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Bipolar disorder always includes one or more episodes of mania, characterized by high mood, grandiose thoughts, and erratic behavior. It also often includes episodes of depression. During a typical manic episode, you would feel terrifically elated, expansive, or irritated over the course of a week or longer. You would also experience at least three of the following symptoms:

• grandiose ideas or pumped-up self-esteem
• far less need for sleep than normal
• an urgent desire to talk
• racing thoughts and distractibility
• increased activity that may be directed to accomplishing a goal or expressed as agitation
• a pleasure-seeking urge that might get funneled into sexual sprees, overspending, or a variety of schemes, often with disastrous consequences.

Between episodes, you might feel completely normal for months or even years. Or you might experience faster mood swings (known as rapid cycling). Bipolar disorder actually takes many forms. For example, symptoms of depression and mania may be mixed during cycles. Or you might not have full-blown mania; instead, you could have a milder version known as hypomania.

Is pain a symptom of depression or a cause?

Pain is depressing, and depression causes and intensifies pain. People with chronic pain have three times the average risk of developing psychiatric symptoms — usually mood or anxiety disorders — and depressed patients have three times the average risk of developing chronic pain. When low energy, insomnia, and hopelessness resulting from depression or anxiety perpetuate and aggravate physical pain, it can be impossible to tell which came first or where one leaves off and the other begins.

Pain slows recovery from depression, and depression makes pain more difficult to treat. For example, depression may cause patients to drop out of pain rehabilitation programs. So it often makes sense to treat both pain and depression; that way they are more likely to recede together.

Brain pathways

Normally, the brain diverts signals of physical discomfort so that we can concentrate on the external world. When this shutoff mechanism is impaired, physical sensations like pain are more likely to become the center of attention. Brain pathways that handle pain signals use some of the same chemical messengers (neurotransmitters) that are involved in the regulation of mood. (See "Nerve cell communication" for more information.)

When these pathways start to malfunction, pain is intensified, along with sadness, hopelessness, and anxiety. And as chronic pain, like chronic depression, takes root in the nervous system, the problem perpetuates itself. The mysterious disorder known as fibromyalgia may be an example of this kind of biological process linking pain and depression. Its symptoms include widespread muscle pain and tenderness at certain pressure points, with no evidence of tissue damage. Brain scans of people with fibromyalgia show highly active pain centers, and the disorder is more closely associated with depression than most other medical conditions. This leads some experts to speculate that the pain sensitivity and emotional storminess of fibromyalgia result from faulty brain pathways.

Treating pain and depression in combination

In pain rehabilitation centers, specialists treat both problems together, often with the same techniques, including progressive muscle relaxation, hypnosis, and meditation. Physicians prescribe standard pain medications — acetaminophen, aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs), and in severe cases, opiates — along with a variety of psychiatric drugs. Almost every drug used in psychiatry can serve as a pain medication (see "Medications used for depression and bipolar disorder"). By relieving anxiety, fatigue, or insomnia, these medications also ease any related pain. In addition, antidepressants — sometimes given in low doses — may relieve pain in ways unrelated to their antidepressant effects.

Exercise and psychotherapy are commonly used at pain centers, too. Physical therapists help patients perform exercises not only to break the vicious cycle of pain and immobility, but also to help relieve depression. Cognitive and behavioral therapies teach pain patients how to avoid fearful anticipation, banish discouraging thoughts, and adjust everyday routines to ward off physical and emotional suffering. Psychotherapy helps demoralized patients and their families tell their stories and describe the experience of pain in its relation to other problems in their lives.

Bipolar disorder usually starts in early adulthood. It's equally common among women and men, although certain variations of it strike one sex more than the other. Hypomania, for example, occurs more often in women. Women are also more likely to experience major depression as their first episode and to have more depressive episodes over all. Men, on the other hand, typically experience manic episodes first and tend to have more of them than depressive cycles.

Bipolar disorder is a recurring illness. Nine out of 10 people who have a single manic episode can expect to have repeat experiences. Suicide rates in people who have bipolar disorder are higher than average. Successful treatment, however, can cut down on the number and intensity of episodes and reduce suicide risk.

What are your symptoms?

Identifying your symptoms can be a useful first step toward gaining a deeper understanding of how depression, dysthymia, or bipolar disorder affects you. It may help you open a discussion with a doctor or therapist, too.

Be aware, however, that self-tests like this one cannot diagnose depression or any other mental illness. Even if they could, it's easy to dismiss or overlook symptoms in yourself. It may help to have a friend or relative go over this checklist with you. Also, remember that your feelings count far more than the number of check marks you make. If you think you are depressed or if you have other concerns or questions after taking this test, talk with your doctor or therapist.

Depression checklist

Start by checking off any symptoms of depression that you have had for two weeks or longer, or that you've noticed in the family member or friend you're concerned about. Focus on symptoms that have been present almost every day for most of the day. Then look at the key below. (The exception is the item regarding thoughts of suicide or suicide attempts. A check mark warrants an immediate call to a doctor.)

• I feel sad or irritable.
• I have lost interest in activities I used to enjoy.
• I'm eating much less than I usually do and have lost weight, or I'm eating much more than I usually do and have gained weight.
• I am sleeping much less or more than I usually do.
• I have no energy or feel tired much of the time.
• I feel anxious and can't seem to sit still.
• I feel guilty or worthless.
• I have trouble concentrating or find it hard to make decisions.
• I have recurring thoughts about death or suicide, I have a suicide plan, or I have tried to commit suicide.

Manic episode checklist

Check off any symptoms you've noticed for a week or longer in yourself or the person you're concerned about. Focus on symptoms that are present almost every day during most of the day.

• I feel extremely elated, uninhibited, or irritable.
• I have ideas or plans that will have a big impact on myself or on others.
• I have a continuous stream of thoughts racing through my brain.
• I am sleeping far less than I normally do.
• I am talking far more than I normally do.
• I feel quite distracted and find it hard to focus.
• I am energetically pursuing my goals, or I feel agitated and unable to sit still.
• I am actively pursuing pleasures that may have negative consequences, such as buying whatever I want or entering into sexual liaisons or business schemes.

Scoring the test

Depression and dysthymia. If you checked a total of five or more statements on the depression checklist, including at least one of the first two statements, you (or your loved one) may be suffering from an episode of major depression. If you checked fewer statements, including at least one of the first two statements, you may be suffering from a milder form of depression or dysthymia.

Manic episode. Checking off four statements on the manic episode checklist, including the first statement, suggests possible bipolar disorder. Note that hypomanic symptoms (milder manic symptoms) may last for as little as four days, not a full week or longer.

Source: from Harvard Health Publications, Copyright © 2008 Harvard University. All rights reserved. Harvard Medical School does not endorse products.
Used with permission of StayWell.
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