Signs and symptoms
Bipolar Disorder is a condition in which people experience abnormally elevated (manic or hypomanic) and, in many cases, abnormally depressed states for periods in a way that interferes with functioning.
Not everyone’s symptoms are the same, and there is no simple physiological test to co.nfirm the disorder. Bipolar Disorder can appear to be Unipolar Depression. Diagnosing Bipolar Disorder is often difficult, even for mental health professionals. What distinguishes BD from Unipolar Depression is that the affected person experiences states of mania and depression.
Often Bipolar is inconsistent among patients because some people feel depressed more often than not and experience little mania, whereas others experience predominantly manic symptoms. Additionally, the younger the age of onset—Bipolar Disorder starts in childhood or early adulthood in most patients—the more likely the first few episodes are to be depression. Because a Bipolar diagnosis requires a manic or hypomanic episode, many patients are initially diagnosed and treated as having Major Depression.
Signs and symptoms of the depressive phase of BD include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal ideation.
In severe cases, the individual may become psychotic, a condition also known as severe Bipolar Depression with psychotic features. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.
Mania is the signature characteristic of BD and depending on its severity is how the disorder is classified. Mania is generally characterized by a distinct period of an elevated mood, which can take the form of euphoria. People commonly experience an increase in energy and a decreased need for sleep, with many often getting as little as 3 or 4 hours of sleep per night, while others can go days without sleeping.
A person may exhibit pressured speech, with thoughts experienced as racing. Attention span is low, and a person in a manic state may be easily distracted. Judgment may become impaired, and sufferers may go on spending sprees or engage in behavior that is quite abnormal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills.
Their behavior may become aggressive, intolerant, or intrusive. People may feel out of control or unstoppable, or as if they have been “chosen” and are “on a special mission,” or have other grandiose or delusional ideas. Sexual drive may increase.
At more extreme phases of Bipolar I, a person in a manic state can begin to experience psychosis or a break with reality, where thinking is affected along with mood. Some people in a manic state experience severe anxiety and are very irritable (to the point of rage), while others are euphoric and grandiose.
To be diagnosed with mania according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a person must experience this state of elevated or irritable mood, as well as other symptoms, for at least one week; less if hospitalization is required.
Severity of manic symptoms can be measured by rating scales such as self-reported Altman Self-Rating Mania Scale and clinician-based Young Mania Rating Scale.
Hypomania is generally a mild to moderate level of mania, characterized by optimism, pressure of speech and activity, and decreased need for sleep. Generally, hypomania does not inhibit functioning like mania. Many people with hypomania are actually in fact more productive than usual, while manic individuals have difficulty completing tasks due to a shortened attention span.
Some people have increased creativity, while others demonstrate poor judgment and irritability. Many people experience signature hypersexuality. These persons generally have increased energy and tend to become more active than usual. They do not have delusions or hallucinations. Hypomania can be difficult to diagnose because it may masquerade as mere happiness, though it carries the same risks as mania.
Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong. In addition, the individual may not be able to recall the events that took place while they were experiencing hypomania. What is called a “hypomanic event,” if not accompanied by complementary depressive episodes (“downs,” etc.), is not typically deemed as problematic; the “problem” arises when mood changes are uncontrollable and, more importantly, volatile or “mercurial.”
If unaccompanied by depressive counterpart episodes or otherwise general irritability, this behavior is typically called hyperthymia, or happiness, which is, of course, perfectly normal. Indeed, the most elementary definition of Bipolar Disorder is an often “violent” or “jarring” state of essentially uncontrollable oscillation between hyperthymia and dysthymia. If left untreated, an episode of hypomania can last anywhere from a few days to several years. Most commonly, symptoms continue for a few weeks to a few months.
Mixed affective episode
In the context of Bipolar Disorder, a mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously. Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. Individuals may also feel incredibly frustrated in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states are often the most dangerous period of mood disorders, during which substance abuse, panic disorder, suicide attempts, and other complications increase greatly.
