Bipolar disorder, formerly known as manic-depressive illness, is a brain and behavior disorder characterized by severe shifts in a person’s mood and energy, making it difficult for the person to function. More than 5.7 million American adults or 2.6 percent of the population age 18 or older in any given year have bipolar disorder. The condition typically starts in late adolescence or early adulthood, although it can show up in children and in older adults. People often live with the disorder without having it properly diagnosed and treated.
What is Bipolar Disorder?
Bipolar disorder is a mental illness marked by extreme shifts in mood ranging from a manic to a depressive state. Bipolar disorder is also called bipolar disease or manic depression.
A person with mania will feel excited, impulsive, euphoric, and full of energy. He or she might engage in risky or unhealthy behavior. Drug use, spending sprees, and impulsive or unprotected sex are common during manic episodes.
The depressive episodes might bring on deep sadness and hopelessness. Depression causes a loss of energy and interest in activities the patient once enjoyed. This phase can include periods of too little or too much sleep. Also, suicidal thoughts or attempts may come with deep depression.
Sometimes the shifts in mood can be severe. At other times one might experience a normal mood between episodes of depression and mania. People with bipolar disorder often have trouble managing everyday life. They may perform poorly at school or work. They may also have trouble maintaining personal relationships.
What are the different types of Bipolar Disorder?
There are several types of bipolar disorder; all involve episodes of depression and mania to a degree. They include bipolar I, bipolar II, cyclothymic disorder, mixed bipolar, and rapid-cycling bipolar disorder.
A person affected by bipolar I disorder has had at least one manic episode in his or her life. A manic episode is a period of abnormally elevated mood, accompanied by abnormal behavior that disrupts life.
Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time. However, in bipolar II disorder, the “up” moods never reach full-on mania.
In rapid cycling, a person with bipolar disorder experiences four or more episodes of mania or depression in one year. About 10% to 20% of people with bipolar disorder have rapid cycling.
In most forms of bipolar disorder, moods alternate between elevated and depressed over time. But with mixed bipolar disorder, a person experiences both mania and depression simultaneously or in rapid sequence.
Cyclothymia (cyclothymic disorder) is a relatively mild mood disorder. People with cyclothymic disorder have milder symptoms than in full-blown bipolar disorder.
Learn about the bipolar spectrum, what it means, and how bipolar is categorized.
What are the symptoms of Bipolar Disorder?
There are several types of bipolar and related disorders. For each type, the exact symptoms of bipolar disorder can vary from person to person. Bipolar I and bipolar II disorders also have additional specific features that can be added to the diagnosis based on your particular signs and symptoms.
Criteria for bipolar disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing bipolar and related disorders. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
Diagnostic criteria for bipolar and related disorders are based on the specific type of disorder:
Bipolar I disorder. You’ve had at least one manic episode. The manic episode may be preceded by or followed by hypomanic or major depressive episodes. Mania symptoms cause significant impairment in your life and may require hospitalization or trigger a break from reality (psychosis).
Bipolar II disorder. You’ve had at least one major depressive episode lasting at least two weeks and at least one hypomanic episode lasting at least four days, but you’ve never had a manic episode. Major depressive episodes or the unpredictable changes in mood and behavior can cause distress or difficulty in areas of your life.
Cyclothymic disorder. You’ve had at least two years — or one year in children and teenagers — of numerous periods of hypomania symptoms (less severe than a hypomanic episode) and periods of depressive symptoms (less severe than a major depressive episode). During that time, symptoms occur at least half the time and never go away for more than two months. Symptoms cause significant distress in important areas of your life.
Other types. These include, for example, bipolar and related disorder due to another medical condition, such as Cushing’s disease, multiple sclerosis or stroke. Another type is called substance and medication-induced bipolar and related disorder.
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.
Criteria for a manic or hypomanic episode
The DSM-5 has specific criteria for the diagnosis of manic and hypomanic episodes:
A manic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). The episode includes persistently increased goal-directed activity or energy.
