Bipolar Disorder

Bipolar disorder is a condition that involves mood swings with at least one episode of mania.

Bipolar disorder is a mental illness, specifically one of the affective (mood) disorders. It is characterized by severe mood swings, at least one episode of mania and may include repeated episodes of depression.

This illness afflicts more than 1% of adults in the United States, up to as many as 4 million people. Some additional facts and statistics about bipolar disorder include the following:

• Bipolar disorder is the fifth leading cause of disability worldwide.
• Bipolar disorder is the ninth leading cause of years lost to death or disability worldwide.
• The number of individuals with bipolar disorder who commit suicide is 60 times higher than that of the general population.
• There seems to be no increase in involvement with violent crime for people with bipolar disorder compared to the general population except for those bipolar disorder sufferers that also suffer from an alcohol or other substance use disorder.
• People who have bipolar disorder are at a higher risk of also suffering from substance abuse such as alcoholism as well as other mental health problems.
• A number of medical problems tend to co-occur with bipolar disorder, including some pain and neurological and genetic disorders.
• Males may develop bipolar disorder earlier in life compared to females.

Bipolar disorder has several types, including:

• Bipolar I disorder
• Bipolar II disorder

Depending on how rapidly the mood swings occur, the episodes of bipolar disorder can also be described as having mixed (mood-disordered episodes that last less than the usual amount of time required for the diagnosis) features or rapid cycling (four or more mood-disordered episodes per year) features.

About two-fifths of people with bipolar disorder have at least one period of rapid cycling throughout their lifetime.

For every type and duration of the illness, the sufferer experiences significant problems with his or her functioning at school, at work, socially, or otherwise in their community, may need hospitalization, or may have psychotic symptoms (for example, delusions or hallucinations).

• Bipolar I disorder diagnosis requires that the individual has at least one manic episode but does not require a history of major depression.
• Bipolar II disorder is diagnosed if the person has experienced at least one episode of major depression and at least one episode of hypomania (a milder form of mania).

Cyclothymic disorder is characterized by at least two years in adults, or one year in children and adolescents, of episodes of having symptoms of depression and episodes of hypomanic symptoms that do not qualify for having either a full major depressive, manic, or hypomanic episode.

Mixed features are defined as meeting full diagnostic criteria for a manic episode while also suffering from at least three symptoms of a depressive episode, or meeting full diagnostic criteria for a major depressive episode while also suffering from at least three symptoms of a manic or hypomanic episode.

People who suffer from significant, debilitating seasonal mood changes year after year may be classified as having a seasonal pattern to their bipolar disorder.

As indicated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), to qualify for the diagnosis of bipolar disorder, a person must experience at least one manic episode. Characteristics of mania must last at least a week (unless it is part of mixed features) and include:

• Elevated, expansive, or irritable mood
• Racing thoughts
• Pressured speech (rapid, excessive, and frenzied speaking)
• Decreased need for sleep
• Grandiose ideas (for example, false beliefs of superiority or failure)
• Tangential speech (repeatedly changing conversational topics to topics that are hardly related)
• Restlessness/increased goal-directed activity
• Impulsivity, poor judgment, or engaging in risky activity (like spending sprees, promiscuity, or excess desire for sex)

Although a major depressive episode is not required for the diagnosis of bipolar disorder, such episodes often alternate with manic episodes. Persistent sadness tends to occur more often than mania in many people with bipolar disorder.

Characteristics of depressive episodes (bipolar depression) include a number of the following symptoms:

• Persistently depressed or irritable mood
• Feelings of apprehension
• Frequent crying, inability to feel pleasure
• Loss of interest in previously pleasurable activities
• Apathy, low motivation
• Increased or decreased appetite, weight loss, or weight gain
• Difficulty falling asleep
• Excess sleepiness, agitation, or lack of activity
• Fatigue/low energy
• Feelings of worthlessness
• Lack of concentration
• Slowness in activity and thought
• Inappropriate feelings of guilt
• Hopelessness
• Thoughts of death, self-harm, or suicidal thoughts, plans, or actions.

One frequently asked question about bipolar disorder is if it is hereditary. As with most other mental disorders, bipolar disorder is not directly passed from one generation to another genetically. Rather, it is the result of a complex group of genetic, psychological, and environmental vulnerabilities.

