Anosognosia, or impaired awareness of one’s own illness, is a common symptom in patients with severe bipolar disorder and schizophrenia. In some cases, the afflicted individual may not have any awareness that they are ill. As a result of this symptom, patients may believe that their delusions and hallucinations are real. They may not see any impairments in their day to day functioning, even though those around them are having to cope with severe consequences of their lack of motivation, initiative, social skills, or ability to live independently. They may have difficulty with their elevated mood and manic behavior is creating a problem, even though they are spending money they don’t have, engaging in promiscuous sex, or making risky and dangerous life decisions, none of which is characteristic of their behavior when not manic.

How common is Anosognosia?

As many as 50% of patients with schizophrenia, and 40% of bipolar patients, suffer from this condition. Anosognosia is caused by damaged to the right side of the brain.  Anosognosia may fluctuate over time within the same individual, so that they may be more or less aware of their own illness at different points in time. It is important to distinguish anosognosia from denial, which is a psychological defense in which the individual does not want to face the seriousness of their problems because it is too painful to do so.

Anosognosia is the most common reason that patients with bipolar disorder and schizophrenia are not compliant with their medications. It makes sense from the patient’s point of view – if you don’t believe you’re sick, why take medications? Unfortunately, taking medications is one of the most effective ways to decrease these symptoms and increase awareness of illness. Patients with this condition are more likely to be hospitalized involuntarily and to end up in the emergency room as well.

How to Get Help for Anosognosia

If you have a loved one with anosognosia, seek help from a mental health professional at the earliest opportunity. Even if the person with the condition will not seek treatment, help is available for you and your family. A qualified mental health professional can explain the legal and clinical procedures that are available to get help for your loved one even if they do not realize that they need help.

References

Lerner, D.S., and Lorenz, J. Anosognosia in schizophrenia: Hidden in plain sight. Innovations in clinical neuroscience, 11 (5-6), 10-17.

Treatment Advocacy Center Briefing Paper (2005). Anosognosia (impaired awareness of illness): A major problem for individuals with schizophrenia and bipolar disorder.

Bipolar Disorder

Bipolar disorder (BPD) is actually a group of mental disorders with similar features and characteristics, called the bipolar spectrum. BPD is a mental disorder that is characterized by swings in mood from mania (mood that is too high) to depression (mood that is too low), back to normal mood. Individuals with BPD experience mood swings in two directions, or two poles (bipolar).

Bipolar disorder is a separate disorder from what most people refer to as “depression,” a different condition in which individuals only experience depression but not mania. This type of depression is referred to as unipolar depression rather than bipolar depression, as these patients only experience mood swings in one direction, from normal mood to depressed.

Older terms for bipolar disorder are manic-depression or manic-depressive disorder. These terms are not commonly used by mental health professionals anymore.

BPD can be very serious if not treated properly. Untreated BPD can lead to severe damage in interpersonal relationships, loss of employment, financial ruin, legal problems, risky behavior with unintended negative consequences, and even suicide.

Mania Phase of Bipolar

“Mania” or “manic” refers to an abnormal mood state lasting more than a few days in which the person is unusually cheerful, euphoric, or irritable, not attributable to drugs or a medical condition. During a manic episode, the individual can go days without sleeping, feel unusually good about themselves, have rapid, exciting thoughts, and speak very quickly. They may be restless and distractible and engage in uncharacteristically risky behavior such as spending sprees, indiscriminate sex, drug use, or other reckless behavior. In severe cases the manic individual can have a break with reality (psychotic symptoms).

Depression Phase of Bipolar

“Depression” refers to an abnormal mood state lasting at least a few weeks in which the person feels depressed and sad or has a loss of enjoyment and pleasure about most daily activities. Individuals with severe depression can also experience changes in appetite, sleep, problems with their attention and concentration, feeling chronically tired, have poor self-esteem or excessive guilt, and have thoughts of suicide or even make a suicide attempt.

