Bipolar Disorder
Overview
Bipolar disorder, formerly called manic-depressive illness or manic depression,[1] is a mental health condition that causes extreme mood swings.[2] A person with this disorder will have periods of emotional highs, feeling joyful, energized, and excited (i.e., mania).[3] These are followed by periods of depressive lows where a person may feel sad or hopeless and lose interest or pleasure in most activities.[4,5]
Mood swings associated with bipolar disorder can affect sleep, energy, activity, judgment, behavior as well as the ability to think clearly. The frequency of mood swing episodes varies – from a rare occurrence to multiple times a year.[6] While people without bipolar disorder experience mood fluctuations, their mood changes typically last hours; those with bipolar may experience mood changes lasting for days. Further, during mood episodes, those with bipolar disorder experience extreme degrees of behavior change and/or difficulties with daily routines and social life. Bipolar disorder can disrupt relationships and cause difficulty at work or in school.[7]
There are three types of bipolar disorder, with each characterized by clear changes in mood, energy, and activity levels. These include:[8]
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder (Cyclothymia)
Bipolar disorder is typically diagnosed during late adolescence (teen years) or early adulthood,[9] with the average age of onset at 25 years old.[10] Symptoms can occasionally appear in children, as well as during a woman’s pregnancy or post-childbirth. Although one’s symptoms may vary over time, treatment for bipolar disorder is usually lifelong. Following a proper, prescribed treatment plan can help manage symptoms, improving one’s quality of life.[11]
Signs & Symptoms
Bipolar I, bipolar II and cyclothymic disorder each have specific signs and symptoms. Bipolar disorder may include mania or hypomania and depression with symptoms causing unpredictable changes in mood and behavior; the result of which leads to significant distress and difficulty in life.[12]
The severity and symptoms of the depressive and manic phases can vary over time.[13,14] Sometimes people experience both manic and depressive symptoms in the same episode. This kind of episode is referred to as an episode with mixed features. People experiencing an episode with mixed features may feel very sad, empty, or hopeless – while also feeling extremely energized.[15]
Changing mood states do not always follow a set pattern, and depression does not always follow a manic phase. Additionally, a person may experience the same mood state several times before experiencing the opposite mood state. Mood changes can happen over a period of weeks, months, and, in some cases, years. A primary indicator of bipolar is that one’s mood changes are a departure from their regular self, with the mood change being sustained for a significant period of time.[16]
Women with bipolar disorder may experience a shift in moods more quickly (i.e., "rapid cycling"), due to the varying levels of sex hormones and activity of the thyroid gland, along with the tendency to be prescribed antidepressants. Women may also experience greater periods of depression than men.[17]
Bipolar I disorder - Those with bipolar I have had at least one manic episode; this may be preceded or followed by hypomanic or major depressive episodes. In some, mania may trigger a break from reality (i.e., psychosis).[18]
Bipolar II disorder - Those with bipolar II have had at least one major depressive episode and at least one hypomanic episode; conversely, they have never experienced a manic episode. Bipolar II disorder is not a milder form of bipolar I disorder; it is a separate diagnosis. While manic episodes of bipolar I disorder can be severe and dangerous, those with bipolar II disorder can be depressed for longer periods, causing significant impairment.[19] During a hypomanic episode, a person may actually feel very good, be able to function fairly normally and keep up with daily life. Conversely, while they may not feel anything is wrong, their family and friends may recognize symptomatic changes in mood or activity levels. Consequently, those experiencing hypomania can develop severe mania or depression if left untreated.[20]
Cyclothymic disorder - Adults with cyclothymic disorder have had at least two years of numerous periods of hypomania symptoms as well as periods of depressive symptoms. However, these depressive symptoms are deemed less severe than in major depression.[21]
Other types – Other types of bipolar and related disorders include those induced by drugs, alcohol or due to a medical condition (e.g., Cushing's disease, multiple sclerosis or stroke).[22]
Those with bipolar disorder experience periods of unusually intense emotions, disturbances in sleep patterns and activity levels, and uncharacteristic behaviors; these often occur without the person cognizant of their harmful or undesirable effects. These mood episodes differ from one’s typical moods and behaviors, with symptoms tending to last continually for several days or weeks.[23] Bipolar disorder precipitates extreme mood shifts: highs (e.g., mania and hypomania) and lows (e.g., depression and major depressive episodes).[24]
Mania and Hypomania – While mania and hypomania are two distinct types of episodes, they exhibit similar symptoms. Mania, however, is more severe than hypomania, causing noticeable problems and dysfunction in relationships, at work, school and social activities.[25,26] Some people experiencing manic episodes have comorbid disorganized thinking, false beliefs[27] from which they cannot be swayed,[28] and/or hallucinations (i.e., psychotic features);[29] in some cases, people imagine having superhuman skills and powers, or think they are god-like.[30] Those undergoing the afore-mentioned symptoms may require hospitalization to ensure their safety.[31]
Symptoms of manic and hypomanic episodes include three or more of the following:[32-35]
Abnormally upbeat, jumpy or wired
Increased activity, energy, agitation or restlessness (e.g., working on several projects at once)
Increased/high sex drive
Exaggerated sense of well-being and self-confidence (i.e., euphoria)
