Bipolar Disorder

Bipolar disorder is a serious mental illness featuring alternating periods of low mood (depression) and abnormally elevated mood (mania or hypomania). With medication such as mood stabilizers and psychotherapy, many patients can manage these mood swings. However, co-morbidities with bipolar disorder are common, including substance abuse, anxiety, and personality disorders, and complicate treatment and outcomes.

What is bipolar disorder?

Bipolar disorder, previously known as manic depression, is a mood disorder and mental health issue featuring alternating periods of depression and periods of unnaturally elevated mood (mania) with an absence of symptoms in between.

During depressive episodes, an individual might feel sad, angry, hopeless, fatigued, and preoccupied with self-loathing and thoughts of suicide. During manic episodes, the individual might feel abnormally energetic and happy, engage in risky, impulsive behavior, and even experience psychosis. In one subtype of bipolar disorder, these upswings are milder and known as hypomania. 

Some people will also experience mixed affective states, with the symptoms of mania and depression experienced simultaneously. 

An estimated 4.4% of Americans will experience bipolar disorder sometimes in their lifetimes.[1] It’s associated with disability, substance abuse, and premature death, especially through suicide. 25 to 50% of bipolar people will attempt suicide at least once in their lives and 15% will die by suicide.[2]

Bipolar disorder is now thought of as a spectrum, including people with symptoms that are below the threshold of diagnosis but still cause impairment or distress. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recognizes three distinct bipolar disorders: bipolar I, bipolar II, and cyclothymic disorder.

Bipolar I

Bipolar I is characterized by more severe mania. To be diagnosed with bipolar I, an individual must have experienced at least one manic episode of at least seven days or so severe as to require immediate hospitalization. They don’t need to have experienced a depressive episode yet.

Bipolar II

People with bipolar II experience milder emotional upswings of hypomania. To be diagnosed with bipolar II, an individual must have experienced at least one hypomanic episode, one or more major depressive episodes, and no full-blown mania.

Cyclothymic disorder

Cyclothymic disorder is characterized by brief, alternating periods of hypomania and depression which don’t last long enough and aren’t severe enough to be categorized as manic or major depressive episodes. As symptoms are at a lower intensity, cyclothymic disorder is thought to be underdiagnosed. Between 20 and 50% of patients seeking out-patient help for mood, anxiety, impulsive, and substance use disorders may be affected by cyclothymic disorder.[3]

Rapid-cycling

Studies have found people with bipolar disorder have, on average, 0.4 to 0.7 episodes per year, with each episode lasting between three and six months.[4] However, some people with bipolar disorder cycle more rapidly between episodes. 

When patients have four or more mood disturbance episodes per year, separated from each other by at least two months of remission or a switch in polarity (from depression to mania or vice versa), they’re classified as having rapid-cycling bipolar disorder. Any subtype of bipolar can be rapid-cycling. Between 25% and 43% of people with bipolar disorder will have a period of rapid cycling, which is usually temporary.[5]

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Symptoms of bipolar disorder

The symptoms of bipolar disorder depend on the type of episode and involve changes in mood, energy levels, behavior, sleeping, and thinking.

Major depressive episode

  • Persistent feelings of sadness, hopelessness, and anger
  • Fatigue and lack of energy

  • Anxiety

  • Despair

  • Loss of interest in previously enjoyed activities

  • Changes in sleep patterns (often sleeping too much, difficulty falling asleep, or waking very early)

  • Difficulty concentrating

  • Feelings of worthlessness and self-loathing

  • Excessive or inappropriate guilt

  • Self-doubt

  • Difficulty concentrating

  • Talking very slowly, struggling to find anything to say

  • Difficulty making decisions

  • Feeling unable to accomplish even simple tasks

  • Thinking about death and suicide

  • Rumination

  • Weight gain or loss [6][7]

The DSM-5 criteria for diagnosing a depressive episode in bipolar disorder and unipolar depression are the same. However, bipolar depression is more likely to have a sudden onset and equally sudden resolution of symptoms. It's also less likely to respond to antidepressants alone.