• Genetically, bipolar disorder and schizophrenia have much in common, in that the two disorders share a number of the same risk genes. However, both illnesses also have some unique genetic risk factors.
• Other mental health disorders, like anxiety and behavior disorders, can increase the likelihood of developing bipolar disorder.
• Stress is a significant contributor to the development of most mental health conditions, including bipolar disorder. For example, gay, lesbian, and bisexual people are thought to experience increased emotional struggles associated with the multiple social stressors that are linked to coping with societal reactions to their sexuality. People who have similar stress levels are equally prone to developing bipolar disorder regardless of nationality, race, or socioeconomic status.

As is true with virtually any mental health diagnosis, no one test definitively assesses that someone has bipolar disorder. Therefore, healthcare clinicians, like psychiatrists and clinical psychologists, diagnose this disease by gathering comprehensive medical, family, and mental health information.

The healthcare professional will also either perform a physical examination or request that the individual's primary care doctor perform one. The medical examination will usually include lab tests to evaluate the person's general health and to explore whether or not the individual has mental health symptoms like:

• Euphoria
• Depression
• Agitated depression
• Rarely paranoia or other symptoms of psychosis that are associated with a medical condition

In asking questions about mental health symptoms, mental health professionals are often exploring if the individual suffers from depression and/or manic disorders, but also anxiety, substance abuse, hallucinations or delusions, as well as some personality and behavioral disorders.

Healthcare professionals may provide the people they evaluate with a quiz or self-test as a screening tool for bipolar disorder and other mood disorders.

Since some of the symptoms of bipolar disorder can also occur in other mental illnesses, the mental health screening is to determine if the individual suffers from bipolar disorder, a depressive disorder, or the less severe symptoms of depression and hypomania associated with cyclothymia.

Any disorder that is associated with sudden changes in behavior, mood, or thinking, like a psychotic disorder, borderline personality disorder, or multiple personality disorder (MPD), may be particularly challenging to distinguish from bipolar disorder. To assess the person's current emotional state, healthcare professionals perform a mental status examination, as well.

Many people, whether they suffer from bipolar disorder or any medical or other mental illness, understandably wonder how they might help themselves to have the best outcome of treatment. While there is no cure for bipolar disorder, medications and psychotherapies remain the mainstays of treatment of this illness.

Medications that treat bipolar disorder

In terms of the overall approach to treatment, people with bipolar disorder can expect their mental health professionals to consider several medical interventions in the form of medications, psychotherapies, and lifestyle advice.

Treatment of bipolar disorder with medications (psychopharmacology) tends to address two aspects:

• Relieving already existing symptoms of the manic or depressive phases of the illness
• Preventing symptoms from returning

Antipsychotic medications are thought to be particularly effective in treating manic and mixed symptoms. Antipsychotic drugs belong to a group of medications called neuroleptics and are known for having the ability to work quickly (in 1-2 weeks) compared to many other psychiatric medications. 

Mood-stabilizer medications as well as antiseizure (anticonvulsant) medications can be useful in treating active (acute) symptoms of manic or mixed episodes, as well as preventing the return of such symptoms. These medications may take a bit longer to work compared to the neuroleptic medications and some require monitoring of medication blood levels.

Antidepressant medications are the primary medical treatment for the depressive symptoms of bipolar disorder. Examples of antidepressants that are commonly prescribed for that purpose include selective serotonin reuptake inhibitors (SSRIs) and serotonergic/adrenergic medications (SNRIs). While antidepressant medication remains a mainstay of treatment for the sadness of bipolar disorder, the prescribing physician will remain watchful since there is some risk that antidepressants can induce a manic or near-manic (hypomanic) episode or the rapid mood-cycling pattern of symptoms.

Despite its stigmatized history, electroconvulsive therapy (ECT) can be a viable treatment for people whose bipolar disorder is severe and has inadequately responded to psychotherapies and several drug trials. Transmagnetic stimulation (TMS) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of mildly resistant depression and is thought to be a helpful addition to medication in the treatment of bipolar disorder in individuals who have not responded to at least one trial of medication. However, it is not yet considered to be an adequate treatment for this illness by itself.

Psychotherapies

Talk therapy (psychotherapy) is an important part of helping individuals who are living with bipolar disorder achieve the highest level of functioning possible by improving ways of coping with the illness from day to day, as well as on a long-term basis. These interventions are therefore seen by some as being forms of occupational therapy for people with bipolar disorder.

Psychotherapy may also engage people with bipolar disorder who prefer to receive treatment without medication. While medications can be quite helpful in alleviating and preventing overt symptoms, they do not address the many complex social and psychological issues that can play a major role in how the person with this disease functions at work, at home, and in his or her relationships.

