Chapter 2

All about Bipolar Disorder

The more you know about your bipolar disorder, the better able you will be to cope with it and make the changes that are most helpful. This chapter informs you about bipolar disorder and mood problems using the latest scientific information. As you read, you will gain a better understanding of what you may be experiencing. You will learn about the different categories of bipolar disorder and the prominent theories as they were formulated through history, and see how bipolar disorder alters your brain structures and functions. With all of this information, combined with a description of the psychological symptoms, you will begin your meditation, armed with the key information you need to start on your path to change.

What Is Known about Bipolar Disorder, East and West

Bipolar disorder affects about one in every twenty-two people, or approximately 4.5 percent of the population (Merikangas et al. 2007), so it’s not as uncommon as you might think. It is classified by the National Institute of Mental Health (NIMH 2012) as a brain disorder with strong shifts of mood, energy, and activity that get in the way of daily life. Work, school, and interpersonal relationships can suffer severe consequences from the symptoms of bipolar disorder.

From the Western, scientific perspective, bipolar disorder correlates with irregularities in the emotion centers of the brain, making emotional reactions more intense than normal. In addition, the parts of the brain that typically are involved in controlling or monitoring strong emotions tend to be smaller and less activated, so your ability to regulate your moodiness may be diminished.

Bipolar disorder is distinguished from simple moodiness. If, every day or in a regular pattern, your life sometimes seems awfully gloomy and other times extremely bright, you probably suffer from moodiness. But if your moods interfere with your life or the lives of those you care about, this may be due to symptoms of one of the forms of bipolar disorder.

The Taoist theory of bipolar disorder is that it’s an energy problem, wherein energy may be blocked, stagnant, excessive, or weak. The common thread that runs through healing practices of the East is to correct these energy conditions by working directly with them. “Protecting and strengthening the right qi [chi, or energy] should be the basic principle behind all methods of health care” (Ming 2001, 283). Diagnosis of bipolar disorder involves determining the energy patterns that are preventing the normal flow.

How do these two theories of bipolar as a brain disorder and an energy disorder come together? We find the integration in the brain itself. The brain is made up of one hundred billion neurons that interact together to form pathways of activations and deactivations that correlate closely with what you think, feel, and do. And what are these activations and deactivations? They are electrical signals: energy! East meets West right there in your own nervous system!

Meditation affects the flow of energy in the brain, altering the on-off electrical signals that bring a better balance to your moods. These signals are dynamic and capable of enhancing the flow of energy or diminishing it as needed. Chapter 3 explains exactly how this happens and the research that supports it. As you meditate, you will alter the flow of energy in your nervous system to help you regulate your emotions and moods. The result is that you gain better self-control in general, along with more balanced moods.

Early Discoveries

Sometimes, understanding the past can help to clarify the present. You are not alone in your suffering. People have suffered from bipolar disorder for millennia. The modern theories of bipolar disorder derive from a fascinating showcase of classical wisdom about mental conditions, from the West as well as the East. And we learn more as time passes.

Ancient References to Bipolar Disorder

The brain aspect of the modern model derives from classical sources. The medical papyri of Egypt, such as the Ebers Papyrus, seem to mention depression and allude to the presence of bipolar disorder. Later, a clear statement by Hippocrates of Greece, the father of Western medicine (460 to 375 BCE), recognized the key role of the brain in bringing about our many moods. He said, “The people ought to know that the brain is the sole provider of pleasures and joys, laughter and jests, sadness and worry, as well as dysphoria and crying” (quoted in Post and Leverich 2008, 3).

Bipolar disorder was also observed thousands of years ago in the East. It was described in The Medical Classic of the Yellow Emperor, a medical text that formed the early basis for Chinese medicine, just as Hippocrates’s work formed the early foundation for Western medicine. Scholars aren’t sure exactly when The Medical Classic of the Yellow Emperor was written, but they date it somewhere between the third and first centuries BCE. This important book is filled with healing methods for many common problems, including bipolar disorder. A section about diseases is devoted to a condition that sounds like bipolar mood swings. It states, “When mania begins, the patient is sad first. Then he is exultant, irascible, and liable to fear” (Ming 2001, 212). The book describes other bipolar symptoms you may have experienced, such as not sleeping or eating well, being overly self-assertive and eloquent, and sometimes hallucinating. Treatments involve balancing the chi using meditation and acupuncture.

