Bipolar Disorders

What is a Bipolar Disorder?

Bipolar disorder is a mental health condition characterized by severe mood swings between depression and elation or mania. These are known as cycles. There are four types of bipolar disorders: bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder due to substance/medication or another medical condition. In addition, there are atypical bipolar conditions that fall into the diagnostic categories of “other specified bipolar and related disorder” and “unspecified bipolar and related disorder.”

What is Bipolar I Disorder?

Bipolar I disorder is marked by “manic episodes” which are distinct periods of elevated, expansive or irritable mood,with increased goal-directed activity or energy, lasting at least 7 days.

Manic Episodes

A manic episode is severe enough to cause impairment in social or occupational functioning, require hospitalization to prevent harm to self or others, or result in psychotic features. For a bipolar diagnosis, the manic episode cannot be attributable to the physiological effects of a substance (e.g., drug of abuse or medication).

During the manic period, three or more of the following symptoms are present for most of the day (four if the patient’s mood is only irritable):

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking
  • Having a flight of ideas or the feeling that one’s thoughts are racing
  • High distractibility to unimportant or irrelevant external stimuli
  • Increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation (purposeless non-goal-directed activity)
  • Excessive involvement in activities that have a high potential for painful consequences (such as unrestrained buying sprees, sexual indiscretions, or foolish business investments)

A bipolar I diagnosis requires at least one lifetime manic episode.

Hypomanic Episodes

A person with bipolar I disorder may also have “hypomanic episodes.” Hypomanic episodes have all the symptoms of manic episodes and are associated with an uncharacteristic change in behavior but are not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization. A hypomanic episode lasts for 4 consecutive days or more.

Depression

Episodes of major depression are common in bipolar I disorder but are not required for a bipolar I diagnosis. Symptoms of major depression include a depressed mood for most of the day, nearly every day, a loss of interest in pleasure and activities, significant weight loss or weight gain, insomnia or sleeping too much, fatigue, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, or recurrent thoughts of death or suicide.

How many people are affected by Bipolar Disorders?

The lifetime prevalence of bipolar disorders is thought to be less than 1 percent of the population. However, it can be difficult to estimate because milder forms of bipolar disorder are often not diagnosed.

Is Bipolar Disorder a genetic condition?

Family studies indicate that if one parent has a mood disorder, their child will have a risk of between 10 and 25 percent for a mood disorder. If both parents are affected, the risk roughly doubles. The risk increases if more members of the family are affected, especially first-degree relatives rather than more distance relatives. Studies of twins provide evidence that genes account for 50 to 70 percent of mood disorders, leaving environmental or nonheritable factors to account for the remainder.

How does Bipolar I Disorder typically develop?

Bipolar I disorder most often starts with depression. Most individuals experience both depressive and manic episodes; however, 10 to 20 percent experience only manic episodes.

Manic episodes typically have a rapid onset of hours or days, but they may evolve over a few weeks. An untreated manic episode lasts about 3 months. Of people who have a single manic episode, 90 percent are likely to have another. As the disorder progresses, the time between episodes often decreases. After about five episodes, however, the time between manic episodes often stabilizes at 6 to 9 months.

Of persons with bipolar disorder, 5 to 15 percent have four or more episodes per year and can be classified as rapid cyclers.

Does Bipolar Disorder affect men differently than women?

Yes. In contrast to major depressive disorder, which affects women twice as much as men, manic episodes are more common in men. When manic episodes occur in women, they are more likely than men to present a mixed picture, such as mania combined with depression. Women also have a higher rate of being rapid cyclers, defined as having four or more manic episodes in a 1-year period.

What is Bipolar II Disorder?

A person with bipolar II disorder experiences periods of both hypomania and major depression, but never has had a manic episode.

Hypomanic Episodes

A hypomanic episode has all the symptoms of a manic episode that characterizes bipolar 1 disorder, with two distinct differences:

  • A hypomanic episode lasts for at least 4 consecutive days (instead of 7 in a manic episode).
  • A hypomanic episode is associated with an uncharacteristic change in behavior but is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization (as a manic episode may cause).

Major Depression

Symptoms of a major depression include five or more symptoms during the same 2-week period: a depressed mood for most of the day, nearly every day, a loss of interest in pleasure and activities, significant weight loss or weight gain, insomnia or sleeping too much, fatigue, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, or recurrent thoughts of death or suicide. The symptoms cause significant distress or impairment in social, occupation, or other important areas of functioning.

For a bipolar II diagnosis, neither the hypomanic episodes nor major depressive episodes can be attributable to the physiological effects of a substance (e.g., drug of abuse or medication) or other medical condition.

What is Cyclothymic Disorder?

Cyclothymic disorder is a type of bipolar condition that is diagnosed when a person experiences during a 2-year period (1 year for children):

  • Numerous periods with hypomanic symptoms that do not meet the full criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet the full criteria for a major depressive episode.
  • The hypomanic and depressive symptoms have been present for at least half the time, and the individual has been without the symptoms for no more than 2 months at a time.
  • They symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.
  • The symptoms are not attributable to the physiological effects of a substance (e.g., drug of abuse or medication) or another medical condition (e.g., hyperthyroidism or schizophrenia).
What is Substance/Medication-Induced Bipolar Disorder?

Substance/medication-induced bipolar disorder is a type of bipolar condition that is caused by substance intoxication or withdrawal, or exposure to a medication.

