Wednesday, May 6, 2015

Bipolar Disorder, the Brain and Energy - Part I

This three part series on the brain and energy is going to be the opening salvo in what I am going to hammer away at length – how much you are your energy and how much I think brain and body energy play critical roles – perhaps the role – in disorders such as bipolar, major depression and perhaps even more minor bouts of depression and important roles in almost every major neuropsychiatric disorder.

As well, recently I have been drawn more into the worlds of Traumatic Brain Injury and Chronic Traumatic Encephalopathy, having been diagnosed with the latter and having many new followers of Taming the Polar Bears who suffer with the former. While quite distinctly different brain injury disorders, both share some common defining symptoms - brain fatigue and/or brain fog. Brain and body fatigue symptoms in both of these disorders will have an at least somewhat different pathology to what I present in this series. Nonetheless, the experience of the brain fatigue and fog is essentially the same and just as troubling and frustrating so there's a lot to relate to here. As well, I feel strongly that brain injuries - whether acute as in TBI or cumulative over long periods like in CTE - will affect mitochondrial function as well. This will take further and deeper research on my part, however. In any case, if you are reading here as a sufferer of either TBI or CTE, I feel this series will be of some value to you. 

While what I'm going to explain about mental energy and body energy in this series is not all that's involved in brain and body energy (and how that's allocated), it will form a very large foundation for understanding how important energy is to brain functions and for what happens when the ability to produce that energy has been impaired.

Now, by “energy” I do not mean “pep”, “vim and vinegar” and things we generally think of when we think of having “energy” or not.

No, I'm talking about the very fundamentals of how your cells and brain cells generate energy. You are made up of trillions of cells, have around eighty-six billion brain cells and what you experience as “energy” is the collective energy created by those trillions of bodily cells and billions of brain cells.

And I'm going to demonstrate – through my own story and other evidence – what happens when “the power goes out”.

I first wrote this series in May of 2014, now three years ago (as of this update of early June 2017). I started off then stating “the depressive phase continues” because it had gone on since August of the previous year. Thank god I had no idea that a full three years later I'd often still be experiencing a crippling lack of energy or I'd have done myself in back then. Back then, I felt that surely the end must be just around the corner and some semblance of normal energy would return.

For the longest time it seemed apparent that I was in the “depressive phase” of a classic – and monstrously long – manic-depressive cycle, with the manic phase starting at the beginning of 2013 through approximately late June of that year (six weeks of full blown no sleep mania, months of classic hypo-mania). I kept my hopes up that with the end of the cycle (and they can be as long as two years) my energy would normalize. However, as the months have stretched into years with no improvement, I am beginning to accept that this is "it". I need to write in more specifics about the great impacts this has one one's life but that will have to wait for a separate piece. 

People generally don't understand what a bipolar "depressive phase" means. The usual assumption is that you sit around feeling negative and sad and sorry for yourself which, while it describes a good deal of the kind of depression most people experience, isn't what we're talking about with bipolar depression. It's not that emotional issues may not be a part of the picture, it's just that these kinds of depression involve severe and debilitating physiological symptoms (elsewhere I'll compile the argument that what are regarded as "emotional issues" are rooted in stress induced brain energy depletion and how energy is allocated throughout the brain though this series will look at the chronic and acute stress plays).

Without getting into all the symptoms of bipolar depression, what I and many others consider to be the defining feature is an absolutely stupefying lack of energy. Reports among anyone who's been through the worst of the depressive phase of bipolar describe an inability to do almost anything physically, mentally or emotionally. The renowned authority on bipolar disorder - and bipolar sufferer herself - Kay Redfield Jamison in her best selling book An Unquiet Mind describes the crippling lack of energy of the depressive phases quite well. I've read many case histories that also describe the debilitating nature of bipolar depression and have heard the stories from people in group therapy or that I met in my research. Just getting out of bed is a major accomplishment. Even simple routines of personal hygiene require the greatest effort. Most day to day activities taken for granted by most people can be out of the question. Furthermore, there are all kinds of cognitive impairments. I've come to see the great mental fatigue as the greatest and most harmful impact. It is increasingly my main hypothesis that the majority of depressive symptoms arise from brain and body cells being unable to adequately produce energy.

Other symptoms (or other ways to think of the fatigue) can be:

  • anedonia (the inability of or difficulty with experiencing pleasure)
  • catatonic or vegetative states
  • psychomotor retardation

But as much as I suffer from it and understand that it's part of the condition, I still can't help feeling like a "wimp" and that there's more that I could do. And the barbed comments I hear about not doing anything all day (or not appearing to do anything in their eyes), the veiled comments about "laziness" and "just being lazy" will always ring in my ear. So it's hard physiologically and psychologically. It just really beats down on your self esteem. An enormous amount of the stigma we will get will be from how people perceive our crippling fatigue. 

And then there are the occasional "lectures" I receive in which people tell me, in effect, if I just pushed past it, if I just exercised enough, if I "just dug down", I'd work my way past the fatigue or I'd find the energy.

Boy, as if I haven't tried pushing myself past it. As if somehow during the now three years of living with this while maintaining great ambitions I somehow forgot to try and dig down for energy when I really needed it.

Personally, I find the fatigue impossible to explain to friends and family. Like many things about human experience, it's very hard to measure and quantify and thus hard to put in perspective for people. Hey, everyone gets fatigued sometimes, so what's my problem?!

The depth of bipolar fatigue, the absolute inability to do anything physical or mental for more than an hour or two and how this persists for months and months (or years) is just beyond the ability for most people to comprehend. Like many aspects of a severe mental health disorder, only those that have been there truly understand (most psychiatrists are particularly clueless about the fatigue). You really do have to go through it to understand how broadly it affects everything you do or can even plan to do.