Development of the Bipolar Diagnosis

Western doctors have contributed greatly to our understanding of bipolar disorder. The circularity of bipolar disorder was recognized in 1851 by the French psychiatrist Jean-Pierre Falret (1784 to 1870), who observed that patients underwent a cyclical change from mania to melancholy throughout their lives.

Emil Kraepelin (1856 to 1926) was a German psychiatrist who made many observations for diagnosis that we still consider accurate and useful today, even though some of his ideas had to be corrected. He named bipolar disorder “manic depression” in 1921, characterizing its dual nature and distinguishing it from schizophrenia, with which it had previously been confused. Patients exhibited hallucinations and delusions during intense episodes, so doctors diagnosed them as psychotic. This misdiagnosis still occurs at times today. The distinction is an important one that strongly affects how you should be treated.

Kraepelin devised a helpful method of charting the cycles. We encourage you to keep an ongoing chart of your mood shifts to help you become more aware. Later in this chapter, you will find a method for charting that has been drawn from Kraepelin.

In modern times, Kraepelin’s terminology has been refined. The term “manic depression” expresses Kraepelin’s belief that at its root, mania is a form of depression. The euphoria, he believed, resulted from denial of depression. This belief is now considered incorrect. Mania is not just a consequence; it coexists with depression in the bipolar condition, with the potential of being a state in itself. This understanding of its true dual nature led to the renaming of the condition as “bipolar disorder,” clearly distinguishing it from monopolar disorders such as depression.

Kraepelin recognized that even though he observed manic and depressive cycles in all his manic-depressive patients, each person had a unique variation. We have observed this too: all our bipolar clients have been talented and creative individuals, with their own rhythms and patterns. We have deep respect for the individuality of our clients. This book helps you to make your creative nature work for you.

The First Medication for Bipolar Disorder

The next leap forward came with the discovery of the stabilizing influence of lithium carbonate on mood, by the Australian psychiatrist John Cade (1912 to 1980) in 1948. The way he first came upon the idea is a good illustration of how, sometimes, positive outcomes emerge from something negative. Cade was captured as a prisoner of war during World War II. During his time in prison, he observed that when some of his fellow prisoners exhibited mood swings, their symptoms lessened after they urinated. This gave him the idea that something in their urine might be involved. After his release, he did careful research until he isolated lithium as a key element for correcting the symptoms. But there were problems with getting lithium patented for manufacture as a drug. First, lithium salts are a naturally occurring substance, so lithium carbonate could not be patented. In addition, long-term experiments needed to be done before the drug could be approved. As a result, lithium wasn’t introduced in the United States as a treatment for bipolar disorder until 1970. During the 1940s, electroshock therapy, lobotomy, and other physical methods were the treatments for disorders. Cade’s discovery helped to shift the emphasis from those extreme treatments toward medication, another positive outcome. Today, more work has been done to develop new medications, along with the recognition that stress reduction and different types of psychotherapy are also effective treatments, as later chapters will discuss. But lithium is still the gold standard for mania.

The Bipolar Spectrum of Moods

You have probably experienced a broad range in your moods in that they fluctuate in a cyclical pattern from low to high, and back again. These variations make sense because the bipolar condition is a spectrum. The bipolar spectrum covers a range in intensity and quality of mood: a deep level of depression, dysthymia (low-grade depression), euthymia (normal mood), hypomania (mild elation), and mania. These are not like the normal ups and downs of emotion. Instead, the mood change can be dramatic and passionate, occurring very quickly or building slowly over time, leading to thoughts, feelings, and behaviors that may be difficult to manage. You have probably felt strong changes in the level of energy that accompanies these different moods.

