Bipolar disorder: Myths vs. realities about the chronic mood swings

Collin Vas, M.D.,
Eric Shellhorn, M.S.N., APRN, PMH-NP (bc)Psychiatry

About 7 million U.S. adults have bipolar disorder, a mental disorder characterized by cycles of sometimes unpredictable mood swings, or highs and lows, that can affect an individual’s ability to carry out day-to-day tasks and impacts relationships, careers, finances, and physical health.

As entertainers such as Bebe Rexha, Ye (Kanye West), and Taylor Tomlinson have opened up about living with bipolar disorder, the condition has been in the spotlight. However, myths and misunderstandings can still overshadow the reality of this chronic mood regulation disorder.

Bipolar disorder, which is sometimes referred to as manic-depressive disorder, is manageable – when properly diagnosed – with lifelong, personalized treatment and lifestyle modification.

UT Southwestern is home to one of the largest psychiatry programs in the country and among the top 10 partners of the National Institute of Health (NIH) for psychiatry research. We have worked with many bipolar patients and can help find the combination of therapies that work best for each individual.

Let’s explore some of the basic information about bipolar disorder, and address some of the common misconceptions about the disorder and how it should be managed.

“Low, depressive symptoms are often the first bipolar symptoms people recognize. However, having an intensely high mood is not a normal, healthy emotional state. Mania episodes can result in erratic, risky behaviors such as reckless driving, spending staggering amounts of money, or bingeing on drugs or alcohol.”

A primer on bipolar disorder

Patients with bipolar disorder experience intense shifts in mood, with or without a triggering event. Episodes of symptoms create what patients often refer to as a “rollercoaster” or “revolving door” of relationships, careers, family feuds, and even brushes with the law.

These episodes include cycles of:

• Mania: Episodes of high energy, which can present as feeling “keyed up,” extremely irritable or excitable, or having an intensely positive mood that patients describe as feeling invincible or unstoppable. This is often accompanied by a decreased need for sleep (or none at all), racing thoughts, and impulsivity.
• Hypomania: Mild mania that, while still disruptive, is typically less intense and sometimes easy to miss.
• Depression: Very low mood that can range from feeling sad and unhappy to suicidal. Other symptoms of depression include slower thinking, lack of interest in things a patient once enjoyed, and diminished sense of pleasure in things.
• Mixed states: Some patients experience mixed-mood symptoms, in which mania and depression symptoms occur simultaneously.
• Stability: Periods of emotional neutrality. These feelings of normalcy may cause some patients to stop taking their medication or have lapses in treatment, triggering another cycle of intense mood swings.

Low, depressive symptoms are often the first signs of bipolar disorder that people recognize. Depressive states are the most prevalent phase of the illness and carry a risk of suicide. The intensely high mood of mania or hypomania is not a normal, healthy emotional state. Mania episodes can result in erratic, risky behaviors such as reckless driving, spending excessive amounts of money, or bingeing on drugs or alcohol. Extreme behaviors are often what the public sees in the media, lending to further misunderstanding about the condition.

There is no cure for bipolar disorder, but the condition is very treatable for most people.

MYTH: Bipolar disorder is just mood swings.

REALITY: Everyone has good and bad days. But people with bipolar disorder experience higher peaks and lower valleys that can last days, weeks, or months, with or without a triggering event.

For example, if you’re enjoying dinner with friends on the patio, it’s normal to feel good. But it’s not normal to feel “winning a multimillion-dollar lottery” good. Or you might wake up one day in a really low mood that you can’t shake for days, regardless what’s going on around you.

There is no specific test to diagnose bipolar disorder. Diagnosis must be personalized based on the individual’s symptoms and family history. To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania (a less extreme form of mania).

MYTH: Bipolar disorder is rare.

REALITY: The condition affects 7 million people in the U.S. and 45 million worldwide.

Often, it goes undiagnosed or misdiagnosed. The average time between symptom onset and diagnosis is 8-10 years, during which time symptoms can worsen and episodes can become more severe and frequent.

Some patients have other conditions, such as post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), a traumatic brain injury, or substance use disorder, that mask symptoms or complicate diagnosis. In some cases, bipolar disorder is misdiagnosed as anxiety, depression, schizophrenia, or borderline personality disorder – and vice versa. An accurate diagnosis is critical, as some medications may either be ineffective or exacerbate the mood changes in bipolar disorder.

