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Bipolar disorder, originally called manic depressive disorder, is a severe disorder that vacillates between extreme “ups” (mania, hypomania) and “downs” (depression).
Previously, bipolar disorder and related disorders were classified with depression and similar disorders under the category of mood disorders; however, in the latest edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), bipolar disorder and its related disorders have become separated from the depressive disorders and placed between the chapters covering schizophrenia spectrum disorders and depressive disorders. This was done in an attempt to recognize that bipolar disorder may represent a bridge between depression and the psychotic disorders. However, bipolar disorder, depression, and related disorders are still referred to as mood disorders by most clinicians. Bipolar disorder is a disorder that presents as alternating between extreme mood states.
It is important to distinguish between the terms mood and affect when understanding how bipolar disorder is diagnosed.
Descriptions of mood often come from self-reports of patients, whereas descriptions of mania may be more likely to be based on observations of the person’s affect.
Disorders affecting one’s mood are categorized by a loss of that internal sense of control and a sense of distress. When mania or hypomania is involved, the person is diagnosed with a variant of bipolar disorder (when manic episodes or hypomanic episodes are present) or cyclothymia (when only hypomania is present). A person who is diagnosed with bipolar disorder has altering expressions of mania or hypomania and depression.
Manic episodes consist of:
Hypomania is similar to mania except that the episode is often shorter (but at least four days in duration). The same criteria for mania are used to determine hypomania except the duration is shorter, and presentation is often not quite as intense. These criteria must cause significant impairment in the person’s functioning (or cause the person to be hospitalized) and cannot be better explained by the use of drugs or by a medical condition.
In bipolar disorder, the manic and hypomanic episodes have shorter durations than the episodes of depression. The criteria to diagnose depression and bipolar disorder consist of displaying at least five of nine potential symptoms that represent a change from the person’s normal level of functioning for a period of at least two weeks.
At least one of the symptoms has to be depressed mood, a major loss of the person’s interests, or the inability to experience pleasure from activities that would typically give the person pleasure. The criteria for depression are:
Again, the person must experience a significant impairment in functioning or experience significant distress from these symptoms, and the symptoms are not the result of taking a drug, a medication, or of a medical condition.
There are two separate bipolar disorder diagnoses:
These symptoms can range from clinically mild to severe. A related disorder, cyclothymia is characterized by at least two years of altering hypomanic symptoms that do not qualify or fit the criteria for mania altering with depressive symptoms. For purposes of this article, cyclothymia will not be considered further.
A number of other potential complications can occur in bipolar disorder, including:
The disorder is more common in divorced and single persons, and people without a college degree. There is a slightly higher prevalence of the disorder found in upper socioeconomic groups. These factors can be important when considering the course of treatment.
The etiology of bipolar disorder is much more speculative than that of clinical depression. A disruption of neurotransmitters has long been suspected, but the perspective of focusing on a single neurotransmitter or neurotransmitter system has shifted to one that focuses on studying neurobehavioral systems, neuroregulatory systems, and neural circuits. Brain imaging techniques have revealed:
In light of the findings that demonstrate a possible biological etiology for bipolar disorder, these findings are still complicated by the notion that many neuroimaging studies are performed on chronic patients with a history of medication and drug usage, and twin studies are complicated by a dearth of adoption studies. However, few would argue the potential for a strong biological influence and contribution on the expression of bipolar disorder compared to many other disorders, such as depression and anxiety disorders. But a strict overarching biological etiology has not been demonstrated by the research.
As mentioned above, bipolar disorder is viewed as a chronic condition. Even though there are a variety of effective treatments available, the use of psychotropic medication is often the first-line treatment option. Interestingly, individuals affected with bipolar disorder will often seek out treatment according to the phase of the disorder currently experienced.
For example, someone in an initial depressive stage would seek out treatment for depression, which could consist of medication or psychotherapy, or both. When in the manic or hypomanic phase of the disorder, the patient often takes on the attitude that medications are not needed, and individuals who are on medication often stop taking them. During these times, referrals from family members, employers, or friends get individuals into treatment, or individuals act in such a manner to get themselves involved in the legal system, and treatment referrals are made from that venue. If none of this occurs when people reach a depressive phase, they will often seek out treatment. In any event, actively manic patients can be very difficult to treat. Bipolar patients are also notoriously prone to self-medicate with drugs or alcohol in attempt to relieve their symptoms.
Medication is almost always a part of the treatment course regime for bipolar disorder. The types of medical interventions commonly prescribed for bipolar disorder include the following:
There is no single approach to treating bipolar disorder with medications, and psychiatrists typically have to adapt a trial-and-error approach with individual patients until the best overall combination that works with that particular patient is achieved. The use of medication for treating bipolar disorder is often divided into three broad categories:
There have been numerous studies that have demonstrated that when treated with medications, the relapse rates for bipolar disorder are substantially reduced and the overall improvement of symptoms is quite substantial. For these reasons, medications will continue to be the first-line treatments for bipolar disorder, but this does not mean that psychotherapy cannot be used to help these patients or to assist with their treatment.
For bipolar patients in psychotherapy, being on medications is often viewed as a necessary evil. This is because many experience side effects from mood stabilizers or atypical antipsychotics yet have to continue to do the work in therapy (as well as their daily routines) in order to adjust and move forward. Both patients and therapists need to be cognizant of the complications of medical interventions, such as psychotropic drugs, when judging their daily levels of functioning and progress in treatment.
There are many roles for the uses of psychotherapy in the treatment of bipolar disorder. Some of the roles for psychotherapy would be psychoeducational, to teach skills for symptom management, to enhance functioning in social and occupational areas, and to keep individuals adherent to their medication routines. Other important goals would be to help these people learn to cope with stress triggers, recognizing that certain types of life events and family tensions are potential risk factors that contribute to the expression of the disorder.
Research indicates that other mental disorders are commonly diagnosed along with bipolar disorder. These include:
Drug abuse and alcohol abuse are common co-occurring disorders in people who are diagnosed with bipolar disorder, especially those with bipolar I disorder. A classic study looking at drug abuse and bipolar disorder found that:
The reason for the high rate of substance use disorders and bipolar disorder co-occurring is a matter of speculation:
Bipolar disorder is a severe disorder that responds best to a multidisciplinary treatment approach. It is clear that the first course of treatment for bipolar disorder consists of pharmacotherapy; however, adjunctive psychotherapies appear to be able to add some noteworthy advantages to recovery. The addition of therapy, whether it is individual therapy, family therapy, or group therapy, results in more positive outcomes for the disorder than can be achieved by the use of pharmacotherapy alone. Individuals diagnosed with bipolar disorder are at increased risk for substance abuse and addiction. Co-occurring diagnoses make the treatment of bipolar disorder more complicated.