Inflated self-esteem
Decreased need for sleep
Tendency to make grand and unattainable plans
Unusual talkativeness, increased or faster speech
Uncontrollable racing thoughts or quickly changing ideas or topics when speaking
Distractibility
Increased denial
Poor decision-making or increased risky behavior (e.g., shopping sprees, taking sexual risks, reckless driving or abnormally foolish investments)
Major Depressive Episode
A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in day-to-day activities, affecting work, school, social activities and/or one’s relationships.[36]
To be categorized as a major depressive episode, five or more of the following symptoms must exist[37] (including at least one of the first two symptoms):[38-41]
Intense sadness or despair (e.g., feeling sad, empty, hopeless or tearful); children and teens can present as irritable in a depressive episode
Loss of interest or lack of pleasure in nearly all activities, even those the person once enjoyed
Uncontrollable crying
Significant changes in appetite or weight (i.e., gain or loss when not dieting)
Changes in sleep patterns (i.e., insomnia or sleeping too much)
Restlessness or slowed behavior
Fatigue, loss of energy
Feelings of worthlessness or excessive/inappropriate guilt
Indecisiveness or a decreased ability to think or concentrate
Headaches, digestive problems, or chronic pain
Symptoms in Children and Teens
Symptoms of bipolar disorder can be difficult to identify in children and teens. Often, it’s difficult to determine whether one is having normal highs and lows, manifestations of stress or trauma, or signs of a mental health problem other than bipolar disorder.[42]
While children and teens may have distinct major depressive or manic or hypomanic episodes, the pattern can vary from that of adults with bipolar disorder. Further, moods can rapidly shift during episodes while some children may have periods without mood symptoms between episodes. The most prominent signs of bipolar disorder in children and teenagers includes severe mood swings that are different from their usual mood swings.[43]
Diagnosis
Although bipolar disorder can occur at any age, it is typically diagnosed in the teenage years or early twenties.[44]
Proper diagnosis and treatment can help those with bipolar disorder to lead healthy and active lives. Mental health care providers typically diagnose bipolar disorder based on a person’s symptoms, and their severity, length, and frequency.[45,46] Talking with a doctor or other licensed health care provider is the first step; a complete physical exam and necessary medical tests can rule out other conditions. A mental health evaluation by a trained mental health care provider (e.g., psychiatrist, psychologist, or clinical social worker who has experience in diagnosing and treating bipolar disorder) can help pinpoint a bipolar diagnosis. Since bipolar disorder symptoms are similar to those of other illnesses, it can be challenging for a health care provider to make a diagnosis. In addition, bipolar disorder can exist with another mental disorders or conditions (e.g., anxiety, substance use disorder or eating disorder). Further, those with bipolar disorder have an increased chance of having: thyroid disease; migraine headaches; heart disease; diabetes; and obesity.[47]
Those with bipolar disorder are more likely to seek help when they are depressed than when they are experiencing mania or hypomania. A careful medical history is essential to ensure that bipolar disorder is not mistaken for major depression since antidepressant medications can trigger a manic episode in people who have an increased chance of having bipolar disorder.[48] The patient’s close friends and family may be able to offer the health care provider with insights that help distinguish a diagnosis of bipolar disorder from major depression.[49]
Causes & Risk Factors
Current research indicates there is no single cause of bipolar disorder; there is the likelihood that many factors contribute to someone’s chance of developing this illness.[50]
Factors that may increase the risk of developing bipolar disorder and/or potentially trigger a first occurrence include:[51]
A first-degree relative (e.g., a parent or sibling) with bipolar disorder
Periods of high stress (e.g., the death of a loved one or other traumatic event)
Substance abuse
While the causal links are still being evaluated, bipolar disorder tends to occur with certain comorbid conditions. It is estimated that sixty percent of those people with bipolar disorder experience drug and/or alcohol dependence. Additionally, bipolar disorder occurs frequently in people with seasonal depression (e.g., seasonal affective disorder) as well as certain anxiety disorders (e.g., post-traumatic stress disorder).[52]
The National Institutes of Health (NIH) notes that some studies indicate brain structure and functioning may have a role in the development of bipolar disorder. Further, current research is on a path to suggest that those with certain genes are more likely to develop bipolar disorder; it is important to note that no one gene can cause the disorder. However, at this time, health care providers must base the diagnosis and treatment plan on a person’s symptoms and history, rather than brain imaging or other diagnostic tests.[53] Research is being conducted to determine the relationship that these factors have in bipolar disorder, how they may help prevent its onset, and what role they may play in its treatment.[54]
Prevention
There is currently no known method to prevent bipolar disorder. Since the exact cause has not yet been determined, it is especially important to know the symptoms and seek early intervention[55] to help prevent bipolar disorder or other mental health conditions from worsening.[56]
Strategies can help prevent minor symptoms from becoming acute episodes of mania or depression:[57,58]
Pay attention to warning signs. Addressing initial symptoms can prevent episodes from worsening. Those with bipolar disorder may identify a pattern to their episodes as well as their triggers; a doctor should be contacted once an episode of depression or mania feels on the rise. Family members or friends should be cognizant to watch for warning signs.
