This is a unique illness as its symptoms appear in different phases, sometimes with sadness and depression and sometimes with elation and hyperactivity.
Often such patients may seem to have extraordinary qualities. They can easily convince other people, and they make grandiose plans that do not materialize.
When such patients are in the manic or hypomanic phase, their activity increases dramatically. They wake up early in the morning and seem very agile. Since they appear to be highly intellectual, their illness remains hidden from people and thus they do not get a chance for treatment until they become aggressive or suicidal.
A few who may consider them ill believe their illness to be the affect of some magic, curse, taweez or due to “Jin” or “Aseb” so they contact the so called “Amil” (faith-healer) or take the patient to various mazars (shrines) for treatment. This results in delay of proper treatment and creates various problems for the patient and the family.
Symptoms
This illness is basically the illness of emotions. The patient exhibits either excessive joy or excessive sadness. However of the symptoms should be such severity that a person is unable to function normally.
(i) Depressive phase:
In the depressive phase the patient starts showing sadness, along with other symptoms like weeping, anxiety, hopelessness, wish for death, suicidal thoughts or attempts, social withdrawal, decreased appetite, headache, vertigo, and bodyache etc.
(ii) Manic phase:
The manic or hypomanic phase is usually associated with cheerfulness and talkativeness, dancing, singing, excessive charity and entertainment, walking for no reason, sleeplessness, irritability, aggression excessive writing of prose or poetry etc.
Some patients have only episodes of depression (Recurrent Depression), while some experience only mania (Recurrent Mania) whereas in between they are more or less normal.
Causes
The exact reason of this illness is not known but experts implicate the following factors:
1. Chemical changes in the brain
This illness may be due to some changes in the Neurotransmitters of the brain. The possible neurotransmitters may be DOPA, Seretonin or GABA. Some authorities claim that the patient has minor abnormalities since birth, but the disease emerges only when the patient’s resistance to stress decreases. Because medication that affect these neurotransmitters show benefit, it is considered a proof of the neurotransmitter theory.
2. Social Problems
Life-events have a direct effect on the patient’s life, especially traumatic ones. Ups and downs in life directly affect the human mind, precipitate the illness and sometimes increase the severity of illness. Since illness adversely affects the person’s abilities in all spheres of life, the affected person loses his ability to deal with everyday problems, with the result that additional problems are created, not only for the patient, but for the whole family.
The situation becomes worse if a female member of the family is affected by this illness. The female patient then wears excessive makeup, goes out of the home frequently and does excessive shopping, starts talking excessively to others with undue frankness. Her sexual desire increases, therefore her relatives including parents, husband and others, develop suspicions about the patient’s character. If the patient is a married one, this may result in a divorce and the whole family may get disintegrated.
3. Genetic Factors
Any person can be affected by this illness, but the likelihood for those increases manifold whose relatives especially the parents or siblings have already been the victim of this disease. In other words this illness shows a greater preponderance in the families of patients as compared to normals.
Treatment
1. Start Treatment as soon as possible. Early treatment of this illness is of utmost importance because delay may have drastic results. It can also result in marital conflict or loss of employment. The illness of one person may affect the life of the whole family. Moreover if treatment is started at an early stage, the chances of recovery are very bright whereas delay in the treatment of this disease might disminish the chances of its recovery.
This is a serious mental illness, and it would be preferable to refer such patients to psychiatrists for proper treatment.
The other important point to note is that medicines take time (4 to 8 weeks) to show their effect, therefore the patients and their caretakers should show patience and should not lose hope even if there is no response in the early stage of treatment. Treatment shows a beneficial effect only when appropriate levels of medication are present in the patient’s blood. Therefore it is wise to follow strictly the instructions given by the therapist in this regard.
2. Phases of Depression and Mania. In most cases the signs of mania disappear and are replaced by the symptoms of depression. Similarly when the signs of depression subside the symptoms of mania appear. Both conditions give the impression to the patient that he has recovered and because of this he may stop taking the medicines. In fact the patient should not only be treated till the symptoms of both kinds subside, rather the treatment should be continued for some further period for the prevention of relapse. How long this period should be is decided by the psychiatrist, but sometimes a life long pattern of the treatment of Diabetes and Hypertension is necessary.
3. Family should be involved. The majority of the patients and their families have no knowledge of this illness with the result that they all keep suffering without any treatment.
For the proper treatment and diagnosis of this illness, complete information is taken from the relatives of the patient and it is highly essential that all family members should cooperate with the therapist in this regard. In other illnesses patient’s condition remains more or less the same, but in this illness there is often a dramatic change from excitation to depression, and the doctor has to adjust the medicines accordingly, and so the importance of keeping close contact with the psychiatrist. Thus the medicines prescribed in the Depressive phase may be actually harmful when the patient’s illness switches to the manic phase and vise versa.
