Bipolar Disorder

Overview

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While most people will experience some emotional symptoms between episodes, some may not experience any.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy).

Symptoms

There are several types of bipolar and related disorders. They may include mania or hypomania and depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life.

• Bipolar I disorder. You’ve had at least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break from reality (psychosis).
• Bipolar II disorder. You’ve had at least one major depressive episode and at least one hypomanic episode, but you’ve never had a manic episode.
• Cyclothymic disorder. You’ve had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression).
• Other types. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing’s disease, multiple sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

Although bipolar disorder can occur at any age, typically it’s diagnosed in the teenage years or early 20s. Symptoms can vary from person to person, and symptoms may vary over time.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work, school and social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

• Abnormally upbeat, jumpy or wired
• Increased activity, energy or agitation
• Exaggerated sense of well-being and self-confidence (euphoria)
• Decreased need for sleep
• Unusual talkativeness
• Racing thoughts
• Distractibility
• Poor decision-making — for example, going on buying sprees, taking sexual risks or making foolish investments

Major depressive episode

A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships. An episode includes five or more of these symptoms:

• Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
• Marked loss of interest or feeling no pleasure in all — or almost all — activities
• Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)
• Either insomnia or sleeping too much
• Either restlessness or slowed behavior
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Decreased ability to think or concentrate, or indecisiveness
• Thinking about, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as anxious distress, melancholy, psychosis or others. The timing of symptoms may include diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during pregnancy or change with the seasons.

Symptoms in children and teens

Symptoms of bipolar disorder can be difficult to identify in children and teens. It’s often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.

Children and teens may have distinct major depressive or manic or hypomanic episodes, but the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift during episodes. Some children may have periods without mood symptoms between episodes.

The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

Causes

Bipolar disorder appears to result from a combination of factors.

Genetic factors: Bipolar disorder is more common in those who have a family member with the condition. A number of genetic features may be involved.

Biological traits: Research suggests that imbalances in neurotransmitters or hormones that affect the brain may play a role.

Environmental factors: Life events, such as abuse, mental stress, a “significant loss,” or another traumatic event, may trigger an initial episode in a susceptible person.

Diagnosis

A medical professional will diagnose bipolar disorder using criteria set out in the DSM-5.

The National Institue of Mental Health (NIMH) explain that in order to receive a diagnosis of bipolar I disorder, a person must have had symptoms for at least 7 days, or less if symptoms were severe enough to need hospitalization. They may also have had a depressive episode lasting at least 2 weeks.

To receive a diagnosis of bipolar II, a person will have experienced at least one cycle of hypomania and depression.

A doctor may carry out a physical examination and some diagnostic tests, including blood and urine tests, to help rule out other causes.

It can be challenging for a doctor to diagnose bipolar disorder, as people are more likely to seek help with a low mood than a high mood. As a result, it can be hard for them to distinguish it from depression.

If the person has psychosis, a doctor may misdiagnose their condition as schizophrenia.

Other complications that may occur with bipolar disorder are:

• use of drugs or alcohol to cope with symptoms
• post-traumatic stress disorder (PTSD)
• anxiety disorder
• attention-deficit hyperactivity disorder (ADHD)

A person who receives a diagnosis of bipolar disorder has a lifelong diagnosis. They may enjoy long periods of stability, but they will always live with the condition.

When to see a doctor

Despite the mood extremes, people with bipolar disorder often don’t recognize how much their emotional instability disrupts their lives and the lives of their loved ones and don’t get the treatment they need.

And if you’re like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out — and perhaps in financial, legal or relationship trouble.

If you have any symptoms of depression or mania, see your doctor or mental health professional. Bipolar disorder doesn’t get better on its own. Getting treatment from a mental health professional with experience in bipolar disorder can help you get your symptoms under control.

Treatment

Treatment aims to stabilize the person’s mood and reduce the severity of symptoms. The goal is to help the person function effectively in daily life.

Treatment involves a combination of therapies, including:

• medication
• counseling
• physical intervention
• lifestyle remedies

It can take time to get a correct diagnosis and find a suitable treatment, as individuals react differently, and symptoms vary widely.

Drug treatment

Drug treatments can help stabilize mood and manage symptoms. A doctor will often prescribe a combination of:

• mood stabilizers, such as lithium
• antidepressants
• second-generation antipsychotics (SGAs)
• anticonvulsants, to relieve mania
• medication to help with sleep or anxiety

The doctor may need to adjust the medication over time. Some drugs have side effects, and they can affect individuals differently. If an individual has concerns about their drug treatment, they should talk to their doctor.