Mania

Kevin was a graduate student who had finals coming up. He felt a surge of positive energy, so instead of spending his time quietly studying as he usually did, he decided to go out on the town with his brother for some excitement. He and his brother ended up reminiscing over old times and barhopping all night. He continued to drink and party with different groups of friends for more than a week. Later, when he came down from his elated mood, he told us that he had performed poorly on his exams: “I knew I should study, but I just had too much energy to sit still!”

Mania is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), published by the American Psychiatric Association (APA 2000), as a distinct period of a euphoric or irritable mood. This “high” is sustained for at least a week, and includes three or more other symptoms, such as grandiosity, agitation, decreased need for sleep, continuous talking, or involvement in pleasurable or risky activities like spending money, taking drugs, gambling, or promiscuity, all with highly negative consequences. Hypomania is a low-grade mood elevation, with feelings of happiness and extra energy that often include irritability.

Depression

June just couldn’t bring herself to attend her three-year-old niece’s birthday party. She knew she should be shopping for presents as she had done last year, but she didn’t feel like doing anything. But then, late at night, she ruminated about how terrible she felt and worried that she was missing out. She told us, “I don’t feel excited like I used to, even though I know how precious this time with my little niece is. I feel sad and guilty about it, but I just don’t have the energy.”

Depression is at the other end of the spectrum from mania and is defined by the DSM-IV-TR (APA 2000) as a loss of interest or pleasure. A major depressive episode lasts for at least two weeks and includes four other symptoms, such as changes in weight, appetite, and/or sleep patterns; lowered energy; feelings of guilt and worthlessness; slowed thinking; difficulty concentrating and making decisions; and thoughts about death and suicide. Dysthymia is a low-grade depression, with less-severe symptoms.

Bipolar individuals also have periods of normal mood, or euthymia. So, you probably have times when you are stable and steady, and this potential is always there. Of course, this stability is an individual balance.

Our client Judy had been diagnosed with bipolar disorder when she was in her twenties. She saw many therapists over the years. But when the treatments encouraged her to calm her mania, she protested. As she put it, “These therapists tried to get me to be something I’m not: blah and boring.” And yet, she wanted to change her extreme moods, because they interfered with her music. Judy was a creative musician who didn’t want to be ordinary. She meditated to become aware of her Tao, her individual way, and discovered a unique balance that wasn’t too extreme but allowed her to express herself fully during performances. The methods in this book, along with the other treatments you may be using, are all meant to help you to discover your individual balance and keep from lapsing into harmful extremes.

Eastern View: Interplay of Opposites

Recall that bipolar disorder follows the flowing interplay between yin and yang. In the lows are the seeds of the highs and vice versa, as pictured in the yin-yang symbol, where a small, dark circle is found in the light half, and a small, light circle is there in the dark half (see figure 2.1).

Figure 2.1

You might not think you could possibly find anything positive about your depression. But if you apply Taoist theory, you know that even in the darkest depression, there must be some positive potential.

Our client Jeremy learned to find value in his depressed mood. He was a painter who struggled with making his work meaningful. As he began to meditate on his emotions, he came to recognize that when he was depressed, he had deep insights about the struggles of life. He learned to channel his depression into his paintings so that his work communicated the “angst” of the human condition. Over time, he became known as a painter of depth and intensity. He told us that he could now be grateful for what he had learned to express during his depression. As he came to accept his feelings, their severity lessened, and he found a better balance.

Western Categories of Bipolar

Bipolar disorder is a personal experience with consistent characteristics and individual differences, but it has been separated into three fundamental categories: bipolar I, bipolar II, and cyclothymia. Some people also have mixed states that combine some of these categories. View these categories as guidelines rather than fixed entities. You may move from one category to another. You might even have periods without symptoms, especially as you find more balance in your life.

