What Is Bipolar Disorder?
Bipolar disorder (BD) is a type of mood disorder. Bipolar disorder was called manic-depressive disorder in the past. It is a psychiatric illness that potentially may cause major disruptions in lifestyle and health.
- Everyone has occasional highs and lows in their moods. But people with bipolar disorder have extreme mood swings. They can go from feeling very sad, despairing, helpless, worthless, and hopeless (depression) to feeling as if they are on top of the world, hyperactive, creative, irritable or euphoric, and grandiose (mania). This disease is called bipolar disorder because the mood of a person with bipolar disorder can alternate between two completely opposite poles, euphoric happiness, and extreme sadness.
- Symptoms of both mania and depression sometimes occur together in what is called "mixed state."
- The extremes of mood usually occur in cycles. In between these mood swings, people with bipolar disorder are able to function normally, hold a job, and have a normal family life. The episodes of mood swings tend to become closer together with age.
- When a person is in the grip of this disease, chaos can occur. Bipolar disorder can cause major disruption of family and finances, loss of job, and marital problems.
- Severe depression can be life-threatening. It may be associated with thoughts of suicide, actual acts of suicide, and even acts of homicide in some cases.
- Extreme mania can lead to aggressive behavior, potentially dangerous risk-taking behaviors, and homicidal acts.
- A number of people with bipolar disorder may turn to drugs and alcohol to "self-treat" their emotional disorder, resulting in substance abuse and dependence.
Most people start showing signs of bipolar disorder in their late teens (the average age of onset is 21 years). These signs may be dismissed as "growing pains" or normal teenage behavior. On occasion, some people have their first symptoms during childhood, but the condition can often be misdiagnosed at this age and improperly labeled as a behavioral problem. Bipolar disorder may not be properly diagnosed until the sufferer is 25-40 years of age, at which time the pattern of symptoms may become clearer.
Bipolar disorder occurs in both men and women. About 5.7 million people in the United States have the disorder. There is no racial group that is more afflicted by this disease.
Because of the extreme and risky behavior that goes with bipolar disorder, it is very important that the disorder be identified. With proper and early diagnosis, this mental condition can be treated. Bipolar disorder is a long-term illness that will require proper management for the duration of a person's life.
What Causes Bipolar Disorder?
The exact cause of bipolar disorder has not been discovered, but many experts believe that multiple factors are involved which act together to cause the disease. Bipolar disorder may result from a chemical imbalance within the brain. The brain's functions are controlled by chemicals called neurotransmitters. An imbalance in the levels of one of these neurotransmitters, such as norepinephrine, may cause bipolar disorder. When levels of this chemical are too high, mania occurs. When levels of norepinephrine drop below normal levels, a person may experience depression. Levels of other neurotransmitters, such as serotonin and dopamine, are also believed to play a role.
There is a significant genetic component to bipolar disorder. If a family member has bipolar disorder, other family members may be at risk. The identical twin of a person with bipolar disorder is at the highest risk for developing the condition. However, stress of some kind often is needed to trigger the onset of the disease. The disease does not occur just because of one gene, and the cause of the disease is likely a combination of multiple genetic and environmental factors.
Sometimes a period of emotional stress, drug use, an illness, or another event seems to trigger the onset of the disease. Stresses can also trigger a manic or depressive episode in people who are known to have the condition.
Not everyone with severe mood swings or a change in personality has bipolar disorder. Mood swings can be caused by other medical conditions that need to be diagnosed and treated properly. Medical diseases and medications that may have symptoms similar to bipolar disorder include the following:
Other psychiatric conditions and drug abuse may also mimic bipolar disorder:
What Are the Symptoms and Signs of Bipolar Disorder?
Mania and depression are the opposing phases in bipolar disorder.
- Mania (the "high" of bipolar disorder): A person in the manic phase may feel indestructible, full of energy, and ready for anything. Other times, that person may be irritable and ready to argue with anyone who tries to get in the way.
- Unrealistic plans, spending sprees, an increase in sexual affairs, or other reckless behavior, such as wild driving, also may occur.