4. Complications in the early days of the treatment. In the beginning of treatment, the patient may show some minor side effects, because of which some patients or their relatives may stop the treatment. This should not be done, rather the doctor should be consulted so that treatment can be continued with proper modifications.
Side-effects seen in the early phase of treatment
Dry mouth, tremor, stiffness of body, slurred speech, rolling up of the eyeballs, excessive salivation, forgetfulness, disturbance in the menstrual cycle in females and delayed ejaculation in males.
It is not necessary that every patient develops all these symptoms or all side effects appear in the same patient. Any patient may develop any of the above side-effects and the therapist can easily treat these if contacted as soon as the problem is perceived.
5. Medicines
Fortunately very effective medicines have been discovered for the treatment of this illness. These medicines take four to six weeks to show their effect. If one medicine shows no effect, it is replaced by another. In this way, the therapist chooses the best possible medicine for the patient’s treatment.
It is very important for everyone to note that the continuous use of medicines during and after the symptoms have subsided is highly essential and failure to do this may lead to relapse. Not only the medication but also the regular check up is also important. This prevents the return of the symptoms because according to most experts, medication should be continued for at least a year after remission.
Usually there is no harm if this medication is combined with others, but it is advisable that when the patient consults some other physician for any other illness, the new physician should be informed about the medicines he or she is already using.
Mood Normalisers
In addition to antidepressants, antipsychotics and ECT such patients need mood normalizers. They are lithium and the anti convulsants Carbamazepine (Lexapine), Valporate (Dapakine), Lamitrogine (Zamictal) and Topimarate (Topiro). The details about the Anti Convulsants can be seen in the chapter on Epilepsy. Lithium is described below.
Lithium (Neurolith)
It has become an essential part in the management of Bipolar Affective Disorder. Not only does it rapidly control the symptoms of illness but reduces the chances of relapse if given prophylactically. This gives stability in the patient’s emotion and anger, but the use of this medicine needs special precautions. It needs to be used in a dose that provides a specific range in blood (0.6 to 1.2). Below this level Lithium usually has no effect, while higher than the therapeutic level produces harmful effects. Therefore it is important that frequent serum level estimations should be obtained, i.e. every ten days in the first month, and every one to three month thereafter. In Pakistan it is available with following names: Priadel, Camcolit, and Neurolith
Side-effects of Lithium
The side-effects of lithium are of two types, the mild and the severe.
(i) Mild
Mild tremor, anorexia, nausea, blurred vision, mouth dryness, fatigue.
(ii) Severe
Severe tremor, vomiting or loose motions, arrhythmia, drowsiness, seizures, hypothyrolism, diabetes insipidus or unconsciousness.
If the patient develops severe side-effects, the medicine should be stopped at once.
Food and Lithium
One should be careful about one’s diet. Patient must take his meal at the proper time and not decrease the quantity of his food too much.
Other medications and lithium
Other medications if prescribed by a physician can be used, but if diuretics are used in addition the dose should be re-evaluated, as much smaller does may be sufficient.
6. Counseling
It is one’s duty as a therapist to provide the patient and his family with as much information as possible. The patient and family members do need a sympathetic and competent psychiatrist who could provide them appropriate guidance relating to their problems so that the patient feels protected and can lead a normal life without extra stress.
7. Electroconvulsive Treatment (ECT)
ECT is also very effective, along with medicines, in both phases of the illness. A course of 7-10 treatments should be given.
8. Hospitalization
Manic patients need hospitalization. Since they do not consider themselves ill, they resist taking medication or even hospital visits. Sometimes they become aggressive and can cause harm to themselves or to the family members. Depressed patients also need protection from suicidal attempts.
Trained staff at the hospital are responsible for their care and for giving meals and medicines on time. If the patient is uncooperative injectable medicines are administered. At home because of the illness of one person, all members of the family get effected. Everyone feels insecure which leads to disturbance in their sleep, daily activities and ability to go to their jobs.
Another benefit of hospitalization is that the patient remains under the care of a therapist who by direct or indirect observation gets complete knowledge of the patient’s personality and illness. Continuous discussion of daily life problems may also provide some solution. Family counseling provides information to the care-takers which helps in dealing with the patient.
Most patients are reluctant to stay in the hospital and insist for their discharge simply because of boredom and lack of entertainment. They are also not habitual of sticking to one place so they pester their relatives to get them discharged. Relatives of the patient are advised not to surrender to their pressure because it is only the hospital where patients can make the quickest recovery.
Duration of Hospitalization
The duration of the treatment depends on the severity of the symptoms but usually patients need 3 to 4 weeks of hospital stay. Then he/she may be discharged. After that the patient may cooperate in his/her further treatment as an outpatient. This phase of treatment may be continued for a year or two. Besides lithium, other medicines are withdrawn slowly depending on the patient’s condition.