Since about 60% of people with bipolar disorder take less than 30% of their medications as prescribed, any supports that can promote compliance with treatment and otherwise promote the health of individuals in this population are valuable.

Psychotherapies that are effective in treating bipolar disorder include:

• Family-focused therapy
• Psycho-education
• Cognitive behavioral therapy
• Interpersonal therapy
• Social rhythm therapy

Family-focused therapy involves the education of family members about the disorder and how to provide appropriate support (psycho-education) to their loved ones. This intervention also includes communication-enhancement training and problem-solving skills training for family members.

Psycho-education involves teaching the person with bipolar disorder and their family members about the symptoms of full-blown depressive and manic symptoms, as well as warning signs (for example, feeling sad, change in sleep pattern or appetite, general discontent, change in activity level, or increased irritability) that the person is beginning to experience either a mood episode or the triggers for mood episodes (like lack of sleep, use of alcohol or other drugs, exposure to severe stress).

In cognitive behavioral therapy, the clinician works to help the person with bipolar disorder identify, challenge, and decrease negative thinking and otherwise dysfunctional belief systems that may impair their functioning relationships and self-esteem.

The goal of interpersonal therapy tends to be identifying and managing problems the sufferers of bipolar disorder may have in their relationships with others.

Social rhythm therapy encourages the stability of sleep-wake cycles, to prevent or alleviate the sleep disturbances often associated with this disorder.

While the prognosis for bipolar disorder indicates that individuals with this disorder can expect to experience episodes of some sort of mood problem (like depression, mania, or hypomania) up to 60% of the time, those episodes can be well managed by the combination of psychotherapy and medication treatment.

Clinical trials indicate that people who have a mixed pattern of symptoms can be more difficult to stabilize with treatment and have a more problematic course than those who do not have mixed episodes. Individuals who were misdiagnosed with other mental illnesses, thereby delaying treatment for bipolar disorder, are at risk for a longer, more difficult duration of illness.

There are several potential complications of bipolar disorder, particularly if left untreated. This illness may be compounded by other mental health problems including substance abuse and addiction, whether it be to legal substances like alcohol or tobacco, prescription medications, or illicit drugs like heroin or cocaine.

Bipolar disorder sufferers tend to experience thinking (cognitive) problems and those who are repeatedly hospitalized psychiatrically have more trouble functioning throughout life. The risk of committing suicide is 60 times higher for people with bipolar disorder compared to the general population. That may be partly due to the chronic emotional pain that some people with this disorder experience, in that they endure years of depressive and manic symptoms, the consequences of their actions during those disease states, as well as potentially longing for the increased energy and sense of well-being of mania that may be quelled by psychiatric medications.

As with people with other mood disorders, those with bipolar disorder are at higher risk for developing a medical illness and for having a higher number of medical illnesses than people who do not have a mental illness. Bipolar disorder is the fifth leading cause of disability and the ninth leading cause of years lost to death or disability worldwide.

While far more seems to be known about the prevention of symptoms of bipolar disorder following its diagnosis, there is emerging research about ways to attempt to decrease the development of the full-blown disease altogether. For example, when family-focused therapy is provided to children who have more subtle symptoms preceding bipolar disorder and who have bipolar relatives, they may be less likely to develop the full-blown disorder as adults.

Depression and Related Affective Disorders Association
2330 West Joppa Road, Suite 100
Lutherville, MD 21093
Phone: 410-583-2919
Fax: 410-614-3241
[email protected]

National Federation of Families for Children's Mental Health
9605 Medical Center Drive
Rockville, MD 20850
Phone: 240-403-1901
Fax: 240-403-1909

National Alliance on Mental Illness (NAMI)
3803 N. Fairfax Dr., Suite 100
Arlington, VA 22203
Main: 703-524-7600
Fax: 703-524-9094
Member services: 888-999-NAMI (6264)

National Depression and Bipolar Support Alliance (DBSA)
730 N. Franklin Street, Suite 501
Chicago, Illinois 60654-7225
Toll-free: 800-826-3632
Fax: 312-642-7243
http://www.DBSAlliance.org

National Foundation for Depressive Illness, Inc.
PO Box 2257
New York, NY 10116
800-239-1265

National Institute of Mental Health
9000 Rockville Pike
Bethesda, Maryland 20892
301-496-4000
NIHinf[email protected]

Mental Health America
2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Phone: 703-684-7722
Toll free: 800-969-6642
Fax: 703-684-5968