- Less sleep (and sometimes less food) than usual is needed.
- The person with mania can stay up all night but may find that not much was accomplished because he or she was easily distracted.
- The person in a manic phase may talk very quickly and jump from subject to subject. They often exhibit pressured speech during mania: The person speaks very fast, as if his or her mouth can't keep up with the rapid thoughts. The person may be unable to respond to social cues to stop talking.
- Increased activity and gestures (pacing, tapping feet) may be seen.
- Poor temper control and irritability can be especially upsetting to friends and loved ones.
- Self-esteem may be inflated. A person may have exaggerated self-confidence.
- Decisions regarding business and finances are often made hurriedly and without careful consideration; this poor judgment may be the result of inappropriate optimism.
- Clothing choices may also change, and the person in a manic phase may start wearing brighter, more flamboyant clothes.
- They are grandiose and may have delusions (false ideas) of grandeur (greatness).
- In severe cases, delusions (false, fixed beliefs) and hallucinations (seeing or hearing things that aren't real) may be seen.
- Hypomania refers to a milder form of mania. People affected by this mood disorder have many of the same features as those with mania, to lesser extremes, without the negative impact on day-to-day functioning. In fact, they may seem to have a great deal of energy and can be very productive, needing less rest than others.
- These behaviors, which can be quite upsetting, usually prompt a family member to take notice and try to get the person help.
- Most people who are going through the manic phase of bipolar disorder deny that anything is wrong with them and refuse to see a medical professional.
- Depression (the "low" of bipolar disorder): Although mania is said to alternate with depression, most people have more depressive episodes than manic ones.
- Sadness and crying spells are common, as are excessive worrying and guilt.
- People who are depressed may not care enough to wash or comb their hair, change clothes, or even get out of bed in the morning.
- These people may sleep too much (hypersomnolence) or have difficulty getting to sleep (insomnia). A loss of energy may result from the change in sleep habits.
- Many of these people have no interest in food or have no appetite and lose weight. However, some eat excessively.
- People with depression have trouble thinking; they may forget to do important things such as paying bills because they feel so down and have difficulty focusing on tasks.
- They withdraw from friends, and social interactions suffer.
- Hobbies and activities that used to bring pleasure suddenly hold no interest for people who are depressed.
- Depression brings feelings of hopelessness, helplessness, pessimism, and worthlessness.
- Some people may develop chronic pain or other bodily complaints that do not actually have any physical cause.
- People who are depressed may not see a point in living anymore and may actually think about ways to kill themselves.
- Untreated bipolar disorder has a 15% risk of death by suicide.
- The risk of attempted suicide is nearly 10 times higher in patients with manic-depressive illness than in the general population.
- Some people with bipolar disorder cycle between the two extremes every few months or weeks. Other people with bipolar disorder may cycle several times within the same day. This is referred to as rapid cycling.
- Substance abuse is common in people with bipolar disorder. The use of drugs or excessive alcohol use can trigger or worsen symptoms. Alternatively, some people may use drugs and alcohol in an attempt to treat their symptoms. Other conditions that may co-occur with BD include conduct disorders, eating disorders, attention-deficit/hyperactivity disorder, thyroid disorders, migraine, and anxiety.
Types of Bipolar Disorder
Bipolar I vs. Bipolar II
- In order to receive the diagnosis of bipolar I disorder, a person must experience at least one full-blown manic episode in their lifetime.
- Individuals with bipolar II disorder experience at least one hypomanic episode, in that they have symptoms less severe than fully manic symptoms.
When Should I call the Doctor about Bipolar Disorder?
Generally, people with severe bipolar disorder symptoms will not seek medical care on their own. A family member or close friend is usually the one seeking help for the person. The person needs to be seen by a medical professional in these situations:
- When changes in personality, including extreme moodiness and episodes of rage, start to affect a person's life, ruin relationships with others, or threaten basic health, the person should be seen by a medical professional. Medical conditions such as diabetes and thyroid disorders can cause mood swings. These are relatively easy to detect and treat. Checking to see if a medical condition is responsible for the symptoms is the starting point of an evaluation of mood swings.