Family and Bipolar Disorder

Bipolar disorder can have a devastating effect on the family members of a patient with untreated BPD. Family members often are left to “pick up the pieces” and the emotional, financial, and legal consequences of the patient’s behavior when ill. Family members often recognize the onset of a bipolar episode long before the patient realizes that they are ill. Mania usually feels good in the initial stages, and many patients are reluctant to let go of the good or “high” feelings that accompany a new episode of mania. As family members realize that the bipolar patient is “ill” rather than “bad,” they can become a tremendous asset in the treatment of BPD by helping the patient get into treatment and stay in treatment.

If any of the above description sounds familiar to you, or seems to describe a loved one, get professional help right away. There are very effective psychological and medication treatments for BPD when administered by qualified mental health experts.

Because bipolar symptoms can also have other medical and psychological causes, it is essential to have an evaluation by a clinical psychologist or a psychiatrist who is a specialist in diagnosing bipolar disorder as quickly as possible.

Cyclothymic disorder is a type of bipolar disorder defined by long periods of fluctuating mood. Individuals with cyclothymia will experience persistent cycling between feelings of elevated or expansive mood and more depressive “down” states. Untreated, these ups and downs can go on for years. Cyclothymic symptoms are less severe than bipolar symptoms: the “highs” are not as high and the “lows” are not as low. Cyclothymic mood episodes do not meet full criteria for manic episodes, hypomanic episodes, or major depressive episodes. However, the cycling between mood episodes is chronic, pervasive, and clinically significant.

An individual with cyclothymia never goes more than two months without experiencing symptoms, and spends at least half the time feeling either too “up” or too “down.” There are rarely periods of wellness, and when they occur, they are short. And though less acute in nature than bipolar disorder, cyclothymic disorder presents with many of the same symptoms.  When in a depressive state, individuals with cyclothymia experience some of the following symptoms:

Depressed mood most of the day, nearly every day
Diminished interest or pleasure in usually pleasurable things
Significant weight loss
Insomnia or hypersomnia
Physical agitation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to concentrate
Recurrent thoughts of death or suicide

In an “up” (also called “hypomanic”) state, cyclothymic patients can experience some of the following symptoms:

Inflated self-esteem or grandiosity
Decreased need for sleep
Pressured speech (pressure to keep talking)
Racing thoughts
Distractibility
Increase in goal-oriented activity
Engagement in risky behavior (buying sprees, sexual indiscretions)

Unlike more severe forms of bipolar disorder, cyclothymic disorder rarely results in impairment severe enough to require hospitalization. However, it still leaves the individual in a state of virtually constant emotional instability. Cyclothymic Disorder can be confused with other psychiatric and medical conditions and intoxication by drugs.  It is important to have a mental health expert evaluate the patient in order to make an accurate diagnosis.

References

American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C., American Psychiatric Association.

 

Bipolar disorder is defined as a disorder of cycling mood.  Individuals with bipolar disorder experience mood states that are too “high” as well as depressed states that are too “low” that typically cycle back and forth over time.  Episodes in which the person’s mood is too high are called manic episodes, or hypomanic episodes if less severe.  Episodes in which the person’s mood is too low are called major depressive episodes.  In bipolar disorder, the untreated individual has chronically unstable mood.  Periods of wellness, manic episodes, and depressed episodes shift back and forth in an unpredictable pattern.

To diagnose bipolar disorder, most clinicians use the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5 (American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force. 2013).  Bipolar disorder is considered to exist on a spectrum from most severe to least severe.  The most severe form is called Bipolar I (one) Disorder, followed by Bipolar II (two) Disorder.  Less severe forms of bipolar disorder are Cyclothymia and Other or Unspecified Bipolar and Related Disorders.  The diagnosis of Bipolar II Disorder will be briefly reviewed in this article.

