Bipolar disorder: from diagnosis to treatment
Early on, Sophie * from the canton of Aargau had the feeling that something was wrong with her. «Since I was 14 or 15 years old, my life has been a constant up and down,» recalls the now 27-year-old. A back and forth between various therapies, diagnoses and medication, Sophie is rather reserved towards strangers as a child. At school, she is one of the best in her class.
That changes during puberty . Sophie: «I suddenly knew lots of people, was constantly doing things, was involved in clubs, partied, was cheerful and optimistic.» Then came the change: due to too many absences, she had to repeat a class at cantonal school and was frequently ill for a while. "During this time, I wasn't feeling well mentally and I withdrew more and more.
In manic phases I'm very active, can't sleep until two o'clock, talk quickly and start things without finishing them.
Delia, 20
When I was 17 or 18, it was so bad that I stopped going to school. I just stayed in my room and didn't do anything." It wasn't until she was 25 that she received the diagnosis that explained everything: bipolar disorder.
In a great mood - but ill
«It is characteristic of bipolar disorder that phases without any particular changes in mood or drive alternate with depressive phases and manic or hypomanic episodes,» explains Miriam Gerstenberg, Senior Physician at the Department of Child and Adolescent Psychiatry and Psychotherapy at the Psychiatric University Hospital Zurich.
In manic phases, the mood is euphoric or irritable or the drive is significantly increased. Those affected have a lot of energy, sleep little, are bursting with ideas and tend to engage in risky behaviour.
In depressive phases, they are depressed, lose interest in things, have little drive and feel insecure. «In manic phases, I always realise relatively quickly that something is different,» says 20-year-old Delia * from Winterthur.
She was diagnosed at the age of 13. «I'm very active then, can't sleep until two in the morning, talk quickly and start lots of things without finishing them. During such times, she had many sexual relationships and even prostituted herself once. "Fortunately, my parents got me out of it,» says Delia.
Helpful strategies
It can be unsettling at first to realise that medication must be taken even in times without symptoms. It is helpful if young people and their parents deal with the topic constructively, are open to questions and remain in dialogue with specialists.
In order to avoid new phases of illness or reduce their effects, individualised strategies developed during therapy can be helpful - such as a regular sleep-wake cycle, regular exercise and avoiding too much stimulation.
A mood diary can help to recognise upward or downward fluctuations or personal patterns (at an early stage).
It is important to keep an eye on psychological and social stress and to recognise excessive or insufficient demands. Over time, helpful personal coping strategies can be developed.
It is also useful to have a network of contacts who can provide long-term support for those affected. These can be relatives and friends, a self-help group and regular contact with specialists.
Bipolar II disorder, in which less pronounced hypomanic episodes occur instead of manic ones, is particularly insidious. «The adolescents are then in a good mood, feel productive and often feel no distress,» says Gerstenberg.
«Peers may experience them as particularly exciting, but parents often just see them as exhausting. That's why help is often not sought during such phases.»
Symptoms are often misjudged as a normal developmental phenomenon
Bipolar disorders become increasingly common around the age of 14. «The diagnosis is usually not made before then because the symptoms are too vague - and because people are still cautious about medication,» says Lars Wöckel, Deputy Medical Director of the Clienia Littenheid Private Clinic and Head Physician at the Centre for Child and Adolescent Psychiatry and Psychotherapy there.
Psychiatrist Gerstenberg also knows that the diagnosis is often not made until five to ten years after the first symptoms appear. There are many reasons for this: "As children and adolescents are constantly developing, parents are used to different phases occurring.
Adolescents with bipolar disorder often have other mental disorders such as ADHD or a social behaviour disorder.
Lars Wöckel, psychiatrist
The symptoms in adolescence are also often less specific and the phases of the illness cannot be clearly differentiated, says Wöckel. «In addition, the symptoms can be confused with other mental illnesses. Adolescents with bipolar disorder often have other mental disorders, in particular ADHD, a social behaviour disorder or problematic alcohol or drug use.»