Manic episode

  • Elevated or irritable mood - eg. happiness, elation, euphoria, sense of well-being, irritation
  • Feeling full of energy, jumpy, or wired

  • Feeling full of great ideas and important plans

  • Inflated self-esteem or grandiosity - feeling very talented and powerful

  • Racing thoughts

  • “Flights of ideas” - talking quickly about a lot of things

  • Being more talkative than usual, with pressured speech that is difficult to interrupt

  • Decreased need for sleep

  • Decreased need to eat

  • Excessive appetites for food, drinking, sex, and other pleasurable activity

  • Impaired judgment

  • Disinhibited social behavior

  • Increase in risky behavior, such as hypersexuality, excessive spending, unrealistic projects, gambling, and reckless driving

  • Increased goal-orientated activities

  • Being easily distracted

  • Disturbed or illogical thinking

  • Psychotic symptoms: delusions and hallucinations

  • Violence [6][7]

To be classified as a manic episode, these symptoms must last most of the day for at least a week. Without treatment, manic episodes usually last three to six months. 

By definition, a manic episode impairs the individual's ability to socialize or work and in some cases, can lead to psychiatric hospitalization, usually involuntary.

Hypomanic episode

Hypomania is distinguished from mania by its milder symptoms and lack of psychotic symptoms. People are often fully functioning during hypomania and may feel nothing is wrong.

  • Having lots of energy

  • Decreased need for sleep

  • Feeling very talkative and speaking quickly

  • Feeling competitive

  • Feelings of creativity

  • Loss of social inhibitions

  • Risk-taking

  • Excessive spending [8]

To meet the criteria for hypomania, these symptoms must last at least four days. However, they may last several weeks.

Mixed affective state

In mixed affective states, symptoms of depression and mania occur simultaneously. This may be depression with manic symptoms or manic states with depressive symptoms. 

Around 40% of patients with bipolar disorder experience mixed states.[9] 

How is bipolar disorder diagnosed?

Bipolar disorder is diagnosed by a psychiatrist or another mental health professional. In making the diagnosis, they’ll consider the self-reported experiences and feelings of the individual, accounts of their behavior from family members, observable signs of illness (eg. pressured or slow speech), and their family history of mental illness.

To be diagnosed with bipolar disorder in the United States, an individual must meet the criteria outlined in the DSM-5, including the necessary duration of symptoms (eg. manic episodes must last at least seven days). Patients can be diagnosed with bipolar I just based on a single manic episode but must have displayed distinct periods of depression and hypomania to be diagnosed with bipolar II.

The doctor must also exclude other causes of the symptoms. Blood tests may be ordered to detect hormone levels. Endocrine disorders such as hypothyroidism and hyperthyroidism can mimic the symptoms of depression or mania. Toxicology screenings, with blood and urine tests, will detect substances such as stimulants that may be responsible for the symptoms. In patients who have had a sudden change in mood or behavior, an MRI or CT scan of the brain may be ordered to rule out certain neurological diagnoses.

What causes bipolar disorder?

The exact cause of bipolar is unknown, but it likely develops from an interaction of genetic predisposition and psychosocial variables in an individual’s environment.

Genetics

Bipolar disorder is one of the most heritable mental illnesses, with an estimated heritability of between 73% to 93% (meaning that genetics account for that much of the difference between individuals' risks). The risk of bipolar disorder is nearly ten times higher in first-degree relatives—children, parents, siblings—of those with the condition.[10]

Bipolar II may be more likely inherited, even when relatives have bipolar I. One study conducted by Johns Hopkins interviewed all the first-degree relatives of patients with bipolar I and II. The researchers found among the relatives of patients with bipolar II, 40% also had bipolar II. Additionally, 22% of the first-degree relatives of bipolar I patients had bipolar II.[11]

A genome-wide association study of 40,000 cases of bipolar disorder and hundreds of thousands of controls has identified 64 locations in the human genome linked to an elevated risk of bipolar disorder.[12]

Environment

Various environmental risk factors have been identified for bipolar disorder, although sometimes the evidence is conflicting.

  • Adverse events in childhood: For instance, around a third (30%) of people with bipolar disorder experienced childhood emotional abuse, compared to 6.5% to 14% of the general population. Rates of sexual abuse (22%), physical abuse (18%), and emotional neglect (31%) are also elevated in people with bipolar disorder. Childhood adversity is also associated with more mood disturbance episodes, earlier age of onset, greater severity of symptoms, rapid cycling, substance abuse, and suicide.[13] 

  • Stressful life events: Recent stressful events, including interpersonal problems, financial difficulties, and job loss have been linked to the onset and recurrence of bipolar episodes.[14]

  • Substance abuse: The use of tranquilizers, stimulants, and sedatives all increased the risk of bipolar disorder, ranging from two-fold (opioids) to five-fold (cannabis). [15] Additionally, cannabis (marijuana) use has been associated with an earlier age of onset of bipolar disorder and more frequent and severe manic episodes.[16] 

  • Infections: One study found a four-fold increase in the risk of bipolar disorder after fetal exposure to influenza. [17]

What treatment options are there for bipolar disorder?