The causes of Bipolar Disorder likely vary between individuals. Twin studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence.
Genetic studies have suggested many chromosomal regions and candidate genes appearing to relate to the development of BD, but the results are not consistent and often not replicated.
Although the first genetic linkage finding for mania was in 1969, the linkage studies have been inconsistent. Findings point strongly to heterogeneity, with different genes being implicated in different families. Advanced paternal age has been linked to a somewhat increased chance of BD in offspring, consistent with a hypothesis of increased new genetic mutations.
Abnormalities in the structure and/or function of certain brain circuits could underlie Bipolar. Two meta-analyses of MRI studies in BD report an increase in the volume of the lateral ventricles, globus pallidus, and increase in the rates of deep white matter hyperintensities.
The “kindling” theory asserts that people who are genetically predisposed toward BD can experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and become recurrent) by itself.
There is evidence of hypothalamic-pituitary-adrenal axis (HPA axis) abnormalities in BD due to stress.
Other brain components that have been proposed to play a role are the mitochondria, and a sodium ATPase pump, causing cyclical periods of poor neuron firing (depression) and hypersensitive neuron firing (mania). This may only apply for Type I, but Type II apparently results from a large confluence of factors. Circadian rhythms and melatonin activity also seem to be altered.
Evidence suggests that environmental factors play a significant role in the development and course of BD, and that individual psychosocial variable may interact with genetic dispositions.
There is consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of Bipolar mood episodes, as they do for onsets and recurrences of Unipolar Depression.
There have been repeated findings that between a third and a half of adults diagnosed with BD report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a worse course, and more co-occurring disorders such as PTSD.
The total number of reported stressful events in childhood is higher in those with an adult diagnosis of Bipolar Spectrum Disorder compared to those without, particularly events stemming from a harsh environment rather than from the child’s own behavior.
Early experiences of adversity and conflict are likely to make subsequent developmental challenges in adolescence more difficult, and are likely a potentiating factor in those at risk of developing Bipolar Disorder.
Diagnosis is based on the self-reported experiences of an individual as well as abnormalities in behavior reported by family members, friends, or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist, or other clinician in a clinical assessment.
There are lists of criteria for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others.
The most widely used criteria for diagnosing Bipolar Disorder are from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are used in Europe and other regions while the DSM criteria are used in the USA and other regions, as well as prevailing in research studies.
An initial assessment may include a physical exam by a physician. Although there are no biological tests which confirm BD, tests may be carried out to exclude medical illnesses such as hypo- or hyperthyroidism, metabolic disturbance, a systemic infection or chronic disease, and syphilis or HIV infection. An EEG may be done to exclude epilepsy, and a CT scan of the head to exclude brain lesions. Investigations are not generally repeated for relapse unless there is a specific medical indication.
Several rating scales for the screening and evaluation of BD exist, such as the Bipolar Spectrum Diagnostic Scale. The use of evaluation scales cannot substitute a full clinical interview, but they serve to systematize the recollection of symptoms. On the other hand, instruments for the screening of BD have low sensitivity and limited diagnostic validity.
Criteria and subtypes
There is no clear consensus as to how many types of Bipolar Disorder exist. In DSM-IV-TR and ICD-10, BD is conceptualized as a spectrum of disorders occurring on a continuum.
Subcategories specify whether there has been more than one episode, and the type of the most recent episode. A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.
Bipolar I Disorder
One or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode. A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.
Bipolar II Disorder
No manic episodes, but one or more hypomanic episodes and one or more major depressive episode. However, a Bipolar II diagnosis is not a guarantee that they will not eventually suffer from such an episode in the future. Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make Bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression.
A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. There is a low-grade cycling of mood that appears to the observer as a personality trait, and interferes with functioning.
Bipolar Disorder NOS (Not Otherwise Specified)
This is a catchall category, diagnosed when the disorder does not fall within a specific subtype. Bipolar NOS can still significantly impair and adversely affect the quality of life of the patient.