Avoid drugs and alcohol. The use of alcohol or recreational drugs can worsen one’s symptoms, making them more likely to reoccur.
Take medications exactly as directed. Regular and continued use of bipolar medication can help reduce episodes or mania and depression. Stopping medication or self-reducing one’s dose may cause withdrawal effects or symptoms to worsen or return.
Complications
If left untreated, bipolar disorder can result in the following catastrophic problems in one’s life:[59]
Substance abuse
Suicide or suicide attempts
Legal or financial problems
Damaged relationships
Poor work or school performance
The following conditions can worsen bipolar disorder symptoms or make treatment less successful:[60]
Anxiety disorders
Substance abuse
Physical health problems (e.g., as heart disease, thyroid problems, headaches or obesity)
Treatment
There is no cure for bipolar disorder, but treatment works well for many people. In most cases, consistent, long-term treatment is needed to stabilize the mood swings.[61] Treatment that is continual has proven more effective in preventing relapses[62] since episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of mood changes, but some people may have lingering symptoms. Long-term, continuous treatment can help people manage these symptoms.[63]
Treatment may include one or a combination of the following: medicine; psychotherapy and electroconvulsive therapy (ECT).[64] Those who also have a substance abuse problem may require more specialized treatment.[65]
Medicine - While bipolar disorder cannot be cured at this time, certain medications can help manage symptoms of the disorder.[66] Proposed guidelines for treatment options are based on the three main phases of bipolar disorder, including: acute manic/mixed mood states; acute major depressive episodes; and the continuation/maintenance phase.[67]
Bipolar disorder treatment is individualized;[68] health care providers may need to prescribe several different medications before finding which work best in each person’s case.[69] It is important to note that it often takes 4 to 6 weeks for antidepressants to have full effect.[70]
Medications generally used to treat bipolar disorder include mood stabilizers (e.g., lithium) believed to correct imbalanced brain signaling and second-generation (“atypical”) antipsychotics.[71,72] Treatment plans may also include medications that target sleep or anxiety. Additionally, health care providers often prescribe antidepressant medication to treat the depressive episodes of bipolar disorder, combining the antidepressant with a mood stabilizer to prevent triggering a manic episode.[73]
It is imperative to avoid stopping any medication without talking to a health care provider first. Despite potentially feeling cured or better, suddenly stopping one’s medication may lead to a “rebound” or worsening of bipolar disorder symptoms.[74]
Psychotherapy - While medication is the primary form of treatment for bipolar disorder, the additional use of psychotherapy (i.e., talk therapy) is often recommended to help prevent future episodes.[75] Cognitive-behavioral therapy (CBT) focuses on changing distorted views one may have of themself and their environment. CBT also seeks to improve interpersonal relationship skills, identify stressors and learn how to manage them.[76] Treatment may also include newer therapies designed specifically for the treatment of bipolar disorder, including interpersonal and social rhythm therapy (IPSRT) and family-focused therapy. Ongoing research is still in the process of determining whether intensive psychotherapeutic intervention at the earliest stages of bipolar disorder can prevent or limit its full-blown onset.[77]
Electroconvulsive therapy (ECT) - This treatment may be used in people with severe, life-threatening depression that has not responded to medicine.[78] ECT is a brain stimulation procedure that can help people find relief from severe symptoms of bipolar disorder.[79] During ECT, a brief electrical current applied to one’s scalp (while under anesthesia) leads to a short, controlled seizure. These seizures are believed to remodel brain signaling pathways.[80] With modern ECT, a person usually undergoes a series of treatment sessions over several weeks. When medication and psychotherapy are not effective or are not safe for a particular patient, ECT can be effective in treating severe depressive and manic episodes. ECT can also be effective when a rapid response is needed, such as in the case of suicide risk or catatonia (i.e., a state of unresponsiveness).[81]
Self-Care
Practicing mindfulness is one way to promote better health and self-care with a bipolar diagnosis. To engage in additional self-care steps, the following may be helpful to undertake during periods of depression:[82]
Get help; if you think you may be depressed, seek a health professional right away.