A person must:

• tell the doctor about any other mediations they are using, to reduce the risk of interactions and adverse effects
• follow the doctor’s instructions regarding medication and treatment
• discuss any concerns about adverse effects, and if they feel the treatment is working
• continue taking medication unless the doctor says it is safe to stop
• bear in mind that the drugs can take time to work

If the person discontinues their treatment, symptoms may worsen.

Psychotherapy and counseling

Psychotherapy can help relieve symptoms and equip a person to manage bipolar disorder.

Through cognitive-behavior therapy (CBT) and other approaches, the individual can learn to:

• recognize and take steps to manage key triggers, such as stress
• identify early symptoms of an episode and take steps to manage it
• work on factors that help maintain a stable mood for as long as possible
• engage the help of family members, teachers, and colleagues

These steps can help a person maintain positive relationships at home and work. For children and teens with bipolar disorder, a doctor may recommend family therapy.

Hospital treatment

Some people may need to spend time in the hospital if there is a risk of them harming themselves or others.

If other treatments have not helped, a doctor may prescribe electroconvulsive therapy (ECT).

Lifestyle remedies

Some lifestyle choices can help maintain a stable mood and manage symptoms. They include:

• maintaining a regular routine
• following a healthful and varied diet
• establishing a regular sleep pattern and taking steps to prevent sleep disturbance
• getting regular exercise

Some people use supplements, but it is essential to discuss this with a doctor first. Some alternative remedies can interact with the drugs used for bipolar disorder. They may make symptoms worse.

References

1. Reilly-Harrington NA et al. A tool to predict suicidal ideation and behavior in bipolar disorder: The Concise Health Risk Tracking Self-Report. Journal of Affective Disorders. 2016;192:212.
2. Bipolar and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://www.psychiatryonline.org. Accessed Dec. 2, 2016.
3. Bipolar disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. Accessed Dec. 2, 2016.
4. Bipolar disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/bipolar-disorder-tr-15-3679/index.shtml. Accessed Dec. 2, 2016.
5. Bipolar disorder in children and teens. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-qf-15-6380/index.shtml. Accessed Dec. 2, 2016.
6. Bipolar disorder. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder. Accessed Dec. 2, 2016.
7. AskMayoExpert. Bipolar disorder. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2016. Accessed Dec. 2, 2016.
8. Suppes T, et al. Bipolar disorder in adults: Clinical features. http://www.uptodate.com/home. Accessed Dec. 2, 2016.
9. Axelson D, et al. Pediatric bipolar disorder: Overview of choosing treatment. http://www.uptodate.com/home. Accessed Dec. 2, 2016.
10. Birmaher B. Pediatric bipolar disorder: Epidemiology, pathogenesis, clinical manifestations, and course. http://www.uptodate.com/home. Accessed Dec. 2, 2016.
11. Picardi A, et al. Psychotherapy of mood disorders. Clinical Practice and Epidemiology in Mental Health. 2014;10:140.
12. Fountoulakis KN, et al. The International College of Neuro-Psychopharmacology (CINP) treatment guidelines for bipolar disorder in adults (CINP-BP-2017), part 2: Review, grading of the evidence and a precise algorithm. International Journal of Neuropsychopharmacology. In press. http://ijnp.oxfordjournals.org/content/early/2016/11/05/ijnp.pyw100.long. Accessed Dec. 6, 2016.
13. Beyer JL, et al. Nutrition and bipolar depression. Psychiatric Clinics of North America. 2016;39:75.
14. Qureshi NA, et al. Mood disorders and complementary and alternative medicine: A literature review. Neuropsychiatric Disease and Treatment. 2013;9:639.
15. Sansone RA, et al. Getting a knack for NAC: N-acetyl-cysteine. Innovations in Clinical Neuroscience. 2011;8:10.
16. Sylvia LG, et al. Nutrient-based therapies for bipolar disorder: A systematic review. Psychotherapy and Psychosomatics. 2013;82:10.
17. Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. Dec. 27, 2016.
18. Krieger CA (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 4, 2017.
19. Post RM. Bipolar disorder in adults: Choosing maintenance treatment. http://www.uptodate.com/home. Accessed Jan. 4, 2016.
20. Janicak PG. Bipolar disorder in adults and lithium: Pharmacology, administration, and side effects. http://www.uptodate.com/home. Accessed Jan. 4, 2017.
21. Stovall J. Bipolar disorder in adults: Pharmacotherapy for acute mania and hypomania. http://www.uptodate.com/home. Accessed Jan. 4, 2017.