4 symptoms & 5 rules for Bipolar Disorder

Several research studies have shown that the left amygdala plays a key role in bipolar disorder. By the time teenagers are developing bipolar disorder, there appears to some loss of volume in the left amygdala, which is shown in MRI images of the brain. (Dickstein DP, Milham MP, Nugent AC, Drevets WC, Charney DS, Pine DS, Leibenluft E. Frontotemporal alterations in pediatric bipolar disorder: results of a voxel-based morphometry study. Arch Gen Psychiatry. 2005 Jul;62(7):734-41). There also appears to be greater activation in the left amygdala of teenagers with bipolar disorder when they process facial expression, which has been shown in functional MRI images. (Rich BA, Vinton DT, Roberson-Nay R, Hommer RE, Berghorst LH, McClure EB, Fromm SJ, Pine DS, Leibenluft E. Limbic hyperactivation during processing of neutral facial expressions in children with bipolar disorder. Proc Natl Acad Sci U S A. 2006 Jun 6;103(23):8900-5.) Functional MRI's show the specific areas of the brain that are active from the increased blood flow to an active area.

The image above shows the amygdala in red. (Image is from Anatomography maintained by Life Science Databases (LSDB), Japan.)  Although the amygdala is not much bigger than an almond, it has many functions. It appears to have a major role in the processing of emotions, particularly fear and anger. It plays an essential role in learning from stress. A popular term, "amygdala hijack," refers to a strong emotional reaction that briefly takes over reasonable thinking.

The research shows that the left amygdala has slightly less volume and a significantly greater signal output in people with bipolar disorder. If the amygdala functions as a "volume control" on the emotions, then it is possible that the changes in bipolar disorder cause the volume control to be set at a higher intensity than is needed. People with bipolar disorder tell me that the experience this effect, when they are happy, they are too happy. When sad, they are too sad. When angry, they are too angry. When worried, they are too worried. The emotions that they experience are more intense than the situation calls for.

Although excessive emotions is part of bipolar disorder, it is not enough to diagnose bipolar disorder, or even be considered a definite early sign of this condition., It is important to try to identify children or teenagers who are on the way to developing bipolar disorder early, because with treatment, it is possible to avoid many of the problems, and sometimes even prevent the development of the full disorder.  The best way to determine the beginnings of bipolar disorder is to watch for definite manic episodes of high mood with rapid speech and decreased sleep alternating with depressed episodes of depressed mood with lower energy. The manic and depressed episodes lasts for days, and there can be times of relatively normal moods, energy, and sleep.

Many times, it is difficult to observe definite manic and depressed episodes that lasts for days. In my work with teenagers who were developing bipolar disorder, and adults who had bipolar disorder, I have found that there are four early symptoms, and having three of them appear to predict the development of bipolar disorder. The four symptoms are, (1) bouts of rapid thinking, (2) violent videos, (3) arguing in the mind, and (4) annoying sexual thinking.  The bouts of rapid thinking last 20 minutes to much longer, with the thoughts so rapid that reasoning or school work is not possible. Violent videos are highly graphic with blood and injury, generally occur during times of anger, but do not mean that the person will act out the violence. Arguing in the mind seems as though two people are intensely arguing in the thoughts, but it is not a hallucination.

I ask those who have or are developing bipolar disorder to follow five rules:

1. Manage rages
2. Avoid drama.
3. Don't trust your feelings.
4. Take medication.
5. Don't use drugs or alcohol.

Managing rages involves learning where the "switch" is, and to be able to avoid "flipping the switch" into an angry rage that dominates reason. Reducing anger can be done with an activity that uses the parietal lobe of the brain, which are visual activities or music. Avoiding drama means avoiding people and situations that brings unnecessary stress. Don't trust your feelings for making decisions, because the feelings are too intense or even out of control. Make decisions based on reasoning, logic, and good advise. The last two rules are easy to understand, take medication that is prescribed, and avoid alcohol as well illegal and unprescribed drugs, which can destabilize the mood.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved.

The Brain's Happy Signal

For me, one of the most exciting findings was published early in 2009. It showed a happy signal activated in the brain.

This image is drawn based on the article, Altered striatal activation predicting real-world positive affect in adolescent major depressive disorder, by Forbes EE, Hariri AR, Martin SL, Silk JS, Moyles DL, Fisher PM, Brown SM, Ryan ND, Birmaher B, Axelson DA, Dahl RE, in the American Journal of Psychiatry. 2009 Jan;166(1):64-73. The scientists developed a game in which teenagers could win money while their heads were in the functional MRI scanner. The functional MRI scan detects which parts of the brain are energized and active based on the increased flow of oxygenated blood to the area of activity.

Teenagers who were depressed and matched teenagers who did not have depression were scanned at the moment they were told that they won. The teenagers who did not have depression showed activation in the caudate nucleus, shown in yellow and orange in the image. The teenagers who had depression had cortical activity reflecting thought, but no activation in the caudate. Thus, the yellow and orange in the image depicts a happy signal.

