When Bipolar Mania Gets Out of Control

For many with bipolar disorder, mania feels dangerously good.

By Jeanie L. Davis
WebMD Feature

Reviewed by Stephen B. Miller, MD

 

There’s no denying the exhilaration that mania brings. For many with bipolar disorder, there’s a period of denial — a disbelief that the wonderful surge of energy and euphoria marks a disease that truly needs treatment.

“Mania is a fascinating thing … it’s the brain creating its own hormonal high,” says Carrie Bearden, PhD, a clinical neuropsychologist and assistant professor of psychiatry at UCLA. “Most people first become manic in their early 20s, at a time in life when they’re not thinking about death, when they feel immortal.”

Indeed, some degree of risky business is the hallmark of mania. Erratic driving and out-of-control spending sprees are common. It’s a time when flashy business ideas are borne, torrents of phone calls made.

And yet, that’s not true for everyone. There are several types of bipolar disorder, and all involve episodes of mania and depression — but to varying degrees.

  • With bipolar I, there are severe mood swings.
  • With bipolar II and cyclothymic disorder, there are milder versions of the illness.
  • Mixed bipolar is both mania and depression at the same time — a dangerous mix of grandiosity, racing thoughts, yet irritable, moody, angry.

People often believe that mania feeds their creativity. The incidence of bipolar disorder is high among poets and writers, Bearden tells WebMD. “A lot of people feel they are most productive during this time. You’re up, feeling good, energetic. A lot of patients I’ve seen, even if they are not in a creative field, pursue some sort of creative endeavor — writing songs, playing music, writing screenplays.”

However, “that simple euphoria doesn’t really last,” she explains. “It’s not like you can hover there. And that’s the hardest thing for people to deal with. Frequently it takes people awhile to realize that they need to be on medication. It’s a trade-off of losing some euphoria to become more stable.”

When Bipolar Mania Gets Out of Control

A lot of bad decision-making can happen during the manic phase, Bearden tells WebMD. “It can ruin lives and relationships. There can be extreme irritability. You start yelling at strangers on the street. That’s often why they’re brought in by police, if they’re causing a big disturbance, if they get into a fight in a bar or something like that.”

“Insight is not the middle name of mania,” says Kay Redfield Jamison, PhD, professor of psychiatry at Johns Hopkins University School of Medicine and author of An Unquiet Mind and other books on bipolar disorder.

“Most manic episodes are highly unpleasant,” Jamison tells WebMD. “Even people who get euphoric can end up having terrifying experiences. Some people recognize when it becomes destructive, but certainly not everyone. That’s when the family and the law come in.”

Many people begin treatment via a trip to the hospital ER — often, against their will. “To be quite honest, if someone were experiencing only the manias — even if they recognize things are bad — it would be difficult to convince them they need to be on medications,” Bearden says.

While depression is difficult for anyone, it’s especially traumatic if you have bipolar disorder, she tells WebMD. “It’s such a dramatic change from the mania. And if the depression becomes very, very severe, people may become suicidal. That’s why a lot of people come for treatment. At that point, people realize they need to be on medication for the depression — and to take the edge off the highs as well.”

Bipolar Disorder Medications: Why Quit?

In recent years, the medication menu for treating bipolar disorder has become quite complex. Most patients with bipolar I start with lithium. Drugs used to treat other illnesses have also been pulled into treatment: antiseizure medications, antipsychotics, calcium channel blockers, and benzodiazepines.

The medications can work very effectively in smoothing the highs and lows, helping people feel “normal,” says Edith Harvey, MD, staff psychiatrist with the Hope Program at the Menninger Clinic in Houston.

“There are a lot of people out there who are extremely functional despite their bipolar disorder — doctors, lawyers, judges, movie stars,” Harvey tells WebMD. “It’s a very treatable disorder. I would have to say the majority of people who get into treatment stick with it. It’s a smaller percentage that repeatedly gets sick.”

What makes people quit taking medication? Very often, it’s denial that the problem is a real illness. Another issue is intolerable side effects, especially lethargy and weight gain. Or the medication may not be working very well, says Harvey.

