Introduction

Everyone experiences changes in mood and most people can probably think of a time when their mood went from happy or “up” to sad and “down.” It is common to have a range of moods that last for a brief time and usually pass on their own without impairing a person’s ability to maintain the activities of everyday life or cause symptoms that put a significant strain on relationships. Some people tend not to exhibit their emotions – others seem to be more emotionally expressive, exhibiting more of their ups and the downs. A person with more obvious ups and downs, but otherwise no other impairments in life, probably does not have bipolar disorder – this is more likely to be a normal variation of typical mood swings.

Bipolar disorder (also known as manic-depressive illness) is an illness characterized by distinct mood changes that are extremely distressing, can be very disruptive and are usually a marked change from the normal variations in mood that most people experience. A person with bipolar disorder has distinct episodes of mania (feeling excessively “up”) and episodes of major depression (feeling very “down”) that last longer and are clearly a change from their typical range of emotions. Mania and major depression are much more disruptive and distressing than the typical “ups” and “downs” of daily life. Bipolar disorder is a serious illness that causes extreme and enduring changes in mood, behavior, thoughts, energy level, activity and judgment.

Impact
Given the marked disruptions and personal distress that mood episodes can cause to relationships, school and participation in daily life, it is not uncommon for people struggling with bipolar disorder to have instability in nearly all areas of their lives. The impact of recurring, distressing and life altering mood disturbances throughout the teen and early adult years can significantly impact success in school, relationships with peers and progression toward independence as a young adult.

Prevalence

Bipolar disorder affects men and women with equal frequency – 2.6% of adults in the U.S. meet criteria for bipolar disorder in a given year. The prevalence of bipolar in teens approaches that of adults, 2.2% meet criteria in a given year. Bipolar disorder often develops in a person’s late teens or early adult years with at least half of all cases starting before age 25.

Nearly 80% of people with bipolar disorder contemplate suicide at some time in the course of their illness, and the lifetime risk of suicide in a person struggling with bipolar disorder is estimated to be about 15 times greater than the general population. If a person who is coping with bipolar disorder talks about suicide or thoughts of harming themselves, it is extremely important to seek help immediately.

Bipolar disorder is a serious and chronic illness; however, treatment can help a person manage symptoms, avoid impairment in their daily lives and minimize disruption of their life’s course.

Signs and Symptoms

The following are many of the signs and symptoms that will be present during a manic episode:

• A constantly elevated, “up,” extremely hyper, irritable mood
• Extremely talkative, much more than normal – not to be confused with being chatty – a manic person appears to be talking as though their words are under pressure, they switch topics quickly and they can’t be interrupted
• Very distracted , poor concentration
• Self-esteem/self-confidence is unrealistically high (inflated) – they can think they can achieve or have achieved much more than is actually true; feel like they have superhuman abilities and achievements
• Increased goal-directed activity (such as coming up with big plans that they can’t stop thinking about) or physically agitated and moving around without purpose
• Increased energy, restlessness, being “revved up”
• Decreased need for sleep – getting only 3-4 hours (or less) sleep per night for days and days without feeling tired
• Increase in risk-taking behavior – reckless driving, sexual promiscuity, spending money they don’t have (spending spree), abusing drugs
• Thoughts are poorly organized or they feel like their thoughts are “racing” in their head
• Poor judgement – for example, unprotected sexual intercourse, gambling or spending much more money than they actually have
• Psychosis – thoughts or perceptions that are not based in reality such as seeing things that are not there or hearing voices

When a person has bipolar depression, most of the following signs and symptoms will be present most of the day, nearly every day:

• Low, sad mood
• Low self esteem
• Poor concentration and inability to make decisions
• Fatigue and loss of energy
• Weight loss, loss of appetite or overeating
• Loss of interest in most or all activities of daily living
• Difficulty sleeping or sleeping too much
• Thoughts of death or suicide

Definitions

Mania or manic episode
Mania (or a manic episode) is a distinct period of persistent and abnormally elevated, irritable, driven mood and persistent and abnormally increased goal-directed energy that lasts most of the day, almost every day for at least one week. In addition, while experiencing the episode of abnormally elevated mood and abnormally increased energy, a person would also show the many distressing symptoms which are a marked changed from how they usually feel or function. In all cases, when a person is struggling with mania their ability to function in their daily lives (school, home, friends, work, outside interests, self-care) can be severely impaired.

Hypomania
Hypomania is a mood state that is elevated above normal, but not as extreme as mania. In hypomania, a person may have a markedly elevated mood, not need much sleep and may be very restless with endless energy, but the mood change does not cause significant impairment. These symptoms typically last for at least 4 days. During a hypomanic episode, a person may not feel that anything is wrong — but family and friends may recognize the mood change as unusual and a shift from typical functioning.

Major Depressive Episode
A Major Depressive Episode in bipolar disorder is when a person experiences a distinct period of low mood (depression) or loss of interest in what usually gives them pleasure and many associated symptoms nearly all day, every day lasting at least 2 weeks. The symptoms of bipolar depression are a significant change from baseline functioning and cause significant distress and impairment in many parts of a person’s daily life including school, friendships, relationships with family and self-care.

Mixed state/mixed features
In some cases of bipolar disorder a person meets the diagnostic criteria for major depression but shows a mixture of symptoms that are associated with mania or hypomania and depression at the same time.

