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.
Mood and Affect
It is important to distinguish between the terms mood and affect when understanding how bipolar disorder is diagnosed.
- Mood is an all-encompassing and sustained feeling tone experienced internally by the person and influences the person’s behavior and perception of the world.
- Affect is the external or outward expression of this inner state. When a clinician asks an individual how he or she feels, the clinician is assessing that person’s mood, whereas when a clinician records observations of the person’s behavioral expressions of mood, such as “the person was extremely fidgety” or “appeared to be sad,” the clinician is reporting on the person’s affect.
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.
Mania and Hypomania in Bipolar Disorder
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:
- Distinctive periods of an abnormally persistent and elevated, expansive, or irritable mood that lasts for at least a week (unless the person required hospitalization for the mood change and then it can last any duration)
- During this manic mood disturbance, three or more of the symptoms below must be present, if the mood disturbance includes increased energy or activity, or four or more, if the mood disturbance is only irritable:
- Inflated feelings of self-esteem or being grandiose
- Markedly decreased need for sleep
- Significantly more talkative than normal
- A flight of ideas or racing thoughts
- Increased and marked distractibility
- A marked increase in goal-directed or in non-directed activity (for example, goal-directed activity would be work-related activities, socially related activities, or even sexual activities, and non-goal-related activity would be useless purposeless activities, such as pacing)
- Marked involvement in activities that have potentially dangerous consequences, such as unrestrained buying, investing, gambling, numerous sexual relationships, etc.
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.
Depression in Bipolar Disorder
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:
- Feeling depressed or down most of the day nearly every day (in children and adolescents, these can also be feelings of irritability)
- A marked diminished level of interest or in getting pleasure nearly every day from things that the person was normally interested in or got pleasure from
- Significant weight loss or weight gain when the person is not trying to lose or gain weight, or an increase or decrease in the person’s appetite (the weight change is typically defined as a change of more than 5 percent of the person’s body weight within a month )
- Insomnia or hypersomina (excessive sleeping) nearly every day
- Fatigue or loss of energy occurring nearly every day
- Psychomotor agitation (extreme restlessness) or psychomotor retardation (extremely slow physical movements) nearly every day
- Marked difficulty with thinking or concentrating, or being very indecisive nearly every day
- Recurrent thoughts of death or suicide
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.
Bipolar I and Bipolar II
There are two separate bipolar disorder diagnoses:
- Bipolar disorder I (bipolar I) is characterized by the presence of at least one or more manic episodes, and sometimes these are interspersed with depressive periods. The person can have hypomanic episode, but must have experienced at least one true episode of mania.
- Bipolar disorder II is characterized by episodes of hypomania and depression.
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:
- Psychosis (hallucinations or delusions)
- Seasonal patterns of their presentation
- Rapid cycling (at least four episodes in a 12-month period that would be classified as manic, hypomanic, or depressive)
- Mixed presentation (e.g., having mania with depression)
Course of Bipolar Disorder
- The prevalence rate for bipolar I is 1 percent and 1.1 percent for bipolar II in the US. Bipolar disorder most often starts with a depressive episode, and it is a reoccurring disorder (the average age of the first symptoms of mania, hypomania, or depression is 18 for bipolar I).
- Most bipolar sufferers experience episodes of both mania and depression, although 10-20 percent are afflicted with only mania.
- Manic episodes typically have a rapid onset (a few hours to a few days), but can develop over longer periods (weeks). Some manic episodes have been known to last as long as three months if not treated.
- Ninety percent of those who experience a manic episode will have another manic episode within two years.
- As time goes on, the period between manic episodes will shorten but will eventually stabilize.
- Bipolar I patients have a poorer prognosis than those with other mood disorders and often are expected to take medication for the course of their lifetime.
- Bipolar disorder occurs equally in men and women (the female to male ratio is 1.1:1), whereas depression occurs significantly more often in women.
- Mania occurs more often in men; when it occurs in women, it is more likely to present as a mixed picture (a mix of mania and depression).
- Women are more likely to be rapid cyclers, meaning that they are more likely to experience four or more manic episodes in a one-year timeframe.
- The mean age onset for a diagnosis of bipolar disorder is 30 years of age but can occur as early as 5 or 6 years old to older than 50 years old in rare cases.
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.
Etiology (Cause) of Bipolar Disorder
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:
- Enlarged brain ventricles
- Cortical atrophy
- Widened sulci indicating that these patients have experienced reduced cortical volume loss (the sulci are the indentations on the surface of the brain)
- Genetic contribution as there is a high concordance rate for bipolar disorder in monozygotic (identical) twins (supported by genetic studies)
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.
- A longstanding clinical observation is that stressful life events precede rather than follow bipolar disorder and almost all other psychiatric disorders.