The Bipolar II categories and I have specifiers that indicate the presentation and course of the disorder. For example, the “with full interepisode recovery” specifier applies if there was full remission between the two most recent episodes.
Most people who meet criteria for Bipolar Disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months. Rapid cycling, however, is a course specifier that is applied to any of the above subtypes. It is defined as having four or more episodes per year and is found in a significant fraction of individuals with BD. The definition of rapid cycling most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic, or mixed episodes are required to have occurred.
Several other mental disorders may involve similar symptoms to Bipolar Disorder. These include Schizophrenia, Schizoaffective Disorder, drug intoxication, brief drug-induced psychosis, Schizophreniform Disorder, and Borderline Personality Disorder. Both BPD and Bipolar Disorder can involve what are referred to as “mood swings.”
In Bipolar Disorder, the term refers to the cyclic episodes of elevated and depressed mood that generally last weeks or months. A Bipolar depression is generally more pervasive with sleep, appetite disturbance, and nonreactive mood, whereas the mood in dysthymia of Borderline Personality remains markedly reactive and sleep disturbance not acute. Some hold that Borderline Personality Disorder represents a sub threshold form of mood disorder, while others maintain the distinctness, though noting they often coexist.
There are a number of pharmacological and psychotherapeutic techniques used to treat Bipolar Disorder. Individuals may use self-help and pursue recovery. Hospitalization may be required, especially with the manic episodes present in Bipolar I. This can be voluntary or (if mental health legislation allows and varying state-to-state regulations in the USA) involuntary (called civil or involuntary commitment).
Long-term inpatient stays are now less common due to deinstitutionalization, although these can still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups, and intensive outpatient programs. These are referred to as partial-inpatient programs.
Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and practicing the factors that lead to maintenance of remission.
Cognitive Behavioral Therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while Interpersonal and Social Rhythm Therapy and Cognitive Behavioral Therapy appear the most effective in regard to residual depressive symptoms.
Most studies have been based only on Bipolar I, however, and treatment during the acute phase can be a particular challenge. Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.
Sodium valproate is a common mood stabilizer. The mainstay of treatment is a mood stabilizer such as lithium carbonate or lamotrigine. Lamotrigine has been found to be best for preventing depressions, while lithium is the only drug proven to reduce suicide in people with Bipolar Disorder.
These two drugs comprise several unrelated compounds that have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and “gold standard” mood stabilizer is lithium, while almost as widely used is sodium valproate, also used as an anticonvulsant.
Other anticonvulsants used in BD include carbamazepine, reportedly more effective in rapid cycling BD, and lamotrigine, which is the first anticonvulsant shown to be of benefit in Bipolar depression. Depending on the severity of the case, anticonvulsants may be used in combination with lithium-based products or on their own.
Atypical antipsychotics have been found to be effective in managing mania associated with Bipolar Disorder. Antidepressants have not been found to be of any benefit over that found with mood stabilizers. Omega 3 fatty acids, in addition to normal pharmacological treatment, may have beneficial effects on depressive symptoms, although studies have been scarce and of variable quality. The effectiveness of topiramate is unknown.
For many individuals with Bipolar Disorder, a good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because BD can have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar Disorder can be a severely disabling medical condition. However, many individuals with BD can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with BD may have periods of normal or near normal functioning between episodes.
Prognosis depends on many factors such as the right medicines and dosage, comprehensive knowledge of the disease and its effects; a positive relationship with a competent medical doctor and therapist; and good physical health, which includes exercise, nutrition, and a regulated stress level. There are other factors that lead to a good prognosis, such as being very aware of small changes in a person’s energy, mood, sleep, and eating behaviors.
A recent 20-year prospective study on Bipolar I and II found that functioning varied over time along a spectrum from good to fair to poor. During periods of major depression or mania (in BP I), functioning was on average poor, with depression being more persistently associated with disability than mania.
