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Ultimate Stressors: Public Drama, Private Pain

charlie-sheenRecently televised interviews with Mr. Charlie Sheen appear to have focused attention on the symptoms and manifestations of the manic phase of bipolar disorder. A public display of inflated self-esteem or grandiosity, profuse talkativeness, increase in goal-directed activity, psychomotor agitation, and the excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish investments) are the textbook criteria for a manic episode. More privately, the individual in the grip of mania also experiences a decreased need for sleep, flight of ideas or racing thoughts, and distractibility. When this disturbance is sufficiently severe, it can cause marked or total impairment in occupational functioning, usual social activities and relationships with others and may necessitate hospitalization to prevent self-harm or harm to others. Episodes of mania, whose symptoms are the opposite of those denoting depression, are rarely seen alone. Usually, the manic state is preceded and followed by depressive periods in an alternating fashion, with each state lasting from many months to a few weeks, the latter being described as ‘‘rapid cycling.’’

This constellation of symptoms was known, until a few years ago, as manic-depressive disorder. Nowadays, it goes by the somewhat more cryptic label of bipolar disorder. The neurochemical basis of bipolar disorder is not exactly known. One of the most valid hypotheses regarding the neurochemical mechanisms of bipolar disorder is the synergy between two neurotransmitters that determine mood states, whereby a lower than normal release of norepinephrine produces a disordered mood (significantly higher or lower than the normal range), while the levels of serotonin determine the direction the symptoms will take, i.e. downward toward depression or upward toward mania.

What Bipolar Disorder Feels Like

The subjective experience of these intense mood swings ranges from abject despair and hopelessness to not entirely distressing and almost pleasurable. Depression produces a pervasive
and relentless sense of gloom, inadequacy, rumination, guilt, and worthlessness. No logic, willful effort or remembrance of wellness seems capable of dispelling these cognitive and emotional experiences, often for prolonged periods.

Mania reverses and accelerates upward from the disappearance of depression, through a state of well-being that can be considered a normal mood state. Normality soon becomes exuberance, enters into a state of unexplained euphoria, and finally culminates into a chaotic state of racing, incomprehensible, disconnected thoughts, and bizarre behaviors. Given a choice, the individuals so affected report that they much prefer the state of mania, in which they experience a release from inhibitions, a hedonistic focus, and a pursuit of pleasure and gratification that can be nearly devoid of accountability or restraint. Self-medication with alcohol and illegal drugs is often present in the manic phase, which sets up a circular relationship that exacerbates its symptoms and impedes treatment and recovery.

An individual in a state of mania can be frightening, annoying, or amusing to the casual observer. It is perhaps easy to overlook the nature of the behavior, especially when there is an assumption of intent. In most cases, however, the individual has virtually no control over thoughts, words and behaviors and little if any insight into their bizarre, provocative, and sometimes dangerous presentation. The loss of reality testing, judgment and moral restraint of bipolar disorder is sure to cause psychological pain to the people who experience it and to the people who love them. Mr. Charlie Sheen has been variously portrayed as victim and perpetrator, and variously diagnosed by experts and entertainment reporters.

Bipolar Disorder: A Brief History

The first connection between a manic state and depression as belonging to the same neurochemical disorder was established in 1686 by the French physician Theophile Bonet, who observed individuals who appeared to cycle between high and low moods, and described their presentation as ‘‘manico-melancolicus.’’ In the middle of the 19th century, two other French researchers, Falret and Baillarger, who had independently observed the same cycling of moods in their patients, arrived at the same conclusion that the symptoms must be two different presentations of the same illness. Falret described the disorder as ‘‘circular insanity’’  and hypothesized a hereditary component to the disorder. In the late 1800s to early 1900s, German psychiatrist Emil Kraepelin elaborated the description and classification for manic–depressive illness that is considered the standard presentation that we see today.

It was John F. J. Cade, a doctor in the Mental Hygiene Department of Victoria, Australia, who introduced and promoted the belief that manic–depression was a biological disorder of the brain. On the basis of his research on neurochemistry, Cade administered a lithium salt preparation to several highly agitated manic patients and observed a remarkable reduction in symptoms, with a near return to a normal mood state. Lithium is currently the standard of care for the pharmacological treatment of bipolar disorder, and still the most effective in the management of its symptoms.