Bipolar Affective Disorder and Mel – Happy Ending Alert

Bipolar Affective Disorder affects about 1 per cent of the population. It is characterised by marked mood fluctuations – someone may feel very elated or “high”. They can display a range of typical symptoms, including pressure of speech – talking very fast and with little opportunity to interrupt; grandiose delusions – thinking they have special powers or are very important; and spending money they do not have on irrational things. They may find difficulty sleeping, mainly because their minds are too full of plans to sleep, and may at times be sexually disinhibited.

They may also have periods of low mood or profound depression. These cycles can often be plotted over time (there are some useful mood diaries around which can reveal these patterns). Many people with Bipolar Affective Disorder will only tend to go “high”. The onset of this disorder is typically in the mid twenties through to early thirties.

It also seems to be a disorder that some people actually seem to want to have – our CMHT often has referrals from GP’s which go along the following lines:

“Dear Team, Florence came into my surgery today convinced she has Bipolar Affective Disorder. She describes rapid mood swings, one minute laughing and cheerful, the next minute tearful and feeling suicidal. She has been researching on the Internet, and thinks the symptoms match those of Bipolar Affective Disorder. Could you assess her?”

Almost invariably, these people do not have Bipolar Affective Disorder – they are more likely to have Emotionally Unstable Personality Disorder – or just be adjusting to some adverse life event. However, they are often unhappy to be told this. Some demand mood stabilising medication, which people who really do have Bipolar Affective Disorder are often very reluctant to take.

I have often written in this blog about my experiences of assessing people with this disorder under the Mental Health Act, but this doesn’t mean that people with Bipolar Affective Disorder will inevitably require detention under the MHA or even a hospital admission.

A diagnosis of Bipolar Affective Disorder also does not mean that they will always be disabled; indeed, I have written about people who have successfully managed to work in positions of responsibility despite this diagnosis. I have even known Consultant Psychiatrists with Bipolar Affective Disorder.

Mel
Mel is a very good example of someone with this disorder who, despite at first encountering serious problems controlling her condition, went on to achieve success and happiness. Yes, this is a story with a happy ending. I’m in a good mood today.

Mel was in her early 30’s when I first started working with her. She was an exceptionally intelligent and charming woman, who had been halfway through a PhD in Parasitology, studying the reproductive processes of deer ticks (more interesting than it sounds), when she had started to develop manic symptoms. Her behaviour became increasingly erratic over a period of a few months until she could no longer continue with her fieldwork. She was diagnosed with Bipolar Affective Disorder and started on mood stabilising medication.

By the time I became her care co-ordinator, she had had to abandon her studies, and was working as a pharmacy assistant in the local general hospital. She lived alone in a small flat, and was struggling.

Mel generally had very good insight into her disorder. We developed a shorthand for describing her mood fluctuations. On a scale of 1 to 10, 5 was normal mood. Below 5 was low, above 5 was high. She also kept a mood chart, and over time we were able to construct an elegant model of her mood changes over time. She seemed to have a two month cycle, where she would gradually become high, then return to normal, before sliding into depression and then gradually recovering.

I was usually able to give her a score on our scale within a couple of minutes of coming to an appointment. Sometimes she would be confused, lethargic and tearful. At other times, she would be vivacious and giggly. Sometimes she could identify when she was high, but sometimes I had to point this out to her, one such example being when she had told me on entering the room that she had just had her navel pierced and then proceeded to show me!

Mel, her psychiatrist and I worked hard to try and even out these mood fluctuations. We tried a whole range of mood stabilising drugs, with varying degrees of success. Over time, her control over her mood seemed to decrease. She went on long term sick leave, as she was no longer able to manage her job, and eventually gave it up completely. She could no longer afford her car, and got rid of it. She made a successful claim for Disability Living Allowance. The condition was beginning to disable her, and she was acutely aware of this.

The length of time Mel spent at either extreme of her mood cycles seemed to grow longer, especially the depressive periods. During these times, she would isolate herself in her flat, spending up to 18 hours asleep. She put on weight, some of this unfortunately precipitated by medication (Olanzapine, while being a very effective anti-psychotic and mood stabiliser, has the notorious side effect of excessive and often unacceptable weight gain). She even had a brief, informal hospital admission.

We worked with her to try and end this decline. Cheryl, our support worker, got involved with her to increase her motivation and work on plans to reduce her weight. We provided her with funds to pay for membership of the local gym. Our psychiatrist found a mood stabiliser that worked for her, and seemed to both stabilise her and lift her mood. Over a period of months the mood charts she kept religiously began to show a levelling out of her fluctuations.

Mel managed to lose weight, and became much fitter. Her confidence increased, to the extent that one day she confided in Cheryl about her interest in a man who worked in the Charwood art gallery. She would like to meet him, but didn’t know how to go about it. Cheryl offered to go in with her on the premise of being interested in purchasing one of the pictures. I wasn’t sure that match-making was a function of a support worker, but decided that it was worth a try.

One day, Cheryl and Mel went into the art gallery. Cheryl engaged the art dealer in conversation, and gave Mel openings to join in. The man seemed to show a genuine interest in Mel, and actually said to her: “We must go and have a coffee sometime.”

Mel was delighted. So was Cheryl. The cunning plan seemed to have shown promise. But no invitation from the man materialised.

“Well, Mel,” I said to her one day, “it’s up to you now. Why don’t you go in there, and say to him, ‘Hi, I was just passing, and thought I’d take you up on that offer of a coffee’ – and see what happens.”

She decided, with some trepidation, to try it. Cheryl and I waited, with some trepidation, to find out what came of it.

I saw Mel a week later. Her eyes were sparkling.

“I did as you suggested,” she said, “—and it worked! We had a coffee. Then he invited me out to the cinema. And next week he’s taking me out to dinner!”

Things just continued to get better from there on. Despite having been unemployed for 2-3 years, Mel applied for a job doing administrative work in the Zoology department at the local University. And got the job. The relationship with the art dealer continued to grow. After a few months they decided to move in together.

One day, Mel confided that she had stopped taking her medication several months previously. This alarmed me, but there had been no recurrence of her mood swings, so we decided to just see what happened.

Despite my fears, Mel’s mood remained stable. She and her partner bought a house together, out of the Charwood CMHT catchment area. On the last appointment before she moved, I asked her if she wanted a transfer of care to the new area. She said she didn’t but promised she would go to her GP if she was concerned about her mental state.

Three years down the line (I have my spies) everything still seems to be absolutely fine.

There can be happy endings in mental health, after all.