- When changes in sleep and appetite begin to affect health, the person needs to be evaluated. Some people may not want any help. If they fear the stigma of having a mental illness, they need to know that many other things could be responsible for the changes in their behavior. This is especially true for anyone older than 40 years of age who develops signs of bipolar disorder.
- When the mood swings have become so severe that a person cannot function at home or work
- When a person has thoughts of suicide, especially with a specific plan as to how to take his or her own life
- If the person might be a danger to self or others, he or she should be seen in a hospital emergency department.
- Suicidal patients are hospitalized until their mood can be stabilized.
- If the person refuses to go to the hospital, you may need assistance in getting him or her there. Call 911 if the situation is dangerous.
- Above all, be sure of your own safety first. A person with bipolar disorder is probably not thinking clearly when in severe mania or depression. He or she may feel that the person calling for help is a traitor.
- With a suicide attempt, call 911 so that the person can be treated in the emergency department. Don't try to take a person who has attempted suicide to the hospital by yourself.
- Homicidal thoughts, threats, or behaviors require immediate intervention. Assure your own safety and then call 911 for help.
How is Bipolar Disorder Diagnosed?
No specific blood tests or instrumental tests will tell the health care professional that a person definitely has bipolar disorder. The diagnosis is made on the basis of all the signs, symptoms and history. Psychiatric doctors use guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM) to establish the diagnosis of bipolar disorder and other psychiatric conditions.
If a person experiences at least four of the symptoms of mania and depression for a period of at least two weeks, that person may have bipolar disorder or another form of mood disorder.
- The person may have a long history of feeling depressed and then finally have a first manic episode. This clinches the diagnosis. However, any potentially treatable medical condition that could account for severe mood swings should be ruled out first.
- A complete physical examination is performed to check for enlarged glands, poor nerve function, or any other signs of a medical condition.
- A detailed interview will focus on the signs of bipolar disorder such as periods of racing thoughts, risky behavior, and inflated self-esteem followed by periods of depression.
- Certain tests may be ordered to rule out medical conditions that could cause mood swings, especially when the first manic episode occurs after the age of 40. Tests will probably be ordered to check the balance of electrolytes and sugar in the blood, hormone function, blood cell counts, and drug and alcohol levels. These tests all are blood or urine tests.
- CT scan or MRI of the head may be ordered to check for blood clots, bleeding, or tumors.
- Rarely, an EEG (electroencephalogram), a study of the electrical impulses in the brain, may be ordered if the person is thought to have a seizure disorder. Electrodes are placed all over the scalp and secured by an adhesive. The electrodes are hooked up to a machine that traces brain signals. This is seldom performed in the emergency department.
- A spinal tap (lumbar puncture) may be ordered to get a sample of spinal fluid. This will be done if signs suggest a brain infection, such as meningitis or encephalitis. Such an infection is generally only considered a possibility if the behavior change happened relatively recently or if a fever or other signs of infection are present. The laboratory will study the fluid and be able to tell if an infection is present.
Treatment is based on the results of these tests. If test results are all normal, the diagnosis is most likely a psychiatric disorder, such as bipolar disorder.
What Is the Treatment for Bipolar Disorder?
There is no cure for BD but, with proper therapy, people with this disease can lead stable and productive lives. Bipolar disorder will not get better without medical treatment.
Self-Care at Home
Self-care without medical treatment is not recommended. Self-care measures are not effective in relieving symptoms or preventing harmful behavior.
Treatment of bipolar disorder centers on (1) medications to stabilize mood swings and (2) counseling with a therapist. However, therapy is more successful with strong support from family and loved ones.
Medications sometimes do not help immediately and may need to be changed many times until the right medication or combination of medicines is found.
- While this change is happening, people with bipolar disorder need to feel that they can count on their friends and family not to give up on them and to bear with them even though their mood swings are causing grief and pain.
- Periods of stress may throw people with bipolar disorder into one of the extremes of mania or depression, and they need strong support systems to help them deal with the disease.
