Mania, Depression, Bipolar Disorder and Parkinson Disease
Copyrighted Abraham Lieberman MD 4/1/05. Revised 3/22/06

Bipolar disorder, also known as manic-depressive disorder, causes marked shifts in a person's mood, energy, and ability to function. The highs and lows of bipolar disorder, like the “on” and “offs” of Parkinson people, are different from the ups and downs of every day life. The highs and lows of bipolar disorder, like the “on” and “offs” of PD people can result in strained personal relationships, poor job performance, and even suicide. There are similarities and differences between the highs and lows of bipolar disorder, the mania and depression, and the “on” and “off” periods of PD, the periods of mobility or hyper mobility with dyskinesia.

The highs and lows of bipolar disorder usually cycle over days or weeks, the “on” and “offs” of PD people cycle over hours, or minutes. The highs and lows of bipolar disorder occur in no relationship to a known drug or chemical although there is a partial relationship to daily changes in hormones including adrenal cortisol and growth hormone. The “on” and “offs” of PD occur in relationship to the dose of levodopa.

There are, however, similarities betweens the highs and lows of bipolar disorder and the “on” and “offs” of PD. PD people when they are “on” are often “high”, they are alert, energetic, creative, similar to people with bipolar disorder when they are “high.” PD people when they are “off” are anxious, depressed, panicky, they will do almost anything to be “on.” In this their behavior resembles people with bipolar disorder who are “low” or “down.”

Until we understand why cycling occurs in the brain, we should keep an open mind between the highs and lows of bipolar disorder and the “on” and “offs” of PD. It is of note, however, that drugs such as lithium, or depakote, or lamictal, drugs that stabilize mood in bipolar disorder do not stabilize the “on” and “offs’ of PD.

More than 3 million Americans, or about 1.0% of the population, have bipolar disorder. This is 3 times the prevalence of PD. Bipolar disorder usually develops in late adolescence. However, some people develop it late in life. It is often not recognized as a disorder, and people may suffer for years before being diagnosed. Like PD, bipolar disorder is a long-term illness.
In some people bipolar disorder, like the “on” and “offs” in PD distorts moods, deranges thoughts, incites bad behaviors, and causes panic. Bipolar disorder causes dramatic mood swings—from overly "high" to hopeless, and then back again, often with periods of normal mood in between. Marked changes in energy and behavior go along with the mood changes. Symptoms of mania include: Increased energy, activity, and restlessness, euphoria, irritability, racing thoughts, fast talking, distractibility, inability to concentrate, need for little sleep, unrealistic beliefs in one's abilities, poor judgment, spending sprees (like the compulsive gambling of some PD people), increased sex drive, abuse of drugs, particularly cocaine, alcohol, and sleeping pills. Symptoms include intrusive, or aggressive behavior and a denial that anything is wrong. A manic episode is diagnosed if a high occurs most of the day, every day, for 1 week or longer. Mild to moderate mania is called hypomania. Hypomania is associated with a feeling of euphoria and well being. Hypomania, however, if not suspected and treated may lead to mania or depression.
Symptoms of depression include: anxiety, sadness, hopelessness, pessimism, guilt, worthlessness, helplessness, lack of interest in activities once enjoyed, decreased energy, fatigue, difficulty concentrating, difficulty in remembering, difficulty in making decisions. The person may sleep too much or be unable to sleep. There may be change in appetite and unintended weight loss or gain. There may be chronic pain or other symptoms that are not caused by a physical illness. There may be thoughts of death. A depressive episode is diagnosed if symptoms last most of the day, every day, for 2 weeks or longer.
Sometimes, episodes of mania or depression include psychosis. Common psychosis symptoms include hallucinations such as hearing, seeing, or otherwise sensing the presence of things not actually there. The symptoms include delusions such as false, but strongly held beliefs not influenced by logical reasoning. The symptoms of psychosis will reflect whether the person in high, or low. For example, if a person is high he will have delusions of grandiosity, such as believing he is the President , or God, or that he has special powers or wealth.
If, however, a person is low he will have delusions of guilt or worthlessness, such as believing that his is ruined or penniless or that he has committed a terrible crime. Similar symptoms of psychosis may appear in some PD people who are evolving a dementia when they are “on” or when they are “off.” Some people with bipolar disorder who have symptoms of a psychosis are incorrectly diagnosed as having schizophrenia.
The moods of a person with bipolar disorder form a spectrum. At one end is severe depression, then moderate depression and then mild depression, called the "the blues." Then there is normal mood, hypomania, mania, and mania with psychosis. In some people, however, symptoms of mania and depression may occur together in a “mixed” bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, marked changes in appetite including binge eating or starvation, psychosis, and suicidal thinking. A person with a “mixed” state may be sad, feel hopeless, and at the same time feel energized.
A person with bipolar disorder may be brought to a doctor because of alcohol or drug abuse, poor work performance, or strained personal relations and, initially, the underlying bipolar disorder may not be appreciated by the patient, the family, or the doctor.

Like many mental disorders, bipolar disorder cannot yet be identified physically, for example, through a blood test or a brain scan. Therefore, a diagnosis of bipolar disorder is made on the basis of initial symptoms, evolution of symptoms, and family history. The diagnostic criteria for bipolar disorder are described in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV). Descriptions offered by people with bipolar disorder give insights into the moods associated with it.

Depression: I doubt my ability to do anything well. It seems as though my mind has slowed down and burned out. I am haunted with the desperate hopelessness of it all. Others say, "It's only temporary, it will pass, you,," but they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?

Hypomania: When I'm high, it's tremendous, ideas comes fast, like shooting stars. . All shyness disappears, the right words and gestures are suddenly there. Uninteresting people become interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. My marrow is infused with unbelievable feelings of power, well-being, omnipotence, euphoria. I can do anything!

Mania: The fast ideas become too fast. They are overwhelming, confusion replaces clarity, I can’t keeping up with it—my memory goes. My friends become frightened, I’m irritable, angry, frightened, trapped.
Suicide. Some people become suicidal. Anyone who thinks about committing suicide needs immediate help. Anyone who talks about suicide should be taken seriously. Symptoms that may accompany suicidal feelings include: talking about wanting to die, feeling hopeless, feeling nothing will change or get better, feeling helpless, feeling a burden, abusing alcohol or drugs, putting personal affairs ins order as a preparation to dying. Symptoms also include writing a suicide, seeking harmful or dangerous situations.
If someone is suicidal, call a doctor, an emergency room, or 911 for help. Be certain the suicidal person is not left alone make. Be certain that he or she has no access to dangerous drugs or weapons. While some suicides are carefully planned, others are impulsive acts that have not been well thought out. With proper treatment, suicidal feelings can be overcome.
Episodes of mania and depression occur throughout a person’s life. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of them have some residual symptoms. The classic form of the disorder involving recurrent episodes of mania and depression, is called Bipolar I Disorder.
Some people, however, never develop severe mania but instead have episodes of hypomania that alternate with depression; this form of the disorder is called Bipolar II disorder. When four or more episodes of mania and/or depression occur within a year, a person is said to have a rapid-cycling. Some people experience multiple episodes within a week, or even a day. Rapid cycling tends to develop later in the course of the disorder and is more common in women than men. In time a person may have more frequent (more rapid-cycling) and more severe manic and depressive episodes than in the past. But in most cases, treatment can reduce the frequency and severity of episodes.