Types

Bipolar I Disorder
Defined by manic episodes that last at least seven days or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, lasting at least 2 weeks. Sometimes, the episodes of depression can be a “mixed state” – this is when a person shows a mix of symptoms that can be seen with mania or depression.

Bipolar II Disorder
Defined by a pattern of depressive episodes and hypomanic episodes, but there are no full-blown manic or mixed episodes.

Cyclothymic Disorder
When a person has numerous episodes of hypomanic symptoms and numerous episodes of depressive symptoms that last for at least 2 years. The difference between these mood swings and those that are seen in bipolar disorder (I or II) is that the symptoms in cyclothymic disorder do not meet the full criteria for hypomania or for major depressive episode.

Causes

The specific biological causes of bipolar disorder are not well understood – though there is clear evidence that the illness tends to run in families. Environmental factors such as stress, sleep disruption (for example, travel involving changing time zones can precipitate manic episodes in some people with bipolar disorder), some medications and drug or alcohol use may trigger the onset or cycling of mood episodes. A stressful event such as a death in the family, an illness, a romantic break-up or other major life event can trigger the first bipolar episode.

What else could it be?
Several other conditions can look like Bipolar Disorder:

• Medical conditions (e.g., epilepsy or thyroid dysfunction)
• Psychiatric illnesses that may account for the symptoms (e.g., major depressive disorder, schizophrenia or a severe personality disorder).
• Additionally, there are a number of conditions that often co-occur with bipolar disorder, including:
  • Anxiety disorders
  • Post-traumatic stress disorder (PTSD)
  • Attention-deficit hyperactivity disorder (ADHD)
  • Substance abuse
  • Migraines

Treatment

Bipolar disorder is treated and managed in several ways – most often and most effectively with a combination of medication and therapy.

Medication
Medications play an important role in successfully managing bipolar disorder – they can reduce the number and severity of manic episodes and may prevent the occurrence of depression. Bipolar disorder can be a complex illness to diagnose, a difficult disorder to treat and it is possible that a person struggling with bipolar disorder might remain on medication for years. Therefore, it is very important to have a comprehensive psychiatric and physical evaluation before starting any medication and to be monitored regularly by a professional who is prescribing the medication.

In general, the types of medication used to treat bipolar disorder are:

• Mood stabilizers
  • While we are not completely certain how these medicines work, they can alleviate depression, mania and stabilize mood. They can be taken alone or with other medications for treatment of bipolar disorder. People respond differently to specific mood stabilizers so it may take some “trial and error” to find out which works best. Other factors, such as a person’s medical condition, might influence which mood stabilizer can be prescribed. A response to mood stabilizers can take weeks; relapse of symptoms can occur if a person discontinues the medications without medical supervision. Examples of mood stabilizers are: Lithium, Depakote (divalproex), Tegretol (carbamazepine), Trileptal (oxcarbazepine), Lamictal (lamotrigine).
• Atypical antipsychotics
  • Antipsychotic medications alleviate depression and stabilize mood. They alter the chemical receptors for dopamine and serotonin in the brain – each antipsychotic has a unique mode of action so their effectiveness will vary from person to person. Atypical antipsychotics can be taken alone or with other medications used for bipolar illness. Like mood stabilizers, factors such as a person’s medical conditions need to be considered before a trial of any antipsychotic medication. Though this type of medication works more quickly than mood stabilizers, the side effects are more serious and distressing (such as major weight gain, diabetes, heart problems, feeling “out of it” and confusion) and can make it very difficult to take them long term. Examples of atypical antipsychotics used for bipolar disorder are: Abilify (aripiprazole), Zyprexa (olanzapine), Seroquel (quetiapine), Risperdal (risperidone), Geodon (ziprasidone) and Latuda (lurasidone).
• Antidepressants
  • When used in combination with a mood stabilizer or atypical antipsychotic medication, anti-depressant drugs can be helpful in the treatment of bipolar depression. Before taking this type of medication, it is important for a person to provide a detailed family and personal history of bipolar illness or manic symptoms because in rare cases, these medications can cause mania or rapid cycling (when the episodes of mania and depression repeat frequently). The types of anti-depressants most commonly used are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

Psychotherapy
In conjunction with medication, therapy can be a helpful part of treatment for bipolar disorder and can provide support, education and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

• Cognitive behavioral therapy (CBT)
  • CBT can help people with bipolar disorder learn to change harmful or negative thought patterns and behaviors. In this type of therapy, a person actively participates in developing skills to recognize distressing thought and behavior patterns; CBT interventions guide a person to learn and master concrete and effective ways to either change these negative thought and behavior patterns or learn to cope in more effective, self-preserving ways.
• Family-focused therapy
  • Family therapy can enhance family coping strategies and help family members recognize and respond to new manic or depressive episodes early. This treatment also improves communication and problem solving within the family and enhances understanding of the ways bipolar illness can impact the entire family.
• Interpersonal and social rhythm therapy (IPSRT)
  • IPSRT can be an effective adjunct therapy (in addition to medication) that helps people with bipolar disorder manage their daily routines (such school schedule, meals), avoid sleep deprivation, recognize situations that might disrupt their regular schedule and stay on their medication. Research has shown that keeping regular routines and stable relationships has a protective effect on recurrent mood disorders.

For more information

• National Alliance on Mental Illness (NAMI) – Bipolar Disorder
• National Institute on Mental Health (NIMH) – Bipolar Disorder
• Mayo Clinic – Bipolar Disorder