Bipolar Disorder

Overview

Bipolar disorder involves periods of excitability (mania) alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.

Statistics

About 5.7 million Americans, or 2.6% of the American population over the age of 18, have bipolar disorder.

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Symptoms

The manic phase may last from days to months and can include the following symptoms:
  • Agitation or irritation
  • Elevated mood
    • Hyperactivity
    • Increased energy
    • Lack of self-control
    • Racing thoughts
  • Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
  • Little need for sleep
  • Over-involvement in activities
  • Poor temper control
  • Reckless behavior
    • Binge eating, drinking, and/or drug use
    • Impaired judgment
    • Sexual promiscuity
    • Spending sprees
  • 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 involves very serious symptoms of major depression:
  • Difficulty concentrating, remembering, or making decisions
  • Eating disturbances
    • 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 sadness
  • Persistent thoughts of death
  • Sleep disturbances
    • Excessive sleepiness
    • Inability to sleep
  • Suicidal thoughts
  • Withdrawal from activities that were once enjoyed
  • Withdrawal from friends
There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can worsen the symptoms.

Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state.

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How does bipolar disorder affect someone over time?

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:
  1. Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.
  2. Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.
  3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
  4. Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.
Some people may be diagnosed with rapid-cycling bipolar disorder. This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.  Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age. One study found that people with rapid cycling had their first episode about four years earlier, during mid to late teen years, than people without rapid cycling bipolar disorder.  Rapid cycling affects more women than men.

Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes than when the illness first appeared.  Also, delays in getting the correct diagnosis and treatment make a person more likely to experience personal, social, and work-related problems.

Proper diagnosis and treatment helps people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

Treatment

For the manic phase of bipolar disorder, antipsychotic medications, lithium, and mood stabilizers are typically used. For the depressive phase, antidepressants are sometimes used, with or without the manic phase treatment.

There is very little long-term evidence suggesting that any medication has great success in the maintenance phase. However, in studies that followed patients for 2 years, lithium and some antipsychotics were found to be moderately successful.

Antipsychotic drugs can help a person who has lost touch with reality. Anti-anxiety drugs, such as benzodiazepines, may also help. The patient may need to stay in a hospital until his or her mood has stabilized and symptoms are under control.

Electroconvulsive therapy (ECT) may be used to treat bipolar disorder. 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. Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications.

Getting enough sleep helps keep a stable mood in some patients. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones.

Risk factors for bipolar disorder

Scientists are learning about the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.


Genetics

Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the "building blocks" of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, most children with a family history of bipolar disorder will not develop the illness.

Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:
  • Missed work because of their illness
  • Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
  • Been treated or hospitalized for bipolar disorder.
The researchers also identified certain traits that appeared to run in families, including:
  • History of psychiatric hospitalization
  • Co-occurring obsessive-compulsive disorder (OCD)
  • Age at first manic episode
  • Number and frequency of manic episodes.
Scientists continue to study these traits, which may help them find the genes that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder.  Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain's structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia.  This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Learning more about these differences, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Someday scientists may be able to predict which types of treatment will work most effectively. They may even find ways to prevent bipolar disorder.

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Tests & diagnosis

A diagnosis of bipolar disorder 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 bipolar affective disorder. Drug abuse may itself be a symptom of bipolar disorder.

Prognosis

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 bipolar affective disorder require immediate emergency attention.

Complications

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.

When to contact a doctor

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
If you have suicidal thoughts

Suicidal thoughts and behavior are common among people with bipolar disorder. If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:
  • Contact a family member or friend.
  • Seek help from your doctor, a mental health provider or other health care professional.
  • Call a suicide hot line number — in the United States, you can reach the toll-free, 24-hour hot line of the National Suicide Prevention Lifeline at 800-273-8255 to talk to a trained counselor.
  • Contact a minister, spiritual leader or someone in your faith community.

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