Bipolar Disorder

Bipolar disorders, or manic-depressive illness, is a group of disorders characterized by the presence of pronounced high-energy phases known as manic episodes. Typically, unusual shifts in mood and energy manifest in increased activity levels and impair ability to function. The impairment created by bipolar disorder can be severe and can result in damaged relationships, poor job or school performance, and even suicide. 

There are several different types of bipolar disorder. Bipolar I disorder refers to a condition in which an individual experiences a full-blown manic episode for at least one week and may or may not also experience depression. The manic symptoms may be so severe that hospitalization is required. Bipolar II refers to the presence of a current or past hypomanic episode, which is a slightly less severe form of mania lasting at least four consecutive days, as well as the presence of a current or past episode of major depression. Cyclothymic disorder, or cyclothymia, refers to recurring hypomanic and depressive mood shifts over at least a two-year period in adults. 

According to the National Institute of Mental Health, an estimated 4.4 percent of adults in the United States experience a bipolar disorder at some point in their lifetime. The condition occurs with equal frequency among males and females. The median age of onset is 25 years. Nevertheless, a bipolar disorder may begin in childhood or may have its onset late in life. Bipolar disorders are typically chronic conditions and require lifelong management. More than 90 percent of people who have a single manic episode go on to have recurrent episodes of mania or depression.

People experiencing a manic episode are often described as excessively cheerful or "feeling on top of the world." Often, however, the dominant mood during a manic episode is irritability. Additionally, persons experiencing mania may display suddenly inflated self-esteem, decreased need for sleep, talkativeness and distractibility, and often engage in activities that have high potential for painful consequences (gambling, heavy spending, sexual indiscretions). Hypomania is similar to mania in that the disturbance in mood and the change in functioning are observable by others, but the episode is not severe enough to cause major impairment in social or occupational functioning or to require hospitalization. 

During a manic episode, an person may start multiple new projects and feel that they are capable of accomplishing anything, regardless of their level of experience or talent. One of the most common features of mania is a decreased need for sleep; a person might go days without sleep, yet not feel tired. Often, a manic person's thoughts race faster than they can be expressed; the result may be abrupt shifts in topic and pressured and incoherent speech. Sometimes during a manic episode people display hostility and angry tirades, particularly if an attempt is made to interrupt them.

Children who are at risk for bipolar disorder (because a parent has the disorder) display a developmental sequence beginning with symptoms that are not specific to bipolar disorder, notably sleep problems and anxiety. The condition progresses from minor mood disorder to major depressive disorder in adolescence, with full-blown bipolar disorder developing in the transition to adulthood, typically with an episode of mania or hypomania or a first episode of psychosis following an episode of depression.

It is characteristic of the condition that those who are experiencing mania do not perceive that they are ill or in need of treatment and resist engaging with treatment. Diagnosis and treatment are incredibly important; the lifetime risk of suicide among individuals with bipolar disorder is at least 15 times that of the general population. Bipolar disorder is often not recognized, or may be confused with other conditions, and people may suffer for years before they receive appropriate treatment.

Symptoms

According to the DSM-5, a manic episode is manifest in an excessively euphoric, expansive, or irritable mood for most of a day, every day for at least a week, and is accompanied by abnormally and persistently increased activity and energy. In addition, three (or four if the dominant mood is irritability) of the following signs must be present

  • Inflated self-esteem or grandiosity, including unrealistic beliefs in one's abilities and powers
  • Decreased need for sleep
  • Unusual talkativeness or pressure to keep talking
  • Flight of ideas or the sense that thoughts are racing
  • Distractibility
  • Increased goal-directed activity, such as work or school projects, or purposeless activity (psychomotor agitation)
  • Involvement in activities that are likely to to have painful consequences, such as buying sprees, sexual indiscretions, poor business investments.

In addition, the mood disturbance is sufficient to cause significant impairment in social or occupational functioning or to require hospitalization to prevent self-harm, or because there are  psychotic features.

What's more, the episode is not explainable by ingestion of a medication, drug of abuse, or medical condition.

The more moderate form of mania, called hypomania, similarly involves an unequivocal change in functioning, albeit for four or more days, but there is typically not significant social or occupational impairment.  Indeed, the person may feel good and highly productive, making it difficult for the person or those around him or her to identify a hypomanic episode. 