Bipolar I

Bipolar I is a condition with a cycle that displays definite symptoms. It is the most severe of the categories, and includes both manic and depressive episodes as part of a cycle that usually recurs. The cycle may cover days, weeks, or months, depending on the individual pattern.

Bipolar I is diagnosed when at least one episode of mania has taken place that could not have been due to a reaction to drugs, medication, alcohol, or something physical. The mood state may include delusions and hallucinations, whether the mood is elation or depression. Delusions are beliefs that are not correlated with logic, reasoning, culture, or religion. Hallucinations are perceptions of people, objects, or events that have no basis in reality. Sometimes, psychosis emerges, which refers to a state of functioning that is out of touch with reality. In the bipolar I category, you may have self-perceptions of grandiosity, manifest great energy, feel extremely elated or excited, talk a lot, and have many thought associations during manic episodes. All of these symptoms are quite out of proportion to reality. You probably also experience a loss of good judgment, along with a wish to spend money without appropriate restraint. You might engage in impulsive behavior with strong emotionality or perhaps, instead, feel a compelling need to engage in behavior that’s inappropriately narrow in goal directedness, such as continuously walking in a circle. In youth and adolescent forms of mania, the mood may be expressed as irritability, impatience, or anger. The sleep cycle is disturbed, with daily periods of only a few hours of sleep or no sleep at all.

Mixed states, sometimes called agitated depression, involve a simultaneous combination of depression and mania. People who have mixed states might shift from one state to another. So, you might start crying when you feel manic, or find your thoughts racing even though you feel depressed. In extreme cases, suicidal thoughts might occur as well, which can lead to life-threatening actions. Thus, the condition must be attended to immediately and responsibly. If you feel so depressed that you begin thinking about suicide, be sure to tell someone who cares, and immediately seek professional help to protect your life.

Bipolar II

If you are in this category, your symptoms tend more toward depression. You may not have needed hospitalization for the symptoms of your moods, because if you are diagnosed with bipolar II, you haven’t lost touch with reality during episodes, as in bipolar I. The manic episodes for bipolar II sufferers, known as “hypomania,” are not as extreme as for those who are diagnosed with bipolar I, and there is less mania, either for shorter periods or with less intensity. The depression part of the cycle tends to be more dominant than the manic part. Since depression can be deep and long lasting, bipolar II may feel very uncomfortable.

Cyclothymia

The mildest category in bipolar disorder, cyclothymia includes mild elation of mood, or hypomania, and mild to moderately depressed mood cycles that keep shifting and changing. The symptoms are not severe enough for a bipolar I or II diagnosis, even though they share the pattern of shifting moods and energy levels. The symptoms must endure for a minimum of two years to be categorized as cyclothymic, so a short period of moodiness wouldn’t result in a cyclothymia diagnosis. Typically, people who have been diagnosed with cyclothymia lasting for at least two years tend to be less likely to develop a full bipolar episode as described in the previous bipolar I and II sections.

Creating a Mood Chart

The meditation methods taught in part 2 will give you an experiential way to keep track of your mood changes. But you can also add a tried-and-true Western method of charting to observe your rhythms and patterns by recording them as they happen. Figure 2.2 is a chart, drawn from the historical method of Kraepelin, for you to fill out. It guides you in noting the observable shifts in mood and energy as they occur in real time. When combined with Eastern meditations, these methods from the West will give you a deeper and clearer understanding so that you can help yourself.

Fill out this chart similarly to the developmental chart (figure 1.2) in chapter 1. In addition, make note of sensations, thoughts, or feelings that correspond with the chart for that day. You can simply note a word or phrase, or add more descriptions in a separate journal if you prefer. Over time, the chart will reveal patterns and experiences that you may not have noticed before. Add your own creative descriptions to personalize the chart with your Tao.

Figure 2.2

Bipolar Disorder and the Brain

Often when we explain bipolar and the brain to clients, they find the terminology a little confusing, so they may miss the main points. Therefore, before we explain how bipolar disorder affects your brain, we offer you a brief tour through the limbic system, which is a collection of many different areas that are involved in the regulation of emotions and moods in the brain. Knowing a bit about these areas will also help you to understand how meditation can affect your brain and help to make you feel better. You will be able to recognize what your nervous system needs, and thereby practice the meditations that will help you the most.