9. Duration of treatment
Because of the long course of illness, some patients and caretakers become frustrated and often say “What is the benefit of such a long treatment”? But they should also be made to visualize the course of treatment for other illnesses like Blood pressure or Diabetes, whose patients need life-long treatment or about some untreatable cancers that have no treatment and no hope of recovery at all. If the patient is able to perform daily life work with the help of 2 or 3 tablets, he/she must consider it a mercy and blessing of God.
10. The signs of relapse
Signs of relapse depend on the phase of the illness. If a patient relapses in depression, he might have sadness, death or suicide wishes, weeping, disturbance of sleep, lack of interest, hopelessness, and decreased appetite. While in mania, he becomes active, talkative and cheerful. Should these symptoms reappear the patient or the caretaker should contact the therapist immediately.
11. Preventive Measure After Recovery
(i) Regular use of medication: -
Take medication regularly. Change in dosage or drug stoppage may result in relapse.
(ii) Contact with therapist: -
It is of utmost importance to visit the doctor on the scheduled appointment. If because of some reason the appointment is missed, visit the doctor on the next day. If the patient resists coming, some other family member should visit the doctor on behalf of the patient.
(iii) Substance Abuse
Keep patient completely away from charas, heroin or any other kind of sedative medicines because it is seen that by using addictive substances the patient may again develop the illness.
(iv) Punctuality in daily work
The patient should perform his daily activity properly and on a fixed schedule. Never change this schedule abruptly. He should take at least 8 hours of sleep daily.
(v) Mania and marriage
Some people believe that mania can be overcome if the patient is married off. This is not true and the majority of such marriages end in divorce. Often marriage results in an increase in the intensity of the illness. It is a fact that marriage is important, but more important than that is health. Marriage should be planned only when the patient’s illness subsides and after consulting the therapist. In fact the patient’s demand for marriage and an abnormality increased sexual desire is a symptom of this illness.
One other but important advice in this regard is that the patient’s illness should be disclosed to the prospective in-laws, as it helps to prevent future complications. Never forget that marriage is a human necessity but not a treatment of any illness.
Clinical Histories
1. Rashid
Mr. Rashid, is a student of 2nd year B.com, and is 23 years old. His mother stated that when he was a student of class X, he fell in love with a girl in the neighbourhood. He wanted to marry the girl. The mother refused, but despite this Rashid regularly went to see the girl even at very odd hours of the night.
Some time later he showed desire for marriage with another girl. Her mother again refused. This resulted in depression. He remained sad for a few days, then started taking alcohol and ‘charas’. His circle of friendship expanded mostly with antisocial elements of that area. He started talking excessively, besides making grandiose plans and demands for car and money and also proposed to a girl from her sister’s in-laws, who was already married. He declared that he plans to stay at the Sheraton or some other such hotel after marriage with that girl. When his excessive demands could not be met, he turned violent and self destructive and started hitting his head on a pillar. Mostly he remains outside his home and uses a taxi for travelling, sings in a loud voice and claims that he must be elected the president of Pakistan, India & Bangladesh.
2. Razia
Razia said “I have no complaint. I am English and was born in America. I am a Scientist, born in England and my language is English. I am a doctor and a psychiatrist”.
Her sister said that she is ill since the last 5 years. Initially she was restless, walked continuously and could never sit at one place. When she developed the illness, she was undergoing training to become a teacher. Because at that time her illness was not severe, she completed her training and joined school but had no interest in teaching, remained sad and had disturbed sleep. After the treatment from a hospital she became symptom-free for six months. Then suddenly her symptoms reappeared. She remained absent from her school, kept herself away from relatives and children, and paid no attention to her duties. Teaching for the last six months, she disowns her pupils, claims that her parents have kidnapped her, sits in the chair of seniors, claiming that she is the supervisor. She takes a bath daily, demands excessive money and spends it all. Shops for no reason, frequently eats ice-cream, takes cold drinks and other edibles, and declares herself as English. Never celebrates Eid or other Islamic festivals because she brands herself as a non-Muslim. Wakes early in the morning, and after taking a bath goes outside alone for long walks. Razia is 24, unmarried and works as a teacher in a local school.
3. Shahida
She is 19 years old. Shahida said that 3 years back she got awakened in the night because of some strange fear, and since then she has experienced three attacks of her illness.
During the attack of her illness, she weeps or laughs for no reason and does not like others to visit her home. She is suspicious about others, is irritable and aggressive, and sometimes becomes violent even against her parents. She also shows excessive interest in listening to songs. She is talkative but becomes very depressed at times. At work she has a large circle of friends. She threatens suicide, specially when her parents restrain her.