Bipolar disorders are typically marked by the occurrence of at least one depressive episode. A depressive episode is characterized by depressed mood, or loss of pleasure or interest, or feelings of hopelessness for at least two weeks. According to the DSM-5, at least five of the following symptoms are also present:

  • The sad, anxious, or empty mood is present most of the day, every day
  • Loss of interest or pleasure in all or most activities is present most of the day, every day
  • Unintended weight gain or loss 
  • Insomnia or excessive sleep 
  • Observable restlessness (psychomotor agitation) or slowing down (psychomotor retardation)
  • Fatigue of less of energy nearly every day
  • Feelings of guilt or worthlessness
  • Diminished ability to concentrate, or indecisiveness
  • Recurrent thoughts of death or suicide, or suicide attempts

the symptoms cause distress or impairment in functioning. And They are not due to the effects of a substance or medical condition.

Sometimes, severe episodes of mania or depression include symptoms of psychosis. Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the president or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. For this reason, bipolar disorder is sometimes incorrectly diagnosed as schizophrenia.

In some people, however, symptoms of mania and depression may occur together in what is called bipolar disorder with mixed features. Symptoms of mixed features often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.

Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention from a health professional. Talk about suicide should be taken seriously. Risk for suicide appears to be higher early in the course of the illness. Recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.

Episodes of mania and depression typically recur across the life span. Between episodes, most people with a bipolar disorder are free of symptoms, but as many as one-third have some residual symptoms. A small percentage experience chronic unremitting symptoms despite treatment.

When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated. Without treatment, however, mood cycling can increase in frequency and severity.

Both children and adolescents can develop bipolar disorder; the condition is most likely to affect the children of parents who have the illness. Children and young adolescents often experience very fast mood swings between depression and mania multiple times a day. Mania in children is most likely to manifest as irritability with proneness to destructive tantrums. The occurrence of mixed symptoms is also common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

Bipolar disorder in children and adolescents can be hard to distinguish from other problems that may occur in these age groups. Irritability and aggressiveness can also be symptoms of attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder.

Alcohol and drug abuse are very common among people with bipolar disorder. Many factors may contribute to the substance abuse problems, including self-medication of symptoms; nevertheless, mood symptoms can be brought on or perpetuated by substance abuse. There may exist risk factors that influence the occurrence of both bipolar disorder and substance-use disorders. Co-occurring substance abuse, when present, is an important part of an overall treatment plan.

Anxiety disorders, such as panic attacks and social anxiety disorder, also may co-occur in people with bipolar disorder, and they may respond to treatments used for bipolar disorder or they may require separate treatment.

Causes

The cause of bipolar disorder is the subject of much research, and the consensus among scientists is that there is no single cause. Rather, many factors act together to produce the illness.

Genetics play a role. One of the strongest risk factors for developing bipolar disorder is having a family history of the illness: Risk of the condition is increased 10-fold among adult relatives of individuals with bipolar I and bipolar II disorders. However, no specific genes have been linked to the condition. Rather, as with many other mental illnesses, multiple genes, each with a small effect, contribute to the likelihood of developing the disorder. There is some evidence that mood, anxiety and psychotic disorders occur with greater frequency in the families of those with bipolar disorders than in the general population. Studies of identical twins, who share all the same genes, indicate that factors other than genes—such as highly stressful events—also play a role in precipitating bipolar disorder. Many genes likely act together in combination with factors in a person's environment.

Brain-imaging studies show that the brains of people with bipolar disorders may differ from those of healthy individuals. For example, researchers have identified several brain regions marked by reduced thickness of the cortex. Other studies show that processing of sensory stimuli is impaired during episodes of mania and depression and may underlie errors in perception.

Treatment

Even in the most severe cases, bipolar disorders are highly treatable conditions. The sooner treatment begins, the greater the likelihood of reducing the severity and frequency of manic and depressive episodes. Because bipolar disorders are lifelong conditions, treatment is also lifelong and aimed not just at treating symptoms but also at preventing recurrence of symptoms. Most people with bipolar disorders can achieve substantial stabilization of their mood swings and related symptoms

The most effective treatment strategy combines medication and psychotherapy. In addition, patients are often instructed to keep a chart of daily mood symptoms, treatments, sleep patterns, and life events. Such tracking has been shown to help patients and their families to better understand and manage the illness; mood changes can often be spotted in time to prevent a full-blown episode. Even when there are no breaks in treatment, mood changes can occur and should be reported immediately to the doctor, who may make adjustments to the treatment plan.