Set realistic goals and be mindful not to take on too much.
Break large tasks into smaller, more-manageable ones. Set priorities, and do what you can, as you can.
Try not to be alone; confide in someone you trust.
Engage in healthy activities that make you feel better. Some examples may include: going to a movie; gardening; painting; hiking; or taking part in religious, social, or other group activities. Doing something nice for another person may also help you feel better.
Get regular exercise.
Expect your mood to get better slowly, not right away. Feeling better takes time.
Eat healthy, well-balanced meals.
Avoid alcohol and drugs; these can interfere with your medication as well as make depression worse.
Postpone big decisions until the depression has lifted. Additionally, before making big decisions (e.g., changing jobs, getting married or divorced), try to discuss your plan with those who know you well and have a more objective view of your situation. You may also wish to discuss these plans with a therapist or other mental healthcare provider.
Be mindful that people cannot “snap out of a depression”. However, with treatment, they can feel a little better day by day.
Try to be patient and focus on the positives. This may help replace the negative thinking that is part of depression - negative thoughts will disappear as depression responds to treatment.
Let family and friends help.
For more information, click here to learn more about bipolar disorder from our psychiatric providers.
If you or someone you know is unsafe (e.g., suicidal, homicidal, putting oneself or others in danger, or experiencing a medical emergency), please call 911 immediately.
Contributed by: Jennifer (Ghahari) Smith, Ph.D.
References
1 “Bipolar Disorder,” NIH: National Institute of Mental Health. (accessed 5-10-2022). www.nimh.nih.gov/health/topics/bipolar-disorder
2 “Bipolar Disorder,” Mayo Clinic. (accessed 5-5-2022). www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc 20355955#:~:text=Bipolar%20disorder%2C%20formerly%20called%20manic,or%20pleasure%20in%20most%20activities
3 “Bipolar Disorder,” Johns Hopkins Medicine. (accessed 5-2-2022). www.hopkinsmedicine.org/health/conditions-and-diseases/manic-depression--bipolar-disorder
4 Ibid.
5 Mayo Clinic.
6 Ibid.
7 “What are Bipolar Disorders?” American Psychiatric Association. (accessed 5-5-2022). www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders
8 NIH: National Institute of Mental Health.
9 Ibid.
10 American Psychiatric Association.
11 NIH: National Institute of Mental Health.
12 Mayo Clinic.
13 “Bipolar Disorder,” Cleveland Clinic. (accessed 5-20-2022). my.clevelandclinic.org/health/diseases/9294-bipolar-disorder
14 Mayo Clinic.
15 NIH: National Institute of Mental Health.
16 Cleveland Clinic.
17 Ibid.
18 Mayo Clinic.
19 Ibid.
20 NIH: National Institute of Mental Health.
21 Mayo Clinic.
22 Ibid.
23 NIH: National Institute of Mental Health.
24 Mayo Clinic.
25 Ibid.
26 American Psychiatric Association.
27 Ibid.
28 Cleveland Clinic.
29 American Psychiatric Association.
30 Cleveland Clinic.
31 American Psychiatric Association.
32 Ibid.
33 Cleveland Clinic.
34 Johns Hopkins Medicine.
35 Mayo Clinic.
36 Ibid.
37 Ibid.
38 Ibid.
39 American Psychiatric Association.
40 Johns Hopkins Medicine.
41 Cleveland Clinic.
42 Mayo Clinic.
43 Ibid.
44 Ibid.
45 NIH: National Institute of Mental Health.
46 Cleveland Clinic.
47 NIH: National Institute of Mental Health.
48 Ibid.
49 Cleveland Clinic.
50 NIH: National Institute of Mental Health.
51 Mayo Clinic.
52 Cleveland Clinic.
53 NIH: National Institute of Mental Health.
54 Cleveland Clinic.
55 Ibid.
56 Mayo Clinic.
57 Ibid.
58 Cleveland Clinic.
59 Mayo Clinic.
60 Ibid.
61 Johns Hopkins Medicine.
62 Cleveland Clinic.
63 NIH: National Institute of Mental Health.
64 Johns Hopkins Medicine.
65 Cleveland Clinic.
66 NIH: National Institute of Mental Health.
67 Cleveland Clinic.
68 American Psychiatric Association.
69 NIH: National Institute of Mental Health.
70 Johns Hopkins Medicine.
71 American Psychiatric Association.
72 NIH: National Institute of Mental Health.
73 Ibid.
74 Ibid.
75 Cleveland Clinic.
76 Johns Hopkins Medicine.
77 NIH: National Institute of Mental Health.
78 Johns Hopkins Medicine.
79 NIH: National Institute of Mental Health.
80 American Psychiatric Association.
81 NIH: National Institute of Mental Health.
82 Johns Hopkins Medicine.