And I do try push past it. There are periods where I'll feel better for a few days and I'll think, "yippee, my energy is back!". I'll rush to use that energy to get a bunch of stuff done, make plans, and just try to move my freaking life forward but I'll quickly burn out and be absolutely floored by total mental and physical fatigue for a week or weeks afterward. I'm talking days of just being being in near vegetative or catatonic states (catatonic states are a long observed in severe or advanced phases of bipolar type 1) , being able to nothing more than sit by the window listening to music virtually unable to think whatsoever and just able to get through very basic things like getting up and getting clothes on, preparing meals and things like that. Even something completely enjoyable and uplifting like hosting a dinner party or a photography excursion out in nature can leave me exhausted and immobile for days afterward. It can be extremely discouraging and dispiriting.

I've made great strides in overcoming many of the most terrible symptoms of bipolar and suicidal depression. I have at times regained hope and a love of life. I live in less fear and am no longer as governed by my emotions and vicious distorted thoughts. I am less reactionary to events around me.

But I cannot escape the incredible fatigue. For me, just the fatigue is the most debilitating part of the disorder. I am no longer able to hold a job. I am no longer able to even think about holding a job. There is no known cure or treatment for bipolar fatigue. I've learned to accept and live with its limitations much better and get about my days without having to spend great deals of time in bed (though I still have those days), but it is still a devastating part of the illness for me. I am fueled by great ambitions and my mind is often alive with ideas, but I absolutely literally do not have the energy to pursue even a fraction of them. The reading, research and writing that I put even into this little blog have often grind to a halt. I have to carefully "budget" anything that requires physical or mental energy so that I can accomplish at least little steps in a few key goals. I have to set aside the vast majority of things I'd love to pursue. 

And in the last several years I've spoken with numerous people - both bipolar or with depression and/or anxiety disorders - who experience very similar fatigue symptoms and the impacts these have had on their lives.  

Which is why I continue to be driven in my quest for the answers to "why?" That's all I want to know - why?

I email anyone and everyone I can in my search. Top research hospitals, famous professors and researchers; you name it. Not too many answer back but Jon Lieff of the excellent science blog Searching for the Mind has. And to make a long story short, while he didn't want to offer any answers, he did give me the clue that mitochondria was a target of much bipolar research.

So your intrepid researcher made it a prime target of his research.

Now there are many possible factors in bipolar depression or major depressive disorder involving (particularly in the former), neurotransmitters, hormones such as the stress hormone glucocorticoid, hyper or under activated limbic regions, certain brain regions that are too "locked on", among others. I touched on some of these in past (now under construction) posts and it seems quite certain that all of these are involved. And as I've also written, there appears to be actual structural change or damage. According to research, both structural and functional MRI studies have identified specific brain regions in BD patients, namely the prefrontal cortex and limbic regions, which both appear to be altered in size and their functions impaired. So fairly serious stuff.

But today we're going right down to the cellular level in our search for understanding the terrible fatigue and exhaustion of the depressive phase.

First of all, what is mitochondria? Mitochondria are the energy factories of cells. All cells in animal bodies (plants are a different matter as you'll see) - as part of their complex inner workings - have mitochondria.

The website HyperPhysics (which has since been taken down, unfortunately) just happened to have a fairly simple straightforward description of mitochondria:

Mitochondria are the energy factories of the cell. The energy currency for the work that animals must do is the energy-rich molecule adenosine triphosphate (ATP). The ATP is produced in the mitochondria using energy stored in food. Just as the chloroplasts in plants act as sugar factories for the supply of ordered molecules in the plant, the mitochondria of animals act to produced the ordered ATP molecules as the energy supply for the processes of life.

A typical animal cell will have on the order of 1,000 to 2,000 mitochondria. So the cell will have a lot of structures that are capable of producing a high amount of available energy. This ATP production by the mitochondria is done by the process of 'respiration', which in essence is the use of oxygen in a process which generates energy. This is a very efficient process for using food energy to make ATP. One of the benefits of "aerobic exercise" is that it improves your body's ability to make ATP using the respiration process.  

Mitochondria look something like this:

As you can see, there's a lot going on in there (which I won't even attempt to address here). Let's have a look at how they fit into a neuron.

That illustration is of course highly simplistic and just representative of what's contained in a neuron. It shows two mitochondrion while in fact there are thousands of them (as you can see in the above clip).

Now, did we just establish mitochondria as the "energy factories" of all cells, including (of course) neurons? Why yes we did. I think you can see where I'm going with this and why these little guys are vitally important to our understanding of the debilitating fatigue in the depressive phase of bipolar or of major depressive episodes or chronic depression.

So to get this very straight and clear, if mitochondria (or mitochondrion) are impaired or damaged, then cells cannot produce energy. If cells cannot produce energy, then cells cannot perform their jobs. As we are essentially just a collection of trillions of cells, if our collective cells cannot produce energy and do their jobs, then we will not have energy or be able to count on the function of cells to do the work we need to - including physical work or mental work. Hence the debilitating physical and mental fatigue.

This is not something you can "will" yourself past or overcome with plucky perseverance and chipper enthusiasm. If these crucial parts of our very cells are compromised or damaged, then energy is not happening in those cells, pure and simple. And thus whatever you require those cells to do in your daily functions is not going to be happening, at least not at normal levels. And thus - tra-la! - debilitating mental and physical fatigue.

And the role of mitochondria and bipolar depression is - again, this is according to top science researchers like Jon Lieff - becoming a huge area of research.

And having defeated or learned to control virtually every other aspect of what I suffered during depressive phases and having been left with only the fatigue, it has given me very unique insight into just how much brain and body energy affects our mental states, something I am going to further establish as we go along.


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