel, Peter Tchaikovsky, Irving Berlin, Cole Porter, Herman Melville, F. Scott Fitzgerald, Charles Dickens, Mark Twain and many others as manic-depressives.

Bipolar disorder is a chronic illness like diabetes or hypertension. The term comes from the switch between depressed and manic states. People who are bipolar have had at least one manic episode during their lives. During that four-to-seven-day period they are overloaded with energy. They have trouble sleeping, can be agitated and irritable. "They start indulging in activities that might seem pleasurable, such as spending sprees or increased sexual activity," Khot said.

There are two types of bipolar disorder. In bipolar I, the most serious type that affects 0.4 to 1.6 percent of adults, symptoms include grandiosity, invincibility, racing thoughts, sleeplessness and impaired judgment. People with bipolar I can be dangerous to themselves and others. When manic they can behave recklessly. Fifteen percent commit suicide, accounting for nearly half the suicides in the U.S. Kurt Cobain, Ernest Hemingway and Virginia Woolf were manic-depressives.

Bipolar II, found in 0.5 percent of the population, is indicated by a slight high and deep depression. There are varieties. Some people cycle up and down rapidly all the time. People with mixed bipolar are up and down at the same time. Another diagnosis is so individualized that it doesn't fit into the other categories but is still considered bipolar. Yet another, called cyclothymia, involves only mild mood swings.

The cause of bipolar disorder is undetermined. A genetic tendency seems clear because the disorder seems to run in families. It can, however, skip generations.

Stress is one trigger of bipolar episodes, said Dr. Prabhakar S. Kamath, a Cape Girardeau psychiatrist. Kamath thinks an overload of emotions is involved in bipolar disorder. His book, "Is Your Balloon About to Pop?," likens the mind to a balloon that keeps filling and filling with emotions until release is inevitable. "The result is like the household voltage going up from the usual 120 volts to 300, 400, 500 or even 600 volts," he writes.

The person is burying feelings rather than dealing with them and will tell you nothing is going on their life, Kamath said. "They are masters of self-deception."

But Khot said episodes sometimes occur in the absence of stress. "It's not clear what the triggers are," he said.

Sent to an institution

Belinda (not her real name), a 54-year-old Cape Girardeau housewife, was not diagnosed with bipolar I until 2000. But her first episode occurred when she was 18 -- close to the median onset age of 20 -- while living in Louisiana. Her suspicious father was waiting when she got home the night she lost her virginity. He slapped her and went looking for the boy with his shotgun.

She experienced what was then called a nervous breakdown. The next day Belinda wore her prom dress waiting for her Prince Charming to rescue her. Three months later her family sent her to a state mental institution in Mandeville.

At Mandeville, Belinda was forced naked into isolation, where she had to urinate and defecate on the floor. A doctor sexually abused her, she said. She had no diagnosis and was hospitalized twice more before marrying a man in the military. He authorized shock treatments for her. They had four children before divorcing.

People with bipolar I have difficulty holding jobs and handling their personal lives. Belinda has had many jobs: housekeeper, real estate broker, health-care administrative assistant and temp. She has worked for two accounting firms. The job she liked best was as a deputy clerk for a circuit clerk, but she couldn't type fast enough to keep up. She was fired from her most recent job in August.

Ray (not his real name) is Belinda's fourth husband. They met in 1996 when he was managing a grocery store in northern Missouri. When they married, she told him about her teenage episode.

"I didn't think anything was wrong," he said.

But Belinda soon became withdrawn. "I got scared," Ray said. "I thought, 'Marriage isn't going to work. My wife doesn't like me anymore.'"

During one manic episode she went on a buying spree, covering the deck of their house with flats of flowers. She bought bunches of pinwheel toys. "I didn't know I was acting weird," she said. "You think you're fine. Somebody has to tell you."

In 1999, her doctor put Belinda on a suicide watch and said she could no longer drive a car. "She said, 'You are like someone with ADHD,'" Belinda said.

After a hospitalization for depression her doctor told her she should not go back to work. That provoked a manic episode. Not working stresses her, she said. "I'm used to bringing my share to the table."

Stress triggers her episodes. She was hospitalized after the terrorist attacks on Sept. 11, 2001. She has been hospitalized twice this year. Each episode lasts three months. Violence has never been part of one. "I think it would have to be in your nature to do that," she said.

Belinda's conversation can be difficult to follow. "It's like a tree. It branches off and branches off," Ray said. "Anytime she goes to tell me something I don't know where the point has gone."

For better or worse

All of Belinda's children are grown and on their own now. She said two have accepted her condition and two don't want to talk about it.

"It takes a lot to live with a person like this," she said. "I don't know if I could do it."

Ray says he can. "Do I understand the disease? No. Do I accept it? Yes. It would be the same as if another person had developed diabetes," he said. "I'll take her for better or worse."

Ray commutes more than an hour to the grocery store he manages. He can't find as good a job nearer to home and needs the health benefits. Each hospitalization for Belinda sets them back financially. Some people with bipolar disorder qualify for state disability benefits. Belinda's application was denied, and her appeal won't be heard until spring. In the meantime they're in danger of losing their house.

"To keep her I'll lose it," Ray said.

Part of the difficulty in treating bipolar disorder is that people who start feeling better because of their medication want to stop taking it.

Khot said many people with bipolar disorder are walking around undiagnosed. Some self-medicate with alcohol and drugs, which actually can trigger episodes. "They don't want to go to a psychiatrist -- especially males," he said.

Treatment includes medication and psychotherapy. All the medications have side effects, including fatigue, weight gain and stiffness of hands and legs.

Lithium, a medicine that has been around for many years, is still the gold standard for treating bipolar disorder. Some patients take a cocktail of three or four medications to control the disorder, but Khot said he always starts by prescribing just one and assessing its effect.

One of Khot's medical school colleagues had bipolar disorder. The surgeon found a medication that worked but made him sleepy and made his hands shake. "You can imagine a surgical resident whose hands are shaking," Khot said. "It works, but does it really work?"

Kamath thinks bipolar disorder is being overdiagnosed. Despite the inferences of advertisements, people who have mood swings are not bipolar, he said. "Thanks to the drug companies, we are now on the verge of becoming a bipolar nation," he writes in his book.

Local help

Help is available through the Depression Bipolar Support Alliance. The group meets at 7 p.m. the fourth Monday of every month in the Assisi Room at Saint Francis Medical Center. The phone number is 334-1100.

Jennifer (not her real name) attends the support group meetings. She originally was diagnosed with schizophrenia, then post-partum depression. "Early on I didn't think they knew what they were talking about," she said.

She didn't take the medications prescribed and had manic episodes that sent her to the state mental facility in Farmington.

"Initially it feels good, better than I ever felt," she said. "I was real elated, real talkative. Then I start to come down and have hallucinations.

"It's like living a nightmare in real life."

Her manic process takes three weeks, and the state hospital in Farmington requires people who are admitted to stay a month. "That's two months out of your life," Jennifer said. "I'm usually begging to get out."

Her last stay was 14 years ago. She works part time and doubts she could handle the stress of a full-time job.

Bipolar disorder can be treated but can get worse if left untreated. "It is not a crazy disorder," Khot said. "People don't have to think they're going crazy. This is an illness that can be treated."

sblackwell@semissourian.com

335-6611, extension 137