Bipolar Disorder

What Are Bipolar Disorders?

Bipolar disorders are brain disorders that cause changes in a person's mood, energy, and ability to function. People with bipolar disorder experience intense emotional states that typically occur during distinct periods of days to weeks, called mood episodes. These mood episodes are categorized as manic/hypomanic (abnormally happy or irritable mood) or depressive (sad mood). People with bipolar disorder generally have periods of neutral mood as well. When treated, people with bipolar disorder can lead full and productive lives.

People without bipolar disorder experience mood fluctuations as well. However, these mood changes typically last hours rather than days. Also, these changes are not usually accompanied by the extreme degree of behaviour change or difficulty with daily routines and social interactions that people with bipolar disorder demonstrate during mood episodes. Bipolar disorder can disrupt a person's relationships with loved ones and cause difficulty in working or going to school.

Bipolar disorder is a category that includes three different diagnoses: bipolar I, bipolar II, and cyclothymic disorder.

Bipolar disorder commonly runs in families: 80 to 90 percent of individuals with bipolar disorder have a relative with bipolar disorder or depression. Environmental factors such as stress, sleep disruption, and drugs and alcohol may trigger mood episodes in vulnerable people. Though the specific causes of bipolar disorder within the brain are unclear, an imbalance of brain chemicals is believed to lead to dysregulated brain activity. The average age of onset is 25 years old.

People with bipolar I disorder frequently have other mental disorders, such as anxiety disorders, substance use disorders, and attention-deficit/hyperactivity disorder (ADHD). The risk of suicide is significantly higher among people with bipolar I disorder than among the general population.

Bipolar I Disorder

Bipolar I disorder is diagnosed when a person experiences a manic episode. During a manic episode, people with bipolar I disorder experience an extreme increase in energy and may feel on top of the world or uncomfortably irritable in mood. Some people with bipolar I disorder also experience depressive or hypomanic episodes, and most people with bipolar I disorder also have periods of neutral mood.

Symptoms of Bipolar I Disorder

Manic Episode

A manic episode is at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behaviour:

  • Decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual
  • Increased or faster speech
  • Uncontrollable racing thoughts or quickly changing ideas or topics when speaking
  • Distractibility
  • Increased activity (e.g., restlessness, working on several projects at once)
  • Increased risky behaviour (e.g., reckless driving, spending sprees)

These behaviours must represent a change from the person's usual behaviour and be clear to friends and family. Symptoms must be severe enough to cause dysfunction in work, family, or social activities and responsibilities. Symptoms of a manic episode commonly require a person to receive hospital care to stay safe.

Some people experiencing manic episodes also experience disorganized thinking, false beliefs, and hallucinations, known as psychotic features.

Hypomanic Episode

A hypomanic episode is characterized by less severe manic symptoms that need to last only four days in a row rather than a week. Hypomanic symptoms do not lead to the major problems in daily functioning that manic symptoms commonly cause.

Major Depressive Episode

A major depressive episode is at least two weeks in which a person has at least five of the following symptoms (including at least one of the first two symptoms):

  • Intense sadness or despair
  • Loss of interest in activities the person once enjoyed
  • Feelings of worthlessness or guilt
  • Fatigue
  • Increased or decreased sleep
  • Increased or decreased appetite
  • Restlessness (e.g., pacing) or slowed speech or movement
  • Difficulty concentrating
  • Frequent thoughts of death or suicide
Treatment and Management

Bipolar disorder symptoms commonly improve with treatment. Medication is the cornerstone of bipolar disorder treatment, though talk therapy (psychotherapy) can help many patients learn about their illness and adhere to medications, preventing future mood episodes.

Medications known as "mood stabilizers" (e.g., lithium) are the most commonly prescribed type of medication for bipolar disorder. These medications are believed to correct imbalanced brain signalling. Because bipolar disorder is a chronic illness in which mood episodes typically recur, ongoing preventive treatment is recommended. Bipolar disorder treatment is individualized; people with bipolar disorder may need to try different medications before finding what works best for them.