For the young people and their parents, this often means a long ordeal. This is also the case for Sophie: her mood is constantly changing, with all-night parties followed by weeks in bed. She starts studying at the Basel School of Art without completing her A-levels.
She saw various psychiatrists for years without any noticeable improvement in her situation. At the age of 21, she was hospitalised for the first time - and was diagnosed with schizophrenia. The medication, the neuroleptic Abilify, helps her. After a while, she feels so well that she stops taking all her medication. Six months later, she falls into depression again.
Early diagnosis is very important because timely treatment can significantly improve the prognosis, says expert Gerstenberg: "It can shorten the duration of the acute phase and reduce the number of new episodes as the disease progresses.
A careful diagnosis should therefore always be made. «Specialists need to know the patient's history well and ask specifically about phases of elevated mood - for example, when depression occurs for the second time,» says the psychiatrist.
«It is also important that the experts treating a child or adolescent network well.» Broad-based information campaigns are also useful to educate the population about bipolar disorder and its treatment options.
Significantly increased risk if the disease is already in the family
Delia was diagnosed relatively early on: «When I was 13, I felt anxious and depressed and went to an outpatient therapist because my teachers had advised me to,» she explains. «A few months later, manic symptoms appeared. Soon after, I was diagnosed with bipolar disorder.»
Sophie, on the other hand, only underwent a detailed diagnosis at the age of 25. The result: bipolar II disorder with rapid cycling and ADHD. Rapid cycling means that four or more episodes occur within a year. «I was really happy to finally know what was wrong with me,» says the young woman.
She receives a neuroleptic, an antidepressant and a psychostimulant or Concerta for the ADHD. «In my opinion, this combination helps to stabilise my basic mood and makes it more difficult for the phases to break out,» she reports.
If bipolar disorder is suspected, it is also important to ask about risk factors in the family, says psychiatrist Wöckel. «If a parent or other family member has the illness, the child's risk of also developing it is significantly increased. Specialists should then keep a close eye on the young person.»
The aim of treatment is to reduce the symptoms of the acute phase and to achieve stable phases for as long as possible in which those affected can lead a relatively normal life. A combination of psychoeducation, medication and psychotherapy is used.
With the help of psychotherapy, young people can become experts on their own illness over time.
«During psychoeducation, young people and their parents receive information about the symptoms of bipolar disorder, what can trigger it, how it can be treated and which strategies are helpful in dealing with the illness,» says Wöckel.
In depressive and stable phases, psychotherapy and psychoeducation take centre stage. According to Wöckel, parents should always be involved: «In psychotherapy, young people find out what is personally stressful for them, for example, and learn to change these situations or reduce their own stress levels.»
Further goals are to develop a regular rhythm of life and to recognise early warning signs of phases of illness in good time and react accordingly. In this way, young people can become experts on their own illness over time.
Attentive relatives are an effective early warning system
«Support from relatives is one of the most effective measures for promoting the mental stability of young people and supporting them in their education and professional life,» says Wöckel. This means that those affected often don't even notice the initial, unspecific symptoms of phases of the illness - or they experience them as positive.
«However, relatives often notice such changes quickly,» says the expert. «They can draw their child's attention to it and motivate them to change something or seek professional help.»
In order to be able to react quickly to the first symptoms of a phase of illness and ensure that medication is taken regularly, long-term professional support can be useful. «This could be regular psychotherapy or visits from a specialist in external hospital help and care,» says Wöckel.
The strain on parents can be so great that they themselves develop a mental illness. It is therefore advisable to seek help early on.
Lars Wöckel, psychiatrist
In order to be able to react quickly to the first symptoms of a phase of illness and ensure that medication is taken regularly, long-term professional support can be useful. «This could be regular psychotherapy or visits from a specialist in external hospital help and care,» says Wöckel.
Anyone who does not take medication reliably must expect relapses
In the course of therapy, young people are also taught that bipolar disorder is a lifelong illness - and that medication usually needs to be taken over the long term in order to prevent new phases of the illness. «Drug treatment for adolescents is similar to that for adults. However, only a few medications are also authorised for adolescents in Switzerland,» says Wöckel.