Moods Involve a Changing Network Throughout the Brain

Emotions and moods correlate with activity in the limbic system of the brain. The limbic system involves a network of structures from the lower-brain areas, which control basic body functions, all the way up to the thinking part of the brain, known as the cortex. What this means is that when you are feeling an emotion, the structures in the limbic system are set in motion and send signals all around your brain. This high connectivity helps to explain why emotions and moods are so important to us.

Here’s how the limbic system works: Imagine for a moment that someone you love has entered the room. A part of your thinking cortex in the temporal lobe recognizes the face of this person and sends a message to your limbic system, specifically to an almond-shaped organ called the amygdala. The amygdala is involved in the processing and storage of emotional events. It becomes more activated when something is emotionally significant to you and signals that this is someone you care about. The amygdala is often considered the gateway to the limbic system, and its activation stimulates memories of your loved one in a memory area of the limbic system called the hippocampus. The signal passes through the thalamus, a gateway from the senses, and is regulated by the hypothalamus, which produces hormones. All of these limbic-system areas are located deep inside your brain. They deliver signals to your peripheral nervous system that reach throughout your body. The part of the peripheral nervous system that spurs you to action is the sympathetic nervous system. It is triggered, causing your heart rate to increase, bronchi to dilate, and even your pupils to enlarge. The result of all these complicated signals and activations is that you feel happy to see this person and walk directly over to extend a warm hug.

By contrast, if a burglar were to enter the room, your amygdala would register danger. A threat signal is passed quickly through the thalamus and hypothalamus, triggering a fear reaction in your peripheral nervous system. We will describe the details of this fear-stress system in chapter 8, on stress. Your sympathetic nervous system reacts immediately, prompting you to take action. The result of all these signals and activations is that you might shout for help, or run to the phone and call the police.

This limbic-system activity will show up on a brain scan, such as positron-emission tomography (PET) or functional magnetic imaging (fMRI). Brain scans measure the parts of the brain that become more active when you do, think, or feel something.

Understand Your Symptoms by Learning How Bipolar Affects Your Brain

If you have been diagnosed with bipolar disorder, you are likely to have irregularities in the natural limbic-system processes described previously. These findings may help to explain why your emotional moods feel so compelling. There is no final word on how bipolar disorder changes the limbic system, but here are some of the emerging trends.

Studies of people with bipolar disorder have found an enlargement in the amygdala (Strakowski et al. 1999). Since bipolar disorder is usually accompanied by stronger-than-normal moods, these results are not surprising. Thus, in our previous examples, you would tend to have stronger and more-extreme reactions. These research findings tell you that any way you can normalize your limbic system is likely to be helpful. Research shows that meditation calms an overactivated limbic system in a number of different ways. Chapter 3 provides the research and explains how meditation helps change the brain.

Another finding that seems to be consistent across many studies is that the face-recognition ability in the temporal lobes and the thinking and control areas of the brain in your frontal cortices tend to be smaller. Researchers found smaller temporal-lobe volumes on both the left and right sides in patients with bipolar disorder than in people who were not bipolar (El-Badri et al. 2006). The temporal lobes are closely linked to the limbic system, making them strongly involved in emotion. They regulate your ability to recognize and react to emotions in other people’s faces. The smaller volumes in your temporal lobe lead to a tendency to misinterpret other people’s emotions (Derntl et al. 2009).