Often, patients, loved ones, and general healthcare providers might not recognize that mania presenting as an extremely good mood is not normal.

MYTH: An intensely good mood is no cause for concern.

REALITY: Feelings of euphoria and invincibility can seem harmless, but for patients with bipolar disorder they aren’t.

These energy-charged states can manifest themselves as:

• Decreased need for sleep, which can last for days
• Distraction or restlessness
• Fast speech
• High, insatiable sex drive
• Impulsivity and risk-taking, such as reckless driving or spending sprees
• Irrational anger or irritability
• Racing or distracted thoughts

MYTH: Patients can stop treatment when they feel better.

REALITY: Bipolar disorder is a lifelong chronic illness.

Much like managing Type 1 diabetes, high blood pressure, or epilepsy, patients must continue taking their medications and following their care plan when they are feeling well to maintain physical and mental health.

There is no cure for bipolar disorder, and despite advertisements suggesting otherwise, there is no single wonder-drug that can control its symptoms. Just as bipolar disorder is a cyclical condition, its management must also be approached with agility and consideration of each patient’s lifestyle, medical history, and environment.

For most patients, bipolar disorder can be managed through a combination of mood-stabilizing medications and complementary treatments such as psychotherapy and maintaining healthy lifestyle habits.

MYTH: All you need is an antidepressant to manage bipolar disorder.

REALITY: Antidepressants are never a sole treatment for bipolar disorder.

These drugs can be used in persons with bipolar disorder but must be carefully monitored for the emergence of mania/hypomania/mixed states and are most often used in conjunction with a mood-stabilizing medication.

Medication is an essential part of bipolar disorder treatment. There are several medications that may work best, either separately or when combined, to help stabilize your mood. However, your medications likely will change with age and life fluctuations.

Lithium is of the most widely used and used medications for treating bipolar disorder, although it doesn’t work for everyone. Some antipsychotic medications and anticonvulsants used to treat seizure disorders also may help manage acute symptoms and reduce the frequency or severity of manic episodes.

It may take some trial and error to find the right medicine or combinations of medications that work for you. Be honest with your doctor about how you’re feeling and whether you’re experiencing any side effects. Finding the right fit is a team effort.

MYTH: Medication is enough to manage bipolar disorder symptoms

REALITY: While medications vary, all patients with bipolar disorder should follow healthy lifestyle recommendations.

Those include:

• Psychotherapy: Talking with a therapist can help you process negative thinking, manage stress, and understand how to navigate your personal triggers.
• Sleep: With bipolar disorder, you may face the dual challenge of symptoms that make it tough to sleep, and poor sleep that worsens symptoms. Establishing and maintaining good sleep habits can improve your mental outlook and reduce symptom severity. UT Southwestern offers CBT-Insomnia (Cognitive Behavior Therapy for insomnia), a highly effective treatment for insomnia.
• Exercise and nutrition: Eating a nutritious diet and getting regular exercise can improve depressive symptoms and help prevent episodes of bipolar disorder. A recent study suggests that increasing particular fatty acids in the diet can help regulate mood in conjunction with medical treatment. Research has also shown that aerobic exercise can influence the neural pathways for sharper focus in patients with bipolar disorder.

Bipolar disorder can be inherited. Approximately 60-80% of people with bipolar disorder have a family member who has it. However, having a family history of the condition does not automatically mean you will develop it. Though there is no test to determine your familial risk, we can help you create a plan to manage your stress, practice healthy sleep habits, and avoid potential triggers.

Where you go for bipolar disorder treatment matters

If you have bipolar disorder, see a health care professional who specializes in diagnosing and treating mental health conditions. You also want to find a provider with whom you feel comfortable expressing what you’re feeling and experiencing.

Two thirds of patients with bipolar disorder have a medical or mental health condition in addition to bipolar disorder. One illness can affect another and vice versa, so receiving comprehensive care in one place like UT Southwestern is helpful in allowing better communication and collaboration between providers and managing continuity of care.

Seeking treatment at an academic medical center like UTSW also may allow you to participate in a clinical trial. These studies provide access to treatments that aren’t available everywhere as well as help researchers better understand bipolar disorder and how to treat it.