Bipolar Disorder

Bipolar disorder, or manic-depressive illness, is characterized by severe mood shifts or a mix of depression and high-energy phases known as manic episodes.

Definition

Bipolar disorders, also known as manic-depressive illness, are a group of brain disorders that cause unusual shifts in mood, energy, and ability to function. The symptoms of bipolar disorder are severe and can result in damaged relationships, poor job or school performance, and even suicide.

There are several different types of bipolar disorders. Bipolar I disorder refers to a condition in which an individual experiences a manic episode for at least one week and may or may not also experience depression. Bipolar II refers to the presence of a current or past hypomanic episode, which is a slightly less severe form of mania, and also the presence of a current or past episode of major depression.

A manic episode is a period of abnormally elevated or irritable mood that includes an abnormal increase in energy level, and lasts for at least one week. Additionally, a person experiencing mania may present with changes from their usual behavior, including a sudden inflation of self-esteem, a decreased need for sleep, a shift to being more talkative and easily distracted, and an involvement in activities that have high potential for painful consequences (gambling, heavy spending, sexual indiscretions).

A hypomanic episode refers to a period of abnormally elevated or irritable mood that includes an abnormal increase in energy level and lasts for at least four consecutive days. 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. 

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, and people display hostility and angry tirades, particularly if an attempt is made to interrupt the individual. During a manic episode, an person may start several 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, and when the sleep disturbance is severe, a person might go days without sleep, yet not feel tired. Often, a manic person's thoughts race faster than they can be expressed through speech, and the result may be abrupt shifts from one topic to another or incoherent speech.

In children, happiness and silliness are generally expected but may veer into the realm of mania when behaviors are inappropriate to the context and beyond what is expected for the developmental level of the child. It is difficult to establish whether children meet the mania criteria of increased activity, but important signs include a child taking on many tasks simultaneously, devising elaborate and unrealistic plans for projects, and developing previously absent and developmentally inappropriate sexual preoccupations. Mania and depression can both manifest as persistent and excessive irritability in children.

About 5.7 million American adults, or about 2.6 percent of the population age 18 and older, in any given year have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them 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 will go on to have recurrent episodes of mania or depression.

Bipolar disorder is often not recognized, and people may suffer for years before it is properly diagnosed and treated. In fact, people who are currently experiencing mania often don't perceive that they are ill or in need of treatment and will resist engaging with treatment. Treatment is incredibly important, however, considering that the lifetime risk of suicide among individuals with bipolar disorder is at least 15 times that of the general population.

Symptoms

Signs and symptoms of a manic episode:

  • Increased energy, activity, and restlessness
  • Excessively high, overly good, euphoric mood
  • Extreme irritability
  • Racing thoughts and fast talking, jumping from one idea to another
  • Distractibility or lack of concentration
  • Lessened need for sleep
  • Increased goal-directed activity (i.e. work or school projects)
  • Unrealistic beliefs in one's abilities and powers
  • Poor judgment
  • Spending sprees
  • A lasting period of behavior that is different from usual
  • Increased sex drive
  • Abuse of drugs—cocaine, alcohol, and sleep medications
  • Provocative, intrusive, or aggressive behavior
  • Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for one week or longer. If the mood is irritable, four additional symptoms must be present.

A mild to moderate form of mania is called hypomania. This form of mania may feel good and inspire productivity, making it difficult for individuals or the people around them to identify a hypomanic episode. A hypomanic episode is diagnosed if the same symptoms of mania, although less severe, are present for at least four consecutive days.

Signs and symptoms of a depressive episode:

  • Lasting sad, anxious, or empty mood
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest or pleasure in activities once enjoyed, including sex
  • Decreased energy, a feeling of fatigue or of being "slowed down"
  • Difficulty concentrating, remembering, making decisions
  • Restlessness or irritability
  • Sleeping too much, or inability to sleep
  • Change in appetite and/or unintended weight loss or gain
  • Chronic pain or other persistent physical symptoms not caused by physical illness or injury
  • Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of two weeks or longer.

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. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.

It may be helpful to think of the various mood states in bipolar disorder as a spectrum. At the bottom end is severe depression, above which is moderate depression and then mild low mood, which many people call the short-lived blues. It is termed persistent depressive disorder when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

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.

