Bipolar Disorder

Bipolar Disorder

There is a tendency to romanticize bipolar disorder. Many artists, musicians, and writers have suffered from its mood swings. But in truth, many lives are ruined by this disease; and without effective treatment, the illness is associated with an increased risk of suicide

 

What is bipolar disorder?

Bipolar disorder is usually diagnosed after a person has one or more manic episodes. People who have the classic form of bipolar disorder experience alternating periods of depressed moods and periods of manic or excited moods. This condition is sometimes referred to as “mood swings” or manic depressive disorder. Other people with bipolar disorder have episodes of a manic mood without episodes of depression. Still others with bipolar disorder have a mixture of depression and mania, a state of hyperactivity, at the same time.

Bipolar disorder, also known as manic-depressive illness, is a serious brain disease that causes extreme shifts in mood, energy, and functioning. It affects approximately 2.3 million adult Americans-about 1.2 percent of the population.2 Men and women are equally likely to develop this disabling illness. The disorder typically emerges in adolescence or early adulthood, but in some cases appears in childhood.3 Cycles, or episodes, of depression, mania, or? Mixed? Manic and depressive symptoms typically recur and may become more frequent, often disrupting work, school, family, and social life.

Depression: Symptoms include a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant change in appetite or body weight; difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; and recurrent thoughts of death or suicide.

Mania: Abnormally and persistently elevated (high) mood or irritability accompanied by at least three of the following symptoms: overly-inflated self-esteem; decreased need for sleep; increased talkativeness; racing thoughts; distractibility; increased goal directed activity such as shopping; physical agitation; and excessive involvement in risky behaviors or activities.

Mixed? State: Symptoms of mania and depression are present at the same time. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic activation.

Especially early in the course of illness, the episodes may be separated by periods of wellness during which a person suffers few to no symptoms. When four or more episodes of illness occur within a 12-month period, the person is said to have bipolar disorder with rapid cycling. Bipolar disorder is often complicated by co-occurring alcohol or substance abuse.4

Severe depression or mania may be accompanied by symptoms of psychosis. These symptoms include: hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person’s cultural concepts). Psychotic symptoms associated with bipolar typically reflect the extreme mood state at the time

 

What is a manic episode?
Some of the characteristics of mania appear as opposites of depression. Rather than a general slowing down of thought and activity, which is very common in depression, the person with mania experiences a speeding up of thought and activity. Also, with a manic episode the person’s self-esteem and mood are elevated, which is unlike what happens in depression. A person experiencing a manic episode frequently encounters difficulty with relationships and problems at work, at school, or with the law.

There is a milder form of mania which is called hypomania. The person who is hypomanic experiences speeded up speech, thought, and behaviors, but usually functions normally.

What characteristics are associated with bipolar disorder?

Characteristics of bipolar disorder include the manic and depressed phases.

Characteristics associated with mania include:

  • Irritability
  • Euphoria
  • Hostility
  • Decreased sleep
  • Rapid speech
  • Difficulty focusing attention
  • Abundance of energy
  • Inflated self-esteem
  • Grandiose or lofty plans
  • Poor judgment
  • Hypersexual feelings

If not controlled, mania can escalate and become a severe condition with psychotic behavior. A manic episode is diagnosed if elevated mood occurs with 3 or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, 4 additional symptoms must be present.

Depressive characteristics include:

  • Increased or decreased sleep
  • Weight gain or weight loss
  • Severe sadness
  • Crying spells
  • Loss of joy
  • Loss of interest in activities

Severe depression may lead to thoughts and plans of suicide. If not treated adequately, death through suicide is a very real possibility in the severely depressed person with bipolar disorder. A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.

Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). 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 or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call “the blues” when it is short-lived but is termed “dysthymia” 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 a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, and 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.

WHAT IS THE COURSE OF BIPOLAR DISORDER?

Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.4

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When 4 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 among men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated (see below — “How Is Bipolar Disorder Treated?”). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared.5 But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Treatments
A variety of medications are used to treat bipolar disorder.5 But even with optimal medication treatment, many people with the illness have some residual symptoms. Certain types of psychotherapy or psychosocial interventions, in combination with medication, often can provide additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family therapy, and psychoeducation.6,7

Lithium has long been used as a first-line treatment for bipolar disorder. Approved for the treatment of acute mania in 1970 by the U.S. Food and Drug Administration (FDA), lithium has been an effective mood-stabilizing medication for many people with bipolar disorder.

Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives to lithium in many cases. Valproate was FDA approved for the treatment of acute mania in 1995. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, are being studied to determine their efficacy as mood stabilizers in bipolar disorder. Some research suggests that different combinations of lithium and anticonvulsants may be helpful.

According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20.8 Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician.

During a depressive episode, people with bipolar disorder commonly require additional treatment with antidepressant medication. Typically, lithium or anticonvulsant mood stabilizers are prescribed along with an antidepressant to protect against a switch into mania or rapid cycling. The comparative efficacy of various antidepressants in bipolar disorder is currently being studied.

In some cases, the newer, atypical antipsychotic drugs such as clozapine or olanzapine may help relieve severe or refractory symptoms of bipolar disorder and prevent recurrences of mania. More research is needed to establish the safety and efficacy of atypical antipsychotics as long-term treatments for this

 

Are there any genetic factors associated with bipolar disorder?

Yes, bipolar disorder tends to run in families. It is quite likely that people with bipolar disorder have close relatives who also have bipolar disorder or depressed moods. More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a heritable component.9 Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

Researchers are using advanced imaging techniques to examine brain function and structure in people with bipolar disorder.10,ll An important area of imaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Better understanding of the neural circuits involved in regulating mood states will influence the development of new and better treatments, and will ultimately aid in diagnosis.

 

Does bipolar disorder affect males, females, or both?

Bipolar disorder is equally common in men and women in the United States. The first episode in men is usually a manic episode. Women are more likely to experience depression as a first episode of their bipolar disorder.

At what age does bipolar disorder appear?

Young people under the age of thirty (30) are at greater risk than older people for developing bipolar disorder.

How often is bipolar disorder seen in our society?

About one percent (1%) of the population has bipolar disorder.

DO OTHER ILLNESSES 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.24 Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder.25, 26 Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment. For more information on anxiety disorders, contact NIMH (see below).

 

Developed by John L. Miller, MD
Reviewed 7/2001
Page last modified on September 28, 2005