A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least four consecutive days.
For both a manic and a hypomanic episode, during the period of disturbed mood and increased energy, three or more of the following symptoms (four if the mood is only irritable) must be present and represent a noticeable change from your usual behavior:
Inflated self-esteem or grandiosity
Decreased need for sleep (for example, you feel rested after only three hours of sleep)
Increased goal-directed activity (either socially, at work or school, or sexually) or agitation
Doing things that are unusual and that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments
To be considered a manic episode:
The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in social activities or relationships; or to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.
To be considered a hypomanic episode:
The episode is a distinct change in mood and functioning that is not characteristic of you when the symptoms are not present, and enough of a change that other people notice.
The episode isn’t severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn’t require hospitalization or trigger a break from reality.
Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.
Criteria for a major depressive episode
The DSM-5 also lists criteria for diagnosis of a major depressive episode:
Five or more of the symptoms below over a two-week period that represent a change from previous mood and functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure.
Symptoms can be based on your own feelings or on the observations of someone else.
Signs and symptoms include:
Depressed mood most of the day, nearly every day, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
Markedly reduced interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
Either insomnia or sleeping excessively nearly every day
Either restlessness or slowed behavior that can be observed by others
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt, such as believing things that are not true, nearly every day
Decreased ability to think or concentrate, or indecisiveness, nearly every day
Recurrent thoughts of death or suicide, or suicide planning or attempt
To be considered a major depressive episode:
Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships
Symptoms are not due to the direct effects of something else, such as alcohol or drug use, a medication or a medical condition
Symptoms are not caused by grieving, such as after the loss of a loved one
Other signs and symptoms of bipolar disorder
Signs and symptoms of bipolar I and bipolar II disorders may include additional features.
Anxious distress — having anxiety, such as feeling keyed up, tense or restless, having trouble concentrating because of worry, fearing something awful may happen, or feeling you may not be able to control yourself
Mixed features — meeting the criteria for a manic or hypomanic episode, but also having some or all symptoms of major depressive episode at the same time
Melancholic features — having a loss of pleasure in all or most activities and not feeling significantly better, even when something good happens
Atypical features — experiencing symptoms that are not typical of a major depressive episode, such as having a significantly improved mood when something good happens
Catatonia — not reacting to your environment, holding your body in an unusual position, not speaking, or mimicking another person’s speech or movement
Peripartum onset — bipolar disorder symptoms that occur during pregnancy or in the four weeks after delivery
Seasonal pattern — a lifetime pattern of manic, hypomanic or major depressive episodes that change with the seasons
Rapid cycling — having four or more mood swing episodes within a single year, with full or partial remission of symptoms in between manic, hypomanic or major depressive episodes
Psychosis — severe episode of either mania or depression (but not hypomania) that results in a detachment from reality and includes symptoms of false but strongly held beliefs (delusions) and hearing or seeing things that aren’t there (hallucinations)
Symptoms in children and teens
The same DSM-5 criteria used to diagnose bipolar disorder in adults are used to diagnose children and teenagers. Children and teens may have distinct major depressive, manic or hypomanic episodes, between which they return to their usual behavior, but that’s not always the case. And moods can rapidly shift during acute episodes.
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. And children who have bipolar disorder are frequently also diagnosed with other mental health conditions.
The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.
What causes Bipolar Disorder?
The National Institutes of Mental Health3 says most experts agree that bipolar disorder has no single cause. It is more likely the result of many factors acting together.
Genetics – some small twin studies have indicated that there is a “substantial genetic contribution” to bipolar disorder risk. People with a blood relative who has bipolar disorder have a higher risk of developing it themselves. Currently, scientists are trying to identify which genes are involved.
A study by an international team of scientists reported in the journal Neuron that rare copy number variants, abnormal sequences of DNA, seem to play a major role in the risk of early onset bipolar disorder.