Bipolar disorder may not clearly seem like a mental illness when it manifests in an individual. Important signs are sudden changes in behavior or lifestyle—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.

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

Course of Bipolar Disorder

Episodes of mania and depression typically recur across one's life span. Between episodes, most people with 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, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent rapid cycling and more severe manic and depressive episodes than those experienced when the illness first appeared. In most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain a good quality of life.

Children and Adolescents with Bipolar Disorder

Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are 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. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or of other types of mental disorders that are more common among adults, such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental-health professional.

Conditions That Can Co-occur with Bipolar Disorder

Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance-use disorders. Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

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

Causes

Scientists are learning about the possible causes of bipolar disorder. Most scientists now agree that there is no single cause for bipolar disorder; rather, many factors act together to produce the illness.

One of the strongest risk factors for developing bipolar disorder is having a family history of the illness. Because there is an average 10-fold increased risk among adult relatives of individuals with bipolar I and bipolar II disorders, researchers have been seeking specific genes that may increase a person's chance of developing the illness. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genetics, then the identical twin of someone with the illness would always also develop it, and this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.

In addition, findings suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene. It is likely that many genes act together and in combination with other factors, such as the person's environment. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that advanced research tools will lead to these discoveries and to new and better treatments.

Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder. New techniques allow researchers to take pictures of the living brain, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). Imaging studies have shown that the brains of people with bipolar disorder may differ from those of healthy individuals. As the differences are more clearly identified and defined through research, scientists should be able to better understand the underlying causes of the illness and determine the most effective treatments.

Treatments

Most people with bipolar disorder, even those with the most severe forms, can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term continuous preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychotherapeutic treatment is optimal for managing the disorder over time. Even when there are no breaks in treatment, mood changes can occur and should be reported immediately to the doctor, who may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

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.

Medications known as mood stabilizers are usually prescribed to help control bipolar disorder. Several types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression.

Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

Anticonvulsant medications such as valproate or carbamazepine also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, are being studied to determine how well they work in stabilizing mood cycles. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine are also used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who begin taking the medication before age 20. Therefore, young female patients taking valproate should be monitored carefully by a physician.

Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication. Therefore, mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.

Atypical antipsychotic medications, including clozapine and ziprasidone, are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants. Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval. Olanzapine may also help relieve psychotic depression.

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.

Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication. 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. 

Thyroid Function

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, it is important that thyroid levels are carefully monitored by a physician. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

Medication 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. The doctor may be able to change the dose or offer a different medication to relieve these. Medication should not be changed or stopped without the psychiatrist's guidance.

Psychotherapautic Treatment

As an addition to medication, psychotherapeutic treatments—including certain forms of psychotherapy, or talk therapy—are helpful in providing support, education, and guidance to patients and their families. Studies have shown that these interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychotherapeutic interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and interpersonal and social rhythm therapy (IPSRT). Researchers at the National Institute of Mental Health are studying how these interventions compare to one another when added to medication treatment.

Cognitive behavioral therapy 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 illness and its treatment and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation may also be helpful for family members.

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

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

As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

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. However, the potential benefits and risks of ECT and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, when appropriate, with family or friends.

Herbal and Natural Supplements

Herbal or natural supplements, such as St. John's Wort, have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient.

Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's Wort can reduce the effectiveness of certain medications. In addition, like prescription antidepressants, St. John's Wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.

Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.

Even though episodes of mania and depression come and go, it is important to understand that bipolar disorder is a long-term illness that has no cure. Staying on treatment, even during periods without episodes, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

People with bipolar disorder may need help to get help:

  • Often they do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
  • They may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing a referral to a mental-health professional.
  • Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
  • A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment, even if this is against his or her wishes.
  • Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for the individual.
  • When the disorder is under control, individuals with bipolar disorder may agree to a preferred course of action in the event of a future manic or depressive relapse.
  • Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
  • Family members of people with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.

References

  • American Psychiatric Association, Diagnostic and Statistical Manual, Fifth Edition
  • National Institute of Mental Health
  • Substance Abuse and Mental Health Services Administration
  • National Institutes of Health
  • Centers for Disease Control and Prevention

Last reviewed 04/19/2017