Many people quit because they don’t like their doctor, Bearden says. “Usually, the doctor saw them for five minutes, gave them a drug, and they didn’t like the drug. Not feeling listened to is a huge factor.”

“People may be aware of the risks of not taking anything, but it’s a free country,” Harvey says. “A lot of times, people have to go off their medications and get sick again before they are more accepting of treatment.”

Fine-Tuning Treatment for Bipolar Disorder

It’s critical that patients get intensive, ongoing psychotherapy plus medication — but very often that doesn’t happen, Jamison tells WebMD. “There is a lot of evidence that the combined use of medications and psychotherapy makes treatment successful. That should be the standard of care, but it is not.”

Indeed, the psychiatrist is the anchor in the treatment program, Bearden says. “Psychiatrists are becoming a lot more tuned in to patients. We’re getting a lot better at listening. We’re really trying to understand what’s going on from the patient’s perspective.”

A large study called STEP-BD looked at the effectiveness of treatments for bipolar disorder. The study showed that people with bipolar disorder receiving intensive psychotherapy in addition to medication recover faster from depression than those receiving medication alone.  These results support the concept of combining medications and psychotherapy in the treatment of bipolar disorder.

“The big focus is on developing a more individualized approach — not just prescribing a medication, but listening to the patient’s feedback on various medications,” she tells WebMD. “It’s more of a team effort. It’s such an art, not just finding the right medication, but finding the right dosage for that person, even using combinations of medications.”

Harvey agrees: “Lithium is a wonderful medication, but some doctors don’t fine-tune lithium as well as they should. If people take high doses of lithium, it may slow them down, and they don’t want to continue with it. Having people on the least amount possible helps them still be productive, still feel that creativity. We can keep them from becoming manic without having the severe side effects — weight gain, water retention, and fine tremor.”

Fine-Tuning Treatment for Bipolar Disorder continued…

Even with medication, some people continue to have manic or depressive episodes, says Harvey. “As with any mental illness, stress can be a trigger. If you’re taking lithium, profuse sweating can affect your lithium level — especially if you’re very sensitive to medication.”

Insomnia is often the first sign that a manic episode is looming, she says. “I give patients a small sedating dose of non-addictive medication that they can take to help them sleep, to try to squash that problem. It’s usually an antipsychotic, because if they were becoming manic, that’s what we would use anyway.”

Patients need to learn about their bipolar disorder, Harvey says. “They need to understand the disorder itself, the medications and side effects that might occur, why different types of medications are important, the importance of taking medications on a regular basis.”

The Ripple Effect of Bipolar Disorder

Treatment should be more than just taming mania and depression. “Just getting rid of symptoms doesn’t help with finding a job,” Harvey says. “You may need to see a case manager for work rehabilitation. Getting back to work and social functioning should be part of treatment.”

Indeed, bipolar disorder has “a huge ripple effect in your social relationships, occupational functioning, everything else,” says Bearden. “People need programs that provide structure and help people get back to functioning.”

At Menninger, Harvey’s team works intensely with patients in relapse prevention, she tells WebMD. “Rehab specialists are important. This has been extremely disrupted in their lives. How does it affect their families? Will they still have their jobs? What kind of treatment support do they need? What support groups or resources do they need?”

For some patients, depression is difficult to treat, says Bearden. “It’s hard to make the depression completely go away. In between manic episodes, they still have some residual depression.”

That’s why a close relationship with a psychiatrist is critical, she says. “If the doctor is trying different medications, adjusting dosages, it gives them a sense they are being listened to. It gives them hope that things can get better … and that improves participation in treatment.”

If you live anywhere near a university that is conducting clinical trials, that’s a good way to get free medications and free treatment, Bearden advises. Look for studies that are comparing medications that are already FDA-approved, comparing one medication against another, so you won’t get a placebo.

“A clinical trial is a great way to get good-quality treatment,” Bearden tells WebMD. “A lot of people are wary about participating in a trial, but if it’s done by an academic institution, it’s generally high-quality. And they’ll get frequent follow-up visits, which, regardless of the type of treatment, is one of the major factors in success.”