Medications

While primary-care physicians who do not specialize in psychiatry may prescribe psychotropic medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment. Several types of medication are commonly used the treat bipolar disorders.

Mood stabilizers are generally prescribed to control manic episodes. Lithium is perhaps the best-known mood stabilizer. The first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, it is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.Other types of mood stabilizer include the anticonvulsants lamotrigine (Lamictal), valproic acid (Depakene), divalproex sodium (Depakote), and carbemazepine (Tegretol and others). Valproate was FDA-approved in 1995 for treatment of mania. 

Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression.

Sometimes treatment with antidepressants results in mood-switching, prompting a manic or hypomanic episode or rapid cycling. Mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect agains such a switch.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine are also used.

Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to possible effects of mood stabilizing medications on the developing fetus and the nursing infant. A skilled clinician can help such women weigh the benefits and risks of all available treatment options.

Antipsychotic medications are also often used to help control manic and depressive symptoms in bipolar disorder, and some help to stabilize mood as well. Antipsychotic drugs include olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) among others.

If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam or lorazepam may be helpful. However, because these medications may be habit-forming, they are best prescribed short-term. Other types of sedative medications, such as zolpidem, are sometimes used instead.

Omega-3 fatty acids found in fish oil are under study for their usefulness, alone or when added to conventional medications, for long-term treatment of bipolar disorder.

Effective management of bipolar disorder may involve changes to the treatment plan at various times over the course of illness. Any changes in type or dose of medication should be made under the guidance of a psychiatrist. To avoid adverse reactions, patients should tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements they may be taking. 

People with bipolar disorder, particularly those with rapid mood cycling, often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, thyroid levels are usually carefully monitored by a physician. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

All medications have side effects. Depending on the medication, side effects may include weight gain, nausea, tremors, reduced sex drive, anxiety, hair loss, movement problems, or dry mouth.  Getting the right balance of treatment benefits may require physician-monitored adjustment in dosage or type of medication. Medication should not be changed or stopped without the psychiatrist's guidance.

Psychotherapy

Studies have documented that several kinds of psychotherapy provided to patients and their families can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. Psychotherapeutic interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and interpersonal and social rhythm therapy (IPSRT). IPSRT emphasizes the importance of establishing stable daily patters of sleeping and waking, as prolonged wakefulness is a  known trigger for manic episodes.

A licensed psychologist, social worker, or counselor typically provides such therapies and often works in concert with the psychiatrist to monitor patient progress. Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

Psychoeducation involves teaching people with bipolar disorder about the condition and its treatment and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation is also often helpful for family members.

Family therapy helps reduce the level of family distress that may contribute to or result from the ill person's symptoms.

Interpersonal and social rhythm therapy help people with bipolar disorder both to improve relationships and to regulate daily routines. Maintaining a daily routine and sleep schedule can help protect against manic episodes.

Electroconvulsive Therapy

In critical situations, such as psychosis or suicidal thought, where medication, psychosocial treatment, and the combination of these interventions prove ineffective or work too slowly to relieve severe symptoms, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, or mixed episodes. The possibility of long-lasting memory problems has been significantly reduced with modern ECT techniques.

References

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • Miklowitz, David, The Bipolar Disorder Survival Guide, Third Edition, 2019, Guilford Press, 444p.
  • Joseph J. ShafferJr, Casey P. Johnson, Jess G. Fiedorowicz, Gary E. Christensen, John A. Wemmie, Vincent A. Magnotta. Impaired sensory processing measured by functional MRI in Bipolar disorder manic and depressed mood states. Brain Imaging and Behavior, June 2018.
  • National Institute of Mental Health
  • Duffy, A, Goodday, S, Keown-Stoneman, C, Grof, P. The Emergent Course of Bipolar Disorder: Observations Over Two Decades From the Canadian High-Risk Offspring Cohort, The American Journal of Psychiatry, December 2018.
  • National Institutes of Health  
  • Centers for Disease Control and Prevention

Last reviewed 02/07/2019