The disorder is characterized by an elevated, expansive or irritable mood or a markedly diminished interest or pleasure in all, or almost all, activities. It may also be accompanied by a depressed mood. The symptoms occur during or soon after substance intoxication or withdrawal or following exposure to a medication.

The symptoms cause significant distress or impairment in social, occupation, or other important areas of functioning.

Can a Person Have a Bipolar Condition that Does Not Match a Specific Bipolar Disorder?

Yes. A person can have a mix of manic, hypomanic or depressive symptoms that do not fit a specific bipolar diagnosis. For example, hypomanic episodes may last just 2-3 days and may not be followed by major depressive episodes. Or a person may experience cyclothymia (lesser symptoms of hypomania and depression) for less than 2 years.

If the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning, a diagnosis of a specified or unspecified bipolar disorder may be given.

Following are examples of symptoms that may fall into the diagnostic category of “other specified bipolar and related disorder” and “unspecified bipolar and related disorder.”

Other Specified Bipolar and Related Disorder

Examples of patient symptoms that would fall under the diagnostic category of “other specified bipolar and related disorder” include:

  • Short-duration hypomanic episodes of 2-3 days and a lifetime history of one or more major depressive episodes.
  • A lifetime history of one or more major depressive episodes who have experienced one or more episodes of hypomania.
  • One or more hypomanic episodes without a prior major depressive episode.
  • Short-duration cyclothymia (less than 24 months).

Unspecified Bipolar and Related Disorder

Examples of conditions that would fall under the diagnostic category of “other specified bipolar and related disorder” include:

  • Bipolar with “anxious distress” during the most recent or current episode of mania, hypomania or depression.
  • Manic or hypomanic episode with mixed features of depression.
  • Depressive episode with mixed features of manic/hypomanic symptoms.
  • Bipolar “with melancholic features” that may include depression that is regularly worse in the morning, excessive guilt, significant anorexia or weight loss, or marked psychomotor agitation or retardation.
  • Bipolar with “atypical features” that include mood reactivity (i.e., mood brightens in response to actual or potential positive events) and other possible symptoms, including significant weight gain or increase in appetite, leaden paralysis, and a long-standing pattern of interpersonal rejection sensitivity.
  • Bipolar with psychotic features or catatonia.
  • Bipolar with peripartum onset if first mood symptoms occur during pregnancy or in the 4 weeks following delivery.
  • Bipolar with a seasonal pattern of lifetime mood episodes, such as during the fall or winter months.
What are the treatments for Bipolar Disorder?

Treatment for bipolar disorders should include both pharmacotherapy and psychotherapy.  Because stressful life events are associated with increases in relapse rates, therapy should address the number and severity of stressors in an individual’s life.

Pharmacotherapy
The pharmacological treatment of bipolar disorders is divided into initial treatment to get the condition under control, and maintenance treatment. Treatment of bipolar disorders requires different strategies for the patient who is experiencing mania, hypomania or depression. The primary treatment has been mood stabilizers (lithium, valproic acid (Depakote, Depakene), carbamazepine (Tegretol), oxcarbazepine (Trileptal), lamotrigine, antipsychotics (primarily atypical), and benzodiazepines. Each of these medications is associated with a unique side effect and safety profile, and no one drug is predictably effective for all patients. Often, a practitioner will try different medications before an optimal treatment is found.

For treatment of acute mania, lithium carbonate is considered the typical mood stabilizer. But because it can take a while to be effective, it is usually supplemented in the early stages of treatment by atypical antipsychotics, mood-stabilizing anticonvulsants, or high-potency benzodiazepines.

For treatment of bipolar depression, lamotrigine, quetiapine, (Seroquel), or other mood stabilizers or atypical antipsychotic medication can be used either alone or incombination. A fixed combination of olanzapine and fluoxetine has been shown to be effective in treating acute bipolar depression for an 8-week period without inducing mania or hypomania. Other medications may be used when a patient does not respond to standard antidepressants.

Maintaining the treatment of bipolar disorder to prevent recurrence of mood episodes is the greatest challenge of managing this condition. Lithium, carbamazepine, and valproic acid, alone or in combination, are the most widely used drugs in the long-term treatment of patients with bipolar disorder. In addition, thyroid supplementation is often needed during long-term treatment.

Patients may be asked to keep a daily record of their mood patterns or other facts that could help in finding the right treatment.

Psychotherapy

Psychotherapy is a vital part of bipolar disorder treatment and can be provided in individual, family or group settings. Several types of therapy may be helpful. These include:

  • Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on the stabilization of daily rhythms, such as sleeping, waking and mealtimes. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet, and exercise.
  • Cognitive behavioral therapy (CBT). This type of therapy focuses on identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. CBT can help identify what triggers a patient’s bipolar episodes. The patient can also learn effective strategies to manage stress and cope with upsetting situations.
  • Family-focused therapy. Family support and communication can help you stick with your treatment plan and help you and your loved ones recognize and manage warning signs of mood swings.
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Mental Health Library Sources:
Information included in all topics of the Mental Health Library comes from the Desk Reference to the Diagnostic Criteria From DSM-5 and Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Complete diagnostic and treatment information may be found within these publications.
Disclaimer:
Information within the Mental Health Library is not intended to be used for self-diagnosis purposes. Rather, it is provided as a public educational service to make people aware of mental health conditions. Please consult a qualified mental health professional for a diagnosis of any suspected mental health illness.
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