Biological traits – experts say that patients with bipolar disorder often have physical changes that occurred in their brains. Nobody is sure why the changes can lead to the disorder.
Brain-chemical imbalance – neurotransmitter imbalances play a key role in many mood disorders, including bipolar disorder, as well as depression and other mental illnesses. Neurotransmitters are chemicals that facilitate the communication between neurons (brain cells). Examples of neurotransmitters are serotonin, norepinephrine, and dopamine.
Hormonal problems – hormonal imbalances are thought to possibly trigger or cause bipolar disorder.
Environmental factors – abuse, mental stress, a “significant loss”, or some other traumatic event may contribute towards bipolar disorder risk. Traumatic events may include the death of a loved one, losing your job, the birth of a child, or moving house. Experts say many things, if the variables are right, can trigger bipolar disorder in some people. They add that we all react differently to environmental factors. However, once bipolar disorder is triggered and starts to progress, it appears to take on a life and force of its own.
How is Bipolar Disorder treated?
Treatment for bipolar disorder aims to reduce the severity and number of episodes of depression and mania to allow as normal a life as possible.
If a person isn’t treated, episodes of bipolar-related mania can last for between three and six months. Episodes of depression tend to last longer, for between six and 12 months.
However, with effective treatment, episodes usually improve within about three months.
Most people with bipolar disorder can be treated using a combination of different treatments. These can include one or more of the following:
* medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilisers and are taken every day on a long-term basis
* medication to treat the main symptoms of depression and mania when they occur
* learning to recognise the triggers and signs of an episode of depression or mania
* psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
* lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep
Most people with bipolar disorder can receive most of their treatment without having to stay in hospital.
However, hospital treatment may be needed if your symptoms are severe, or if you’re being treated under the Mental Health Act, as there’s a danger you may self-harm or hurt others.
In some circumstances, you could have treatment in a day hospital and return home at night.
Several medications are available to help stabilise mood swings. These are commonly referred to as mood stabilisers and include:
* lithium carbonate
* anticonvulsant medicines
* antipsychotic medicines
If you’re already taking medication for bipolar disorder and you develop depression, your GP will check you’re taking the correct dose. If you aren’t, they’ll change it.
Episodes of depression are treated slightly differently in bipolar disorder, as the use of antidepressants alone may lead to a hypomanic relapse.
Most guidelines suggest depression in bipolar disorder can be treated with just a mood stabiliser. However, antidepressants are commonly used alongside a mood stabiliser or antipsychotic.
If your GP or psychiatrist recommends you stop taking medication for bipolar disorder, the dose should be gradually reduced over at least four weeks, and up to three months if you are taking an antipsychotic or lithium.
If you have to stop taking lithium for any reason, see your GP about taking an antipsychotic or valproate instead.
In the UK, lithium carbonate (often referred to as just lithium) is the medication most commonly used to treat bipolar disorder.
Lithium is a long-term method of treatment for episodes of mania, hypomania and depression. It’s usually prescribed for at least six months.
If you’re prescribed lithium, stick to the prescribed dose and don’t stop taking it suddenly (unless told to by your doctor).
For lithium to be effective, the dosage must be correct. If it’s incorrect, you may get side effects such as diarrhoea and vomiting. However, tell your doctor immediately if you have side effects while taking lithium.
You’ll need regular blood tests at least every three months while taking lithium. This is to make sure your lithium levels aren’t too high or too low.
Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases.
While you’re taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they’re prescribed by your GP.
In the UK, lithium and the antipsychotic medicine aripiprazole are currently the only medications licensed for use in adolescents with bipolar disorder who are aged 13 or over.
However, the Royal College of Paediatrics and Child Health states that unlicensed medicines may be prescribed for children if there are no suitable alternatives and their use can be justified by expert agreement.
Anticonvulsant medicines include:
These medicines are sometimes used to treat episodes of mania. They’re also long-term mood stabilisers.