Hypomania

To diagnose Bipolar II Disorder, a severe type of the illness, an individual must have experienced at least one lifetime episode of hypomania, and at least one lifetime episode of major depression.  A hypomanic episode consists of elevated, expansive, or irritable mood and increased activity and energy, lasting 4 days or longer, that is clearly different from the person’s normal mood state.  Several other symptoms must also accompany this change in mood state, as follows:

Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual, called “pressure of speech”
Racing thoughts, called “flight of ideas”
Distractibility
Excessive involvement in highly pleasurable activities that can result in bad consequences, such as excessive spending, gambling, indiscriminate sex, or drug abuse.
Excessive goal-directed activity in work, school, or personal situations, or excessive restlessness in pointless non-goal directed activity

A hypomanic episode is clearly different from the person’s normal mood and behavior and is observable to others.  The person’s hypomanic symptoms are not severe enough to interfere with routine occupational or social functioning, the individual does not requires hospitalization, and he or she does not ever exhibit psychotic symptoms (a break with reality).

A more severe form of bipolar disorder, Bipolar I Disorder, can be distinguished from Bipolar II Disorder by the presence of mania.  Mania is similar to hypomania but more severe.  The symptoms need to last at least 7 or more days (or any length if hospitalization is necessary).  The symptoms must be severe enough to interfere with social or occupational functioning, and psychotic symptoms may be present in Bipolar I Disorder but not Bipolar II Disorder.  If a person is having a manic episode, or has had such an episode in the past, they cannot be diagnosed with Bipolar II Disorder.

Major Depression

To diagnose Bipolar II Disorder, the individual also must have had one or more lifetime major depressive episodes.  A major depressive episode is a distinct period of mood lasting 2 weeks or longer in which the person feels either depressed or has little or no interest in day to day activities.  In addition to either or both of these symptoms, the individual also must have several of the following additional symptoms nearly daily over the same 2 week period:

Increased or decreased appetite, or significant weight loss or gain
Insomnia or excessive sleep
Noticeable psychomotor agitation, as noted above, or psychomotor retardation, which is moving more slowly and sluggishly than normal
Feeling tired and worn out for no apparent reason
Feeling worthless or irrationally guilty
Cognitive problems involving thinking, concentration, or indecisiveness
Thoughts of death, suicidal thoughts, suicidal plans, or a suicide attempt
Bipolar II Disorder can be confused with other psychiatric and medical conditions and intoxication by drugs.  It is important to have a mental health expert evaluate the patient in order to make an accurate diagnosis.

References

American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C., American Psychiatric Association.

Bipolar disorder is defined as a disorder of cycling mood.  Individuals with bipolar disorder experience mood states that are too “high” as well as depressed states that are too “low” that typically cycle back and forth over time.  Episodes in which the person’s mood is too high are called manic episodes, or hypomanic episodes if less severe.  Episodes in which the person’s mood is too low are called major depressive episodes.  In bipolar disorder, the untreated individual has chronically unstable mood.  Periods of wellness, manic episodes, and depressed episodes shift back and forth in an unpredictable pattern.

To diagnose bipolar disorder, most clinicians use the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5 (American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force. 2013).  Bipolar disorder is considered to exist on a spectrum from most severe to least severe.  The most severe form is called Bipolar I (One) Disorder, followed by Bipolar II (Two) Disorder.  Less severe forms of bipolar disorder are Cyclothymia and Other or Unspecified Bipolar and Related Disorders.  The diagnosis of Bipolar I Disorder will be briefly reviewed in this article.

Diagnosing Bipolar I Disorder

To diagnose Bipolar I Disorder, the most severe type of the illness, an individual must have experienced at least one lifetime episode of mania, and typically has experienced one or more depressive episodes as well.  A manic episode consists of elevated, expansive, or irritable mood that is clearly different from the person’s normal mood state.  Several other symptoms must also accompany this change in mood state, as follows:

Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual, called “pressure of speech”
Racing thoughts, called “flight of ideas”
Distractibility
Excessive involvement in highly pleasurable activities that can result in bad consequences, such as excessive spending, gambling, indiscriminate sex, or drug abuse.
Excessive goal-directed activity in work, school, or personal situations, or excessive restlessness in pointless non-goal directed activity, called psychomotor agitation

A manic episode is clearly different from the person’s normal mood and behavior when not in an episode.  The person’s symptoms are so severe as to interfere with routine occupational or social functioning, or the person requires hospitalization, or the person expresses psychotic symptoms (a break with reality).