In some cases, when medication and psychotherapy have not helped, an effective treatment known as electroconvulsive therapy (ECT) may be used. ECT involves several rounds of a brief electrical current applied to the scalp while the patient is under anaesthesia, leading to a short, controlled seizure. ECT-induced seizures are believed to remodel brain signalling pathways.

Since bipolar disorder can cause serious disruptions in a person's daily life and create a stressful family situation, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies for coping, participating actively in the treatment, and obtaining support.

Bipolar II Disorder

A diagnosis of bipolar II disorder requires someone to have at least one major depressive episode and at least one hypomanic episode (see above). People return to their usual functioning between episodes. People with bipolar II disorder often first seek treatment as a result of their first depressive episode since hypomanic episodes often feel pleasurable and can even increase performance at work or school.

People with bipolar II disorder frequently have other mental illnesses, such as an anxiety disorder or substance use disorder, the latter of which can exacerbate symptoms of depression or hypomania.

Treatment

Treatments for bipolar II are similar to those for bipolar I: medication and psychotherapy. The most commonly used medications are mood stabilizers and antidepressants, depending on the specific symptoms. If depressive symptoms are severe and medication is not effective, ECT (see above) may be used. Each person's treatment is individualized.

Cyclothymic Disorder

Cyclothymic disorder is a milder form of bipolar disorder involving many "mood swings," with hypomania and depressive symptoms that occur frequently. People with cyclothymia experience emotional ups and downs but with less severe symptoms than bipolar I or II disorder.

Cyclothymic disorder symptoms include the following:

  • For at least two years, many periods of hypomanic and depressive symptoms, but the symptoms do not meet the criteria for hypomanic or depressive episodes.
  • During the two years, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months.
Treatment

Treatment for cyclothymic disorder can involve medication and talk therapy. For many people, talk therapy can help with the stresses of mood swings. Keeping a mood journal can be an effective way to observe patterns in mood fluctuation. People with cyclothymia may start and stop treatment over time.

FAQs

It depends. Mood shift frequency varies from person to person. A small number of patients may have many episodes within one day, shifting from mania (an episode where a person is very high-spirited or irritable) to depression. This has been described as “ultra-rapid cycling.”

Not necessarily. Studies have shown that approximately 10 per cent of patients have a single episode only. However, the majority of patients have more than one. The number of episodes within a patient’s lifetime varies. Some individuals may have only two or three within their lifetime, while others may have the same number within a single year. The frequency of episodes depends on many factors, including the natural course of the condition as well as on appropriate treatment. Not taking medication or taking it incorrectly are frequent causes of episode recurrence.

Although it is possible that during the natural course of the illness, individual patients may get well without any medication, the challenge is that it is impossible to identify or determine beforehand who those fortunate patients are. Although some patients don’t get well or have partial response to the best available treatments, on average—and for the vast majority of patients—the benefits of medications outweigh the risks.

The term “mixed episode” was changed to “mixed features” in the last edition of the Diagnostic and Statistical Manual (DSM-5-TR) published by the American Psychiatric Association in 2022. The new term may apply to either episodes of mania with additional symptoms of depression or, the opposite, episodes of depression with additional symptoms of mania. The overall idea is that the presence of both symptoms of mania and depression can exist at the same time. Symptoms of mania include elated or irritable mood, decreased need to sleep, or racing thoughts. Symptoms of depression can include depressed mood, impaired sleep, and feelings of hopelessness or worthlessness.

Outcomes are always better when there is a strong family support network. Think of bipolar disorder as any other severe medical condition. However, also note that in many severe psychiatric conditions, patients may not be aware that they are ill. They may minimize the severity of their condition. The result of these factors may be that patients will not follow through on their treatment. In very severe cases, there may be instances of a lack of behavioural control where family members may not be able to look after their loved ones. In those cases, assistance from providers or crisis services (call the national 988 Suicide and Crisis Lifeline) may be necessary.

The main difference between bipolar disorder and major clinical depression is the presence of manic episodes. This is why depression alone is not enough to diagnose an individual with bipolar. However, one manic episode (meeting DMS-IV criteria) is sufficient to make a bipolar diagnosis.

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