Functioning between episodes was on average good — more or less normal. Sub threshold symptoms were generally still substantially impairing, however, except for hypomania (below or above threshold), which was associated with improved functioning.
Another study confirmed the seriousness of the disorder as “the standardized all-cause mortality ratio among patients with BD is increased approximately two-fold.” Bipolar Disorder is currently regarded “as possibly the most costly category of mental disorders in the United States.” Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes.
Recovery and recurrence
A naturalistic study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndrome recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years.
72% percent achieved symptomatic recovery (no symptoms at all) and 43% percent achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndrome recovery, and 19% switched phases without recovery.
People with BD, those related to mania, can reliably identify symptoms preceding a relapse specially. There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results.
Bipolar Disorder can cause suicidal ideation that leads to suicidal attempts. 1 out of 3 people with BD report past attempts of suicide or completed it, and the annual average suicide rate is 0.4%, which is 10 to 20 times that of the general population. The standardized mortality ratio from suicide in BD is between 18 and 25 years of age.
The manic phase may last from days to months and can include the following symptoms:
Agitation or irritation
Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
Little need for sleep
Noticeably elevated mood
Lack of self-control
Over-involvement in activities
Poor temper control
Binge eating, drinking, and/or drug use
Tendency to be easily distracted
(These symptoms of mania are seen with Bipolar Disorder I. In people with Bipolar Disorder II, hypomanic episodes involve similar symptoms that are less intense).
The depressed phase of both types of Bipolar Disorder includes the following symptoms:
Daily low mood
Difficulty concentrating, remembering, or making decisions
Loss of appetite and weight loss
Overeating and weight gain
Fatigue or listlessness
Feelings of worthlessness, hopelessness, and/or guilt
Loss of self-esteem
Persistent thoughts of death
Inability to sleep
Withdrawal from activities that were once enjoyed
Withdrawal from friends
(There is a high risk of suicide with Bipolar Disorder. While in a phase, patients may abuse either alcohol or other substances, which can make the symptoms worse. Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state).
Signs and tests
A diagnosis of BD involves consideration of many factors. The health care provider may do some or all of the following:
Ask about your family medical history, particularly whether anyone has or had Bipolar Disorder
Ask about your recent mood swings and for how long you’ve experienced them
Observe your behavior and mood
Perform a thorough examination to identify or rule out physical causes for the symptoms
Request laboratory tests to check for thyroid problems or drug levels
Speak with your family members to discuss their observations about your behavior
Take a medical history, including any medical problems you have and any medications you take
(Note: Use of recreational drugs may be responsible for some symptoms, though this does not rule out BD. Drug abuse may itself be a symptom of Bipolar Disorder).
Spells of depression or mania return in most patients, in spite of treatment. The major goals of treatment are to:
Avoid cycling from one phase to another
Avoid the need for a hospital stay
Help the patient function as best as possible between episodes
Prevent self-destructive behavior, including suicide
Reduce the severity and frequency of episodes
The doctor will first try to determine what may have triggered the mood episode, and identify any medical or emotional problems that might interfere with or complicate treatment.
Drugs called mood stabilizers are considered the first-line treatment. The following are commonly used mood stabilizers:
Valproate (valproic acid)
Other drugs used to treat Bipolar Disorder include:
Antipsychotic drugs and anti-anxiety drugs (benzodiazepines), which can be used to stabilize mood.
Antidepressant medications can be added to mood-stabilizing drugs to treat depression. People with Bipolar Disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, an antidepressant is only used in people who are also taking a mood stabilizer.
Electroconvulsive Therapy (ECT) may be used to treat the manic or depressive phase of BD that does not respond to medication. ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia. ECT is the most effective treatment for depression that is not relieved with medications.
Transcranial Magnetic Stimulation (TMS) uses high frequency magnetic pulses that target affected areas of the brain. It is most often used as a second-line treatment after ECT.
Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stabilized and their behaviors are under control.
Doctors are still trying to decide the best way to treat Bipolar Disorder in children and adolescents. Parents should consider the potential risks and benefits of treatment for their children.