«I was against taking medication at first,» reports Delia. «But then I realised that I couldn't do without it.» However, despite taking medication, she suffered a relapse about once a year, so she had to increase her dose.
Many young people take their medication irregularly, forget to take it or stop taking it because of side effects.
Lars Wöckel, psychiatrist
«But part of the reason was that I hadn't taken the tablets regularly,» admits Delia. This is a common problem, says Wöckel: «Many young people take their medication irregularly, forget to take it or stop taking it again because of side effects. "That's why doctors should provide good information about the fact that discontinuation and irregular intake can quickly lead to relapses,» says the specialist.
There is no reason for parental guilt with this diagnosis
For relatives, especially parents, their child's bipolar disorder is often a great burden. «In manic or hypomanic or depressive phases, they have to look after their child a lot. This often leads to conflicts because the parents want to intervene, but the child wants to detach and be independent during puberty,» says Wöckel.
Parents often feel guilty and ask themselves what they have done wrong - but there is no reason for this in the case of bipolar disorder. «The stress can be so severe that parents themselves develop a mental illness,» says the psychiatrist.
«It can often be helpful for them to seek support themselves - for example from a psychotherapist or in a self-help group for relatives.» In the early years of their illness, Sophie and Delia report that their relationship with their parents was difficult. «I didn't tell them much about myself and they worried a lot,» says Sophie.
«But they also put a lot of emotional pressure on me, I didn't feel seen. There were constant arguments, so I withdrew even more from them.» From Delia's point of view, her parents also interfered too often.
«I wanted to do a lot of things myself and there were often arguments,» she says. "They also quickly realised when I slipped into mania or depression and then wanted to tell me what to do. I didn't like that at all. On the other hand, the two young women admit that their parents always supported them - and their relationship with them has also improved considerably in the meantime, they both say.
Getting a grip on life again
Experience shows: How the disease progresses varies greatly from person to person. However, there is hardly any reliable data on how many patients can lead a largely unimpaired life.
«Most bipolar sufferers have a few episodes in their lives,» says Gerstenberg. «Around ten per cent experience more than ten episodes in total, and some have several episodes a year.»
Here you will find information and help:
Selbsthilfe Schweiz, search for self-help groups for sufferers and relatives: www.selbsthilfeschweiz.ch
German Society for Bipolar Disorders (DGBS): www.dgbs.de
Institut Kinderseele Schweiz, information about mental illnesses for children and adolescents: www.kinderseele.ch
Sophie now feels that she has found a good way of dealing with the illness. «I've now realised that I have to live with it,» she says. "This includes taking my medication regularly and taking good care of myself.
She now knows the early warning signs of phases very well and can take countermeasures herself. «Then, for example, I can add an extra therapy session, increase my medication a little and make sure that I approach everything more moderately.» The exchange in a self-help group, which she has been attending since autumn 2020, is also helpful.
Delia also thinks that she is now on the right track. «With my current medication, I feel pretty stable - and fit enough to do everything I want to do,» she says. She has been living in an assisted living centre since May 2022 and is currently looking for a part-time job. «In the foreseeable future, I would also like to start an apprenticeship in sales.»
* Names of the persons concerned changed
Was ist eine bipolare Störung?
Bipolar disorder is a mental illness in which genetic factors play an important role. (Hypo-)manic phases with elevated mood and drive and depressive phases occur. The phases can be triggered by an irregular rhythm of life, stress and psychological strain.
How often does it occur?
Around 3 to 5 per cent of all adults are affected by bipolar disorder. Studies suggest that 0.6 to 2 per cent are affected before the age of 18 - boys just as often as girls. As the diagnosis is often made in retrospect, the figures are probably higher.
Wie sieht die Behandlung aus?
It should consist of psychoeducation, drug treatment and psychotherapy. Good management of the disease is important to ensure that sufferers remain stable in the long term - for example, recognising early symptoms and taking medication regularly. Relatives can be a great source of support here.