- One theory is that traumatic stress might change the brain and alter normal brain functioning.
- Life events, such as the death of a loved one or other stressing events, increase the risk of developing depression, which precedes mania in many bipolar sufferers.
- There is no single personality factor that is consistently associated with the development of bipolar disorder, but stressful life events could conceivably also interact with innate factors to lead to the expression of the disorder.
Treatment of Bipolar Disorder
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:
- Mood stabilizers: This group includes many of the older bipolar disorder medications, such as lithium, which are still reliable and well tolerated by many patients. Others include drugs that were initially used the treatment of other disorders such as epilepsy (e.g., Depakote, Tegretol, Lamictal). These were the first-line medication treatments for bipolar disorder at one time, but now many have replaced them with the use of the atypical antipsychotics. Mood stabilizers often have side effects such as lethargy, cognitive issues, diarrhea, and others.
- Atypical antipsychotics: These medications were designed for use with psychotic disorders, such as schizophrenia, but research indicates that they may provide greater symptom relief for bipolar disorder. They have more side effects, such as tremors, tardive dyskinesia, cognitive problems, sedation, and others. Atypical antipsychotics are believed to involve other neurotransmitters besides dopamine and include such drugs as Risperdal, Zyprexa, and Seroquel.
- Other medications often include the use of antidepressant medications along with an antipsychotic or mood stabilizer and even anxiolytic (anti-anxiety) medications.
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:
- In the acute treatment phase, the focus is on suppressing current symptoms and continues until the person is considered to be in remission, which occurs when symptoms have been meaningfully reduced and controlled for a significant time period.
- Continuation treatment is designed to prevent a reoccurrence of the symptoms from the same depressive or manic episode.
- Maintenance treatment is designed to prevent a recurrence of symptoms after the last episode has been controlled.
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.
Treatment of Bipolar Disorder
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.
- Psychoeducation: One of the most distressing issues regarding bipolar disorder is that patients have traditionally expressed their resentment regarding how little information they are given about the disorder that plagues them or the medications they are prescribed. Psychoeducational sessions consist of actual lectures about the disorder, the medications involved, the need for adherence, what to expect regarding side effects, etc. Early studies that used manual-based education programs that teach patients about the signs and symptoms of the disorder and medication management display significantly lower rates of relapses than those that only receive medication management instruction, although the relapse rates in some studies were still high attributing to the chronic nature of the disorder.
- Cognitive Behavioral Therapy: There has been quite a bit of research investigating the use of Cognitive Behavioral Therapy (CBT) used in conjunction with medications for treating bipolar patients. In a review of therapy studies, Goodwin reported that between the years 1960 and 1998, there were more than 30 published studies that investigated the use of combined psychological and pharmacological treatments for bipolar disorder. In spite of the methodological limitations of many of the studies reviewed, the participants in a majority of the studies who received adjunctive psychotherapeutic treatments demonstrated better clinical and social outcomes than the participants undergoing standard treatments comprised of medications (most often mood stabilizers) with some outpatient support.
- Other therapies: There have since been a large number of studies in several different countries. Many of the trials focus on psychoeducational models and the best researched psychotherapeutic approaches, including CBT and family-focused therapy. They indicate that therapy is effective to improve awareness, adherence to medications. Therapy is also shown to be effective in instructing the patient in the recognition of prodromal symptoms (early warning signs) and techniques aimed at relapse prevention.
Research indicates that other mental disorders are commonly diagnosed along with bipolar disorder. These include:
- Anxiety disorders
- Attention deficit hyperactivity disorder (ADHD).
- Any type of conduct or impulse control disorder
- Substance use disorders (alcohol abuse appears to be common)
The Relationship between Bipolar Disorder, Substance Abuse, and Addiction
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:
- Over half of individuals with bipolar disorder in the study had experienced drug or alcohol addiction.
- Over 40 percent of the group were addicted to alcohol or had abused alcohol.
- Over 40 percent had abused other drugs or addicted to other drugs.
The reason for the high rate of substance use disorders and bipolar disorder co-occurring is a matter of speculation:
- Some individuals may attempt to block out or numb recollections of painful experiences or the symptoms of bipolar disorder, whereas the use of these drugs may actually trigger manic type symptoms in some individuals who find those sensations to be pleasurable.
- It appears that young males are the highest risk group to be diagnosed with both a substance use disorder and bipolar disorder compared to females and older individuals.
- Other empirical evidence suggests that there are significant genetic contributions to the susceptibility to substance abuse in individuals diagnosed with bipolar disorder.
- Individuals being treated for substance use disorders and bipolar disorder are more prone to relapse, treatment noncompliance, and suicide attempts. In general, they have a poorer prognosis.
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.