Those people who are a danger to themselves or others will have their medications started in the hospital and will remain there until they are able to control their emotions enough to function at home.
- Psychiatric hospitalization protects the safety of the person with bipolar disorder and loved ones.
- Medical staff can monitor the effects of medications when a person is in the hospital.
- Medications can be adjusted more quickly in the hospital than over a series of outpatient visits.
- Group therapy or one-on-one sessions with a psychiatrist also start while in the hospital.
Not all episodes are serious enough to require hospitalization. Many people can be treated as outpatients.
Bipolar Disorder Medications
A variety of medications are available by prescription. These medications are usually referred to as mood stabilizers. Other classes of medications, including anticonvulsant medications and atypical antipsychotic medications, may also be helpful in treating bipolar disorder.
- Many people start by taking lithium, which has been used for many years to treat bipolar disorder.
- Other possibilities for medical treatment are antiseizure medications that function as mood stabilizers. Antiseizure medicines that are sometimes used to treat bipolar disorder as well include
- The atypical antipsychotic medications used to treat psychosis are sometimes used to treat bipolar disorder; these medications have been shown to be effective for mood stabilization. They include:
- All medications have side effects, and each person with bipolar disorder needs close monitoring for the side effects while taking the medication.
- Antidepressant medication is sometimes taken with a mood-stabilizer medication during depressive episodes. Taking the antidepressant medication alone might trigger mania.
The choice of medications is customized for each person.
- Be sure to tell your health care professional about any other medical conditions you have.
- Tell your health care professional about all medications you take, including over-the-counter drugs and herbal preparations. These may interact with the medications used for bipolar disorder. For example, the herbal preparation known as St. John's wort may reduce the effectiveness of some medications. Also, since it is itself an antidepressant, it may trigger a manic episode in a person with BD who is not on another mood stabilizer.
- Women also should discuss any plans for pregnancy and breastfeeding with their health care professional, because a change in medication may be necessary.
Lithium: The exact way lithium works in controlling the mood swings of bipolar disorder is unknown.
- Lithium may take as long as two weeks to take full effect.
- It may have an "anti-suicide effect."
- Levels of the drug must be closely monitored with blood tests.
- Drink plenty of fluids and do not restrict intake of salt while taking lithium because dehydration can cause the level of the drug in the blood to be dangerously high.
- If you have kidney or heart problems, you may be started on another medication instead.
- Most common side effects are thirst, increased urination, diarrhea, nausea, tremors, and dizziness.
Carbamazepine (Tegretol): This medication reduces the excitability of brain cells and helps to control the symptoms of bipolar disorder.
- It is especially good for those who cycle between mania and depression very quickly.
- This drug may be used alone or in combination with another medication.
- Levels of medication and blood cell counts are monitored.
- Do not use this drug if you have a liver or blood disease.
- Do not drink alcohol if you are taking this drug.
- Side effects include dry mouth, constipation, drowsiness, nausea, trouble urinating, and low blood count (rare).
Valproic acid (Depakote): This drug works for bipolar disorder by controlling abnormal electrical activity in the brain that may cause mood swings.
- This medication can be used alone or in combination with another medication.
- Blood levels should be monitored.
- Liver function is tested occasionally.
- Do not drink alcohol with this drug; the combination may cause excessive sleepiness.
- Its most common side effects are drowsiness, nausea, diarrhea, tremor, and weakness.
Lamotrigine (Lamictal): This medication appears to be most useful for the depressed phase of bipolar disorder.
- This drug usually is used in combination with another medication.
- Do not take this drug if you have kidney, lung, or heart problems.
- Possible side effects, though rare, include severe rash, lip and tongue swelling, balance problems, and vision changes.
Olanzapine (Zyprexa): This medication is approved for treatment of both acute mania and maintenance once the symptoms are under control.
- This medication may be used in combination with an antidepressant for treatment of depression in bipolar disorder.
- One must be cautious of hyperglycemia in patients on any of the "atypical antipsychotics," of which Zyprexa is one. Patients who are known to have diabetes need to watch for poorer control of their blood sugar. Weight gain is possible, with or without problems with blood sugar.