Having a smaller volume in part of the thinking areas of the brain may contribute to the difficulty you have in controlling your moods. Another study (Bremner 2005) found smaller volumes in the prefrontal cortex among people with bipolar disorder. This also makes sense, since the prefrontal cortex is used when people are performing executive functions like planning, working toward a goal, or making decisions. The smaller volumes in the prefrontal cortex help to explain why it feels so difficult to plan and do things when you are feeling depressed. And smaller prefrontal-cortex volumes may also explain poor decision making and difficulty making sensible plans when you are manic. Regular meditation practice enhances executive functioning, making it easier to make decisions, carry out plans, and follow through on goals. Meditation has been shown to thicken the attentional areas located in the prefrontal cortex (Lazar et al. 2005). So meditating may help to correct the smaller volumes in the prefrontal cortex, as chapter 3 will describe. And you will see improved thinking after regular meditation, which will help moderate your moods.

Here is another bit of compelling evidence that helps to explain some of your bipolar reactions. The cingulate gyrus, a deep part of the cerebral cortex, is located close to the limbic system. It connects the limbic system structures to higher parts of the frontal lobes, and sends messages between your emotional limbic system and key parts of your thinking cortex. The cingulate gyrus becomes activated when you try to control your emotions and moods. Thus, the cingulate gyrus is involved in self-regulation, a term that psychologists use to describe how you calm yourself down when you are feeling angry and irritable, or cheer yourself up when you are feeling sad and sluggish. Being able to self-regulate is a very important skill, and meditation has been found to help people regulate their emotions (Tang et al. 2009). Bipolar patients were found to have lower density in the cingulate gyrus, compared to people without bipolar disorder (Benes, Vincent, and Todtenkopf 2001). These findings may explain why you have difficulty regulating your emotions. Chapter 3 will present the meditation research that shows that meditating helps you regulate your emotions. So you have good reasons for trying meditation to help you with your moods.

Treatments

A diagnosis of bipolar warrants both prescriptions for medication and treatment of behavioral symptoms. Because bipolar is classified as a brain disorder, medications that alter the brain have been and continue to be a viable treatment for bipolar disorder. A variety of medications are used, some of which might seem to be suited to other problems. Although you can also exert a lot of influence on your own condition, medication is an important resource. The methods included in this book are not substitutes for correct use of pharmacology, which is directed by your doctor or psychopharmacologist. But using the methods presented in this book in conjunction with medication improves your chances of good management and recovery from dark moments in your bipolar condition. If medication has been prescribed for you, we strongly urge you to take it, and some of the meditations offered in this book will make it easier for you to remember to do so.

However, medications alone do not give most people relief from suffering. In fact, according to the National Institute of Mental Health, medication combined with some kind of therapeutic intervention works best for the treatment of people of all ages who are depressed, with early evidence presented in the 1990s and continuing to build over decades (Antonuccio, Danton, and DeNelsky 1995; Kennard et al. 2008). A comprehensive study of bipolar disorder has not been conducted, but our clinical experience over many years in working with bipolar clients who are also taking medication has shown us that adding meditation can improve the effectiveness of treatment overall. Meditation has its own body of research showing how it will complement your pharmacological treatments in a number of important ways. First, meditation has been found to stabilize the nervous system (Dillbeck et al. 1986). It also has dual effects, simultaneously bringing relaxation and alertness (Hugdahl 1996; Lazar et al. 2005). In addition, meditation helps to regulate emotions (Tang et al. 2009). Chapter 3 will give you the details of this research.

Conclusion

Bipolar disorder involves a dynamic, changing shift in moods that interferes with your life. Western and Eastern treatments work well together to improve symptoms. Medications help to alter your brain chemistry for the better. Meditation changes your brain balance, offering stability to the limbic system and increased activation to the attentional system, a fundamental part of the thinking brain. So, by meditating, you can help to correct some of the irregularities in your brain. In addition, you become more alert and aware, thereby improving your thinking abilities, which are so important in helping you to regulate your moods.

This book gives you methods that help you affect your emotional state with meditation, not just medication. The best path is the middle one, including some yin and some yang on the spectrum. The positive effects you bring about are lasting and will contribute to a meaningful life.

Now that you have some background on your bipolar disorder, you will find chapter 3 helpful for learning how you can change your brain by what you do and how meditation can help you bring your brain and nervous system into better balance.