Most patients with Bipolar I Disorder also have one or more major depressive episodes.  A major depressive episode is a distinct period of mood lasting 2 weeks or longer in which the person feels either depressed or has little or no interest in day to day activities.  In addition to either or both of these symptoms, the individual also must have several of the following additional symptoms nearly daily over the same 2 week period:

Increased or decreased appetite, or significant weight loss or gain
Insomnia or excessive sleep
Noticeable psychomotor agitation, as noted above, or psychomotor retardation, which is moving more slowly and sluggishly than normal
Feeling tired and worn out for no apparent reason
Feeling worthless or irrationally guilty
Cognitive problems involving thinking, concentration, or indecisiveness
Thoughts of death, suicidal thoughts, suicidal plans, or a suicide attempt

Some but not all patients with Bipolar I Disorder also have psychotic experiences, such as hallucinations and delusions.  Hallucinations are false sensory experiences, such as hearing voices, and delusions are false beliefs, such as believing that others are out to harm the person when there is no objective evidence confirming the belief.

Bipolar I Disorder can be confused with other psychiatric and medical conditions.  It is important to have an expert evaluate the patient in order to make an accurate diagnosis.

References

American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C., American Psychiatric Association.

If you are considering psychotherapy for yourself or a loved one for the treatment of bipolar disorder, it may be helpful to get information about available treatments. Psychotherapy is an effective treatment for bipolar disorder.

Psychotherapy is Effective

Many different types of psychotherapy are available to help patients with psychological problems. Research has shown that mainstream forms of psychotherapy work well when treating depression, anxiety, and most other psychological, psychiatric, and mental disorders. These different types of psychotherapy are all generally effective when compared against one another in large research studies.

Bipolar Psychotherapies

Three types of therapy have been developed for the treatment of bipolar disorder. These therapies have been specifically shown to be effective in treating bipolar disorder in research studies.

All three types of psychotherapy include psychoeducation, which involves helping the patient (and at times his or her family) understand the causes, symptoms, and course of illness. All therapies also emphasize the importance of taking bipolar medications as an important keystone of recovery and maintenance.

Cognitive Behavioral Therapy for Bipolar Disorder
Cognitive Behavioral Therapy (CBT) for bipolar disorder is designed to change negative thoughts, behaviors, and emotions associated with the disorder. CBT identifies irrational negative beliefs and helps the patient to challenge them and replace them with healthier thoughts. Changing destructive thoughts can lead to changes in destructive emotions and behaviors.

Interpersonal and Social Rhythm Therapy for Bipolar Disorder
Interpersonal and Social Rhythm Therapy (IPSRT) for bipolar disorder is designed to reduce current interpersonal stress and stabilize circadian rhythms (24 hour cycles). IPSRT identifies one or more areas of interpersonal conflict and helps the patient develop healthy ways of coping with the conflict. IPSRT also actively focuses on helping the patient to stabilize daily sleep and wake patterns and daily routines.

Family Focused Therapy for Bipolar Disorder
Family Focused Therapy (FFT) for bipolar disorder is a type of family therapy in which families and the patient meet with the therapist to cope with the effect of an ill family member on the family. Families are helped to develop an early response strategy for relapses. The patient and families also learn better communication and problem-solving skills when interacting with one another.

Combining Therapies

Any qualified mental health professional should be trained to provide effective forms of psychotherapy. However, most mental health professionals are not trained in bipolar-specific forms of psychotherapy listed here. For bipolar patients, it may be helpful to combine more traditional forms of psychotherapy with these more targeted treatments. This may involve seeing two different therapists who are communicating with one another and providing coordinated treatment. Or, it may involve getting brief specialty treatment in a bipolar disorder treatment center or setting followed by aftercare with traditional psychotherapy.