Bipolar disorder is a lifelong condition, with periods of relapse and remission. But a combination of medication and psychotherapy can prevent and limit the severity of mood episodes and improve functioning.

Medication

Several different medications are prescribed for bipolar disorder. A specific regime will be developed for each patient, often using trial and error.

  • Mood stabilizers: Lithium and the anticonvulsants valproate, lamotrigine, and carbamazepine are used to prevent bipolar episodes and treat them when they do occur.

  • Antipsychotics: Antipsychotics are often prescribed short-term to treat mania and seem to be more effective than mood stabilizers. Atypical antipsychotics may be used to treat bipolar depression that isn't responding to mood stabilizers.

  • Antidepressants: Antidepressants aren’t usually prescribed alone for bipolar disorder because they can trigger a manic episode, especially in patients with bipolar I. However, they may be used in conjunction with a mood stabilizer or antipsychotic to lift bipolar depression. [18]

Psychotherapy

Talking therapy is a key part of bipolar treatment. Research has found that the combination of medication and psychotherapy is more effective than medication alone.[19]

Therapeutic approaches used may include:

  • Interpersonal and social rhythm therapy (IPSRT): helps people develop and maintain a stable daily rhythm of sleeping, waking, eating, and exercising. Circadian rhythms are often disrupted in people with bipolar disorder and sleep deprivation is a common trigger of mood episodes. IPSRT has been found to increase quality of life, reduce mood symptoms, and prevent relapse.

  • Cognitive behavioral therapy (CBT): helps people identify and challenge negative thought patterns and behaviors and replace them with healthier alternatives. In bipolar disorder, CBT can help patients challenge and break free of the rumination and feelings of worthlessness and guilt that accompany depressive episodes. It can also teach them to identify the symptoms of mania and take action to reduce their risk-taking and promote well-being during episodes. CBT can also equip patients with the skills to manage stress, a known trigger for mood episodes. CBT has been found to improve depressive symptoms, reduce the severity of mania, limit relapses, and improve social functioning. [20]

Electroconvulsive therapy (ECT)

A historic treatment for bipolar disorder, ECT is still used for patients who don’t improve with medication, can’t take medication, or are at high risk of suicide.

Inpatient hospitalization and alternatives

Short-term psychiatric hospitalization may be required during severe manic states, especially when an individual is thought to pose a danger to themselves and others. 

However, long-term psychiatric hospitalizations are now rare. In their place, patients may access treatment and support through intensive-outpatient programs, at drop-in centers, through visits from community mental health care teams, supported employment, and support groups.

Bipolar disorder and substance abuse

Substance abuse frequently accompanies bipolar disorder. The U.S. National Epidemiological Survey on Alcohol and Related Conditions found that substance abuse co-occurs with bipolar disorder at a higher rate than with any other mental disorder. Estimates of lifetime co-occurrence of substance use disorder with bipolar disorder range from 21.7% to 59% and 12-month co-occurrence have been measured anywhere between 4% to more than 25%.[21]

The relationship between bipolar disorder and substance abuse is complex. For some people, the symptoms push them to use drugs. They may take drugs to feel better when they’re depressed. They may also take drugs as part of the reckless behavior of a manic state.

At the same time, drug use, including marijuana use, may trigger relapses in people with bipolar disorder and even accelerate the onset of the disorder in young adults.

Substance abuse and bipolar disorder also share risk factors, including childhood trauma, and may emerge independently in some individuals.

Additionally, substance abuse and withdrawal can sometimes mimic the symptoms of bipolar disorder and drug use must be ruled out when a diagnosis is made.

Addiction and bipolar disorder complicate treatment for each other and lead to worse prognoses. That’s why both the American Psychiatric Association and the Substance Abuse and Mental Health Services Administration recommend that they be treated simultaneously.

Getting help for bipolar disorder

Bipolar disorder is a life-long condition. However, many patients are able to manage their symptoms, minimize mood episodes, and lead happy and productive lives. Early diagnosis and treatment improve outcomes.[22]

If you believe you or a loved one have bipolar disorder, you should:

  • Speak to your general practitioner

  • Consult with a psychiatrist

  • Use the Substance Abuse and Mental Health Services Administration’s (SAMHSA)’s Early Serious Mental Illness Treatment Locator to find local treatment options for someone experiencing their first onset of symptoms.

Visit the website of the Depression and Bipolar Support Alliance (DBSA) to get information about bipolar disorder and treatment and connect with support groups for patients and their friends and family.