- There may be increased levels of blood lipids (fats) and weight gain, especially in children and adolescents who are prescribed this medication.
- There is a possibility of so-called extrapyramidal side effects (EPS) at higher doses of this medicine. Oversedation or at least decreased alertness may occur.
- This medicine may be safer in pregnant women who have bipolar disorder than some of the other medications mentioned above.
Risperidone (Risperdal): This is another of the atypical antipsychotic medications, and it has been approved by the U.S. Food and Drug Administration (FDA) for use in acute mania.
- At higher doses, this medicine may cause restlessness, tremor, or other EPS symptoms.
- Other side effects are similar to those of olanzapine.
Quetiapine (Seroquel): This is another of the atypical antipsychotic medications which has been FDA-approved to treat both the depressive episodes and acute manic episodes in bipolar disorder.
- This medication may be used alone or in combination with other medications.
- The most common side effects are sedation and dry mouth.
- Recent studies suggest that this medication is unlikely to increase the chance of suicidal thoughts.
- Weight gain is minimal.
Other Therapy for Bipolar Disorder
For most people with bipolar disorder, medications do not relieve symptoms completely. Psychological counseling (psychotherapy) complements drug therapy and is considered a crucial part of effective therapy.
- Counseling usually begins in the hospital or when medical treatment begins.
- Different types of therapy are used. Therapy may be individual or in a group; both can be effective if approached with a positive attitude.
- Psychoeducation teaches a person about their illness so that they are able to recognize signs of relapse. This allows them to get help early before symptoms are severe.
- Cognitive behavior therapy teaches people how to change negative thought patterns and behaviors.
- Family therapy helps to improve communication between people with BPD and their families. Families learn how to recognize early symptoms so that they can get help for their loved one.
- Social rhythm therapy teaches people to track their moods, sleep patterns, and other behaviors so that they can identify relapses early, improve their relationships with others, and optimize social functioning.
- The goal is to help the person accept and cope with the disease.
- It is often very important for the spouse or other family members to be involved during visits to the therapist.
- It is important to treat the whole family, not just the person with bipolar disorder, not because they are all "sick," but because this disorder affects them all.
- Family members can learn valuable ways to deal with their loved one's mood swings.
Bipolar Disorder Follow-up
It is critically important for people with bipolar disorder to take all medication as directed. You will very likely be tempted to stop your medication. Many people with bipolar disorder do so. Don't do so. Instead, talk it over with your health care professional. Stopping your medication will probably cause your symptoms to come back. It may also cause uncomfortable or alarming withdrawal symptoms.
Depending on which medication is used, you may need regular blood tests to monitor levels and to check for side effects of the drug.
You should have regular appointments with your health care professional to see how well the treatment is working and detect any instability of your mood.
Regular sessions with a psychotherapist or counselor are also important.
Ongoing education for you and your family is crucial to help everyone deal with the disease.
You and your family should be taught to watch for early warning signs of crisis and ways to deal with stress to prevent recurrences.
How Can I Prevent Bipolar Disorder?
Nothing is known to prevent bipolar disorder. It is best to avoid drugs that may trigger the disease (such as cocaine or methamphetamine). Adopting a healthy lifestyle with regular sleep and exercise may help.
Relapses can be prevented or made less severe by following the treatment recommendations of your health care professionals. This includes taking medication as directed and attending counseling sessions.
What Is the Prognosis for Bipolar Disorder?
Bipolar disorder is a long-term condition with no actual cure, only ways to control the symptoms.
With treatment, many people are able to lead normal lives. Some (about one in 10) may never have another manic episode.
People with bipolar disorder and their families and friends can learn to pay attention to signs and symptoms of the depression or mania emerging and have their medications adjusted to prevent a relapse of the low or high. Through education and support, they can be able to monitor themselves.
Others battle mood swings for the rest of their lives. With proper medication and regular psychotherapy, however, the disease can be well controlled with few flare-ups.
If untreated, bipolar disorder may lead to risky activities, dysfunction in family and work, and even suicide or homicide.