Ups, Downs and In-Betweens:
Manic Depression and Bipolar Disorder, One and the Same

Because the terms “bipolar disorder” and “manic depression” are often used independently in the popular media, it is a fairly common presumption that they describe two separate conditions of ill health.

But bipolar disorder and manic depression are the same thing, nomenclature notwithstanding. This insight and others about the illness are offered by Robert C. Risinger, MD, Medical College of Wisconsin Assistant Professor of Psychiatry and Behavioral Medicine.

“Bipolar disorder is the propensity to go through periods of depression and periods of mania, which is why it’s called bipolar,” said Dr. Risinger. “There are two extremes, depression and mania.

“Manic depression is what it’s traditionally been called. In the DSM (Diagnostic and Statistical Manual of Mental Disorders), it’s Bipolar Disorder. Manic depression is simply more descriptive. There are frantic ‘manic’ episodes and after there are also low ‘depressions,’ which characterizes the cycling nature of the illness. It’s the same thing, absolutely the same thing, as bipolar disorder.”

Increased understanding of the causes of poor mental health explains some of the history behind using “disorder” instead of “illness” or “disease” to describe certain conditions.

Phenomenology Meets Biochemistry
“Right now psychiatry is based on phenomenology, which means symptoms,” said Dr. Risinger. “So you take the symptoms of the problems that someone is suffering with and classify them according to certain criteria.

“And then, whatever shakes out is the diagnosis. It turns out that this phenomenology actually holds true biochemically as well. There are fairly consistent changes in what are called biogenic amines, a certain kind of chemicals in the brain that are decreased in depression and increased in mania.

“This illness tends to strike families, so there is a genetic component. If you have one parent with bipolar disorder you have a one in four chance of having it yourself. If you have two parents with bipolar disorder you have a fifty percent chance.”

Distinguishing between types of mental illness presents a tremendous challenge to health care practitioners. For example, depression (without mania) is an illness unto itself and requires different treatment than manic depression, yet the distinctions are not easy to spot from the view provided by phenomenology.

“It can be subtle, especially if you’re young and you haven’t had clear-cut episodes of mania,” said Dr. Risinger. “You may have had episodes of what’s called hypomania, which is the only psychiatric diagnosis associated with increased function.

“Most people think that if you have a psychiatric illness you don’t do well at work, or you have problems with relationships or your moods. Well, during a hypomanic period people with bipolar disorder will tend to be more productive at work. They will tend to be gregarious and socially outgoing. Their mood is ‘up’ and they have lots of energy and they can spend that energy in focused goal-directed activities and be very productive.”

Mania Symptoms Often Misunderstood
There are subtleties within the subtleties of the mania cycle. Mania does not always reveal itself as a happy or euphoric state but instead can manifest as irritability, anxiousness or aggression. “There’s a state called mixed mania,” said Dr. Risinger, “and the reason it’s called mixed is because it has characteristics of both depression and mania.

“So even though someone may have, for example, lots of energy, even though they may be very reactive to other people, intrusive or racing thoughts (one of the diagnostic criteria for manic depression), people in a mixed state can be very dysphoric. They can be very unpleasant to be around, and this can even reach the point of their becoming suicidal.”

The devastating impact of bipolar disorder, depression, mixed mania and other forms of mental illness adds great urgency to the need for early and accurate diagnosis so that the proper course of treatment can be started as soon as possible.

“First-line treatment for bipolar disorder is lithium, a mood stabilizer, whereas first-line treatment for depression is not lithium, but an antidepressant; further, if people have bipolar disorder they have to be very careful about what antidepressant they’re taking,” said Dr. Risinger. “If you’re bipolar and you have depression and you’re put on certain kinds of antidepressants, there’s a certain risk that the antidepressant will cause your mood to cycle up and down. It’s as if these antidepressants work almost too well in some cases.”

“It’s very important to get all of the symptoms from the patient,” said Dr. Risinger. It’s important that people tell their physicians all of their symptoms and problems so that their doctor can make an accurate diagnosis and monitor treatments. A lot of people go to psychiatrists thinking they can read their minds. We can’t.”

Getting a Clearer Picture with fMRI
There’s a new tool in development that comes close to mind reading, though, as it is a way to measure brain function with stunning accuracy and diagnose a variety of psychiatric and neurological disorders.

In the February 15 edition of HealthLink, Dr. Risinger discusses the great promise of functional magnetic resonance imaging (fMRI) and how the Medical College’s Functional Imaging Resource Center is leading the way in putting it to work.

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.