Support Programs and Therapies
Family treatments that combine support and education about BD (psycho education) appear to help families cope and reduce the odds of symptoms returning. Programs that emphasize outreach and community support services can help people who lack family and social support.
Important skills include:
Coping with symptoms that are present even while taking medications
Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
Learning to take medications correctly and how to manage side effects
Learning to watch for early signs of a relapse, and knowing how to react when they occur
Family members and caregivers are very important in the treatment of Bipolar Disorder. They can help patients seek out proper support services, and help make sure the patient follows medication therapy. Getting enough sleep is extremely important in BD, because a lack of sleep can trigger a manic episode. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for BD patients and their loved ones.
A patient with Bipolar Disorder cannot always reliably tell the doctor about the state of the illness. Patients often have difficulty recognizing their own manic symptoms. Mood variations in BD are not predictable, so it is sometimes difficult to tell whether a patient is responding to treatment or naturally emerging from a Bipolar phase. Treatment strategies for children and the elderly have not been well studied, and have not been clearly defined.
Mood-stabilizing medication can help control the symptoms of Bipolar Disorder. However, patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.
Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.
Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with BD require immediate emergency attention.
Stopping or improperly taking medication can cause your symptoms to come back, and lead to the following complications:
Alcohol and/or drug abuse as a strategy to “self-medicate”
Personal relationships, work, and finances suffer
Suicidal thoughts and behaviors
This illness is challenging to treat. Patients and their friends and family must be aware of the risks of neglecting to treat Bipolar Disorder.
Call your health provider or an emergency number right way if:
You are having thoughts of death or suicide
You are experiencing severe symptoms of depression or mania
You have been diagnosed with Bipolar Disorder and your symptoms have returned or you are having any new symptoms
When broadly defined, 4% of people experience Bipolar at some point in their life. The lifetime prevalence of BD I, which includes at least a lifetime manic episode, has generally been estimated at 2%. It is equally prevalent in men and women and found across all cultures and ethnic groups.
Lay interviewers who follow fully structured/fixed interview schemes typically carry out prevalence studies of Bipolar Disorder; responses to single items from such interviews may suffer limited validity. In addition, diagnosis and prevalence rates are dependent on whether a categorical or spectrum approach is used.
Concerns have arisen about the potential for both under diagnosis and over diagnosis. Late adolescence and early adulthood are peak years for the onset of Bipolar Disorder. One study also found that in 10% of Bipolar cases, the onset of mania had happened after the patient had turned 50.
Variations in moods and energy levels have been observed as part of the human experience since time immemorial. The words “melancholia” (an old word for depression) and “mania” have their etymologies in Ancient Greek.
The basis of the current conceptualization of Manic Depressive Illness can be traced back to the 1850s; on January 31, 1854, Jules Baillarger described to the French Imperial Academy of Medicine a biphasic mental illness causing recurrent oscillations between mania and depression, which he termed folie à double forme (‘dual-form insanity’). Two weeks later, on February 14, 1854, Jean-Pierre Falret presented a description to the Academy on what was essentially the same disorder, and designated folie circulaire (‘circular insanity’) by him.
The two bitterly disputed as to who had been the first to conceptualize the condition. These concepts were developed by the German psychiatrist Emil Kraepelin (1856–1926), who, using Kahlbaum’s concept of cyclothymia, categorized and studied the natural course of untreated Bipolar patients. He coined the term Manic Depressive Psychosis, after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally.
The term Manic Depressive Reaction appeared in the first American Psychiatric Association Diagnostic Manual in 1952, influenced by the legacy of Adolf Meyer, who had introduced the paradigm illness as a reaction of biogenetic factors to psychological and social influences. German psychiatrist Karl Leonhard first proposed sub classification of Bipolar Disorder in 1957; he was also the first to introduce the terms Bipolar (for those with mania) and Unipolar (for those with depressive episodes only).
Source: Medical Marijuana