Anticonvulsant medicines are often used to treat epilepsy, but they’re also effective in treating bipolar disorder.
A single anticonvulsant medicine may be used, or they may be used in combination with lithium when the condition doesn’t respond to lithium on its own.
Valproate isn’t usually prescribed for women of childbearing age because there’s a risk of physical defects to babies such as spina bifida, heart abnormalities and cleft lip. There may also be an increased risk of developmental problems such as lower intellectual abilities, poor speaking and understanding, memory problems, autistic spectrum disorders and delayed walking and talking.
In women, your GP may decide to use valporate if there’s no alternative or if you’ve been assessed and it’s unlikely you’ll respond to other treatments, although they’ll need to check you’re using a reliable contraception and advise you on the risks of taking the medicine during pregnancy.
If you’re prescribed valproate, you’ll need to visit your GP to have a blood count when you begin the medication, and then again six months later.
Carbamazepine is usually only prescribed on the advice of an expert in bipolar disorder. To begin with, the dose will be low and then gradually increased.
Your progress will be carefully monitored if you’re taking other medication, including the contraceptive pill.
Blood tests to check your liver and kidney function will be carried out when you start taking carbamazepine, and again after six months.
You’ll also need to have a blood count at the start and after six months, and you may also have your weight and height monitored.
If you’re prescribed lamotrigine, you’ll usually be started on a low dose, which will be increased gradually.
See your GP immediately if you’re taking lamotrigine and develop a rash. You’ll need to have an annual health check, but other tests aren’t usually needed.
Women who are taking the contraceptive pill should talk to their GP about taking a different method of contraception.
Antipsychotic medicines are sometimes prescribed to treat episodes of mania or hypomania. Antipsychotic medicines include:
They may also be used as a long-term mood stabiliser. Quetiapine may also be used for long-term bipolar depression.
Antipsychotic medicines can be particularly useful if symptoms are severe or behaviour is disturbed. As antipsychotics can cause side effects – such as blurred vision, dry mouth, constipation and weight gain – the initial dose will usually be low.
If you’re prescribed an antipsychotic medicine, you’ll need to have regular health checks at least every three months, but possibly more often, particularly if you have diabetes. If your symptoms don’t improve, you may be offered lithium and valproate as well.
Aripiprazole is also recommended by the National Institute for Health and Care Excellence (NICE) as an option for treating moderate to severe manic episodes in adolescents with bipolar disorder.
You may be prescribed a combination of lithium and valproate if you experience rapid cycling (where you quickly change from highs to lows without a “normal” period in between).
If this doesn’t help, you may be offered lithium on its own or a combination of lithium, valproate and lamotrigine.
However, you won’t usually be prescribed an antidepressant unless an expert in bipolar disorder has recommended it.
Learning to recognise triggers
If you have bipolar disorder, you can learn to recognise the warning signs of an approaching episode of mania or depression.
A community mental health worker, such as a psychiatric nurse, may be able to help you identify your early signs of relapse from your history.
This won’t prevent the episode occurring, but it will allow you to get help in time.
This may mean making some changes to your treatment, perhaps by adding an antidepressant or antipsychotic medicine to the mood-stabilising medication you’re already taking. Your GP or specialist can advise you on this.
Some people find psychological treatment helpful when used alongside medication in between episodes of mania or depression. This may include:
* psychoeducation – to find out more about bipolar disorder
* cognitive behavioural therapy (CBT) – this is most useful when treating depression
* family therapy – a type of psychotherapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health
Psychological treatment usually consists of around 16 sessions. Each session lasts an hour and takes place over a period of six to nine months.
If you, or someone you know, suffers from depression, or any other mental health issues, and needs help, please contact the South African Depression and Anxiety Group. SADAG is Africa’s largest mental health support and advocacy group. On this website you will find comprehensive mental health information and resources to help you, a family member or loved one.
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