A similar finding was in a previous article, Reward, motivation, and emotion systems associated with early-stage intense romantic love, by Aron A, Fisher H, Mashek DJ, Strong G, Li H, Brown LL, in the Journal of Neurophysiology. 2005 Jul;94(1):327-37. When young adults who were in love were shown photos of their loved once, their scans showed activation in the ventral tegmental area, shown in red, and in the caudate. Brain cells in the ventral tegmental area send connections to the caudate.

This changed what I thought about depression. I used to think that depression involved excessive stress and negativity in life. But this showed that depression involves not having sufficient happy signals to balance out stress and negativity. This implies that to avoid depression and maintain a reasonably happy life, it is important to always make sure that there are enough positive activities to generate enough happy signals to balance out the signals of stress and dealing with negative events.

The two articles showed activation of the “reward circuit” (which I call “happy signals”) from winning a game and from seeing a beloved one. There are many other ways to activate happy signals in the brain, including, joking with friends, giving and receiving positive feedback, solving a problem, eating an amazing meal. Nerdy people get happy signals by learning something interesting or engaging in their own nerdy activities. There is even a quiet calming joy in doing an Obsessive-Compulsive activities such as organizing.

Although the research so far implies that happiness involves activity in the caudate, it seems to me that different kinds of happiness can have distinctly different feelings. Eating vanilla ice cream and chocolate ice cream are different experiences, but the both are ice cream. Happiness has different flavors as well.  The elation of love feels a little different from the excitement of a nerdy discovery, which is different yet from the thrill of watching home team win, yet all are happy feelings.

Other feelings don't appear to have different flavors. Anxiety and anger can be of different degrees and intensities, but anxiety or anger from one stress does not feel different from another stress.  Sadness, too, can be of different intensities, but there appears to be two versions, an agitated sadness with crying, and a low energy depression where it is difficult to accomplish tasks.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved.

The Worse Surgical Resident

During 1978, Dr. Bill (not his real name) had a reputation as being the worse surgical resident at the Thomas Jefferson University Hospital. Actually, he was a very bright young physician, as well as a careful, skilled surgeon. But the surgical residency in our university hospital was high-powered. All of the surgeons-in-training were very bright, and they lived, breathed, and slept surgery. The chief surgical resident even named his cat, “Stitch.” The surgical professors who taught those residents were exacting, perfectionistic, and totally intolerant of even the smallest mistake. Unfortunately for Dr. Bill, the other surgical residents were just a little more skilled than he. Consequently, Dr. Bill was frequently yelled at in the operating room.

Dr. Paul (also not his real name) was a surgeon from the suburbs who was asked by the patient to come to Jefferson University Hospital to remove the patient’s spleen. Maybe feeling a little put out, the house surgeons had Dr. Bill assist him. I was a third year medical student, and I scrubbed in to observe and assist.

What I observed is that Dr. Bill physically performed the surgery, from the first incision to the placement of the last suture. As the teacher, Dr. Paul told Dr. Bill what to do in small steps, giving him 5 to 10 instructions per minute. Under Dr. Paul’s clear direction and close supervision, Dr. Bill performed this difficult surgery in an careful, efficient, effective manner. I had never seen Dr. Bill do so well. In the end, Dr. Paul was satisfied and Dr. Bill was elated. I thought I saw him skip down the hall away from the surgical suite. And I learned what real medical teaching is all about.

Flash forward, thirty years later, and I’m an Assistant Clinical Professor, teaching third-year medical students at the Florida State University College of Medication. They are all brilliant, knowledgeable, enthusiastic, and compassionate, exactly what we want our future physicians to be. But the expectations are high and stress is intense, as they are given tests and compared to the other medical students across the nation. My observations of Dr. Paul’s surgery has shown me how to guide them through the skills they learn, step-by-step, so that when the skills come together, they can independently help the patients.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved.

How Men Solve the Unsolvable

Women talk about problems, especially unsolvable problems (such as their kids or husbands). Women feel better when they talk about their problems.

My advise for men is that they should listen to the women that they love, and share their feelings when women talk about unsolvable problems. Definitely don't tell her to not think about it, forget it, or think about something else. That works for man-to-man, but never is helpful for a woman. Men should not try to solve the woman's problem, unless the woman asks specifically for help solving the problem. If a woman wants advise, they'll ask for it. What is really needed is to pay attention, listen, share the feelings, and don't give advise. Woman feel much better when talk about problems, and will appreciate their men listening to them.

Men feel worse when they talk about unsolvable problems. Men will talk about a problem with someone who can help with a solution.

But if there is no solution, men usually will try to avoid talking about it.

So, if men won't talk about unsolvable problems, then how to they deal with them? Men IGNORE unsovable problems. Women should not fret if their men do not want to talk about the unsolvable problem that is bothering them.

When an unsolvable problem is ignored, one of three things happen:

1. The problem resolves on it's own. This is the most common outcome to the unsolvable problem.

2. In the course of not thinking about the problem, a solution will bubble-up in the man's mind.

3. The problem will become worse, but in the worsening, a solution to become apparant. For example, a car's intermittant noise is very hard to diagnose and resolve. If the car stops totally, then it becomes easy to diagnose and resolve.

Copyright 2010, Henry A. Doenlen, M.D. All rights reserved