Doctor's Notes on Bipolar Disorder
Bipolar disorder (BD) is a psychiatric diagnosis that includes episodes with both mood changes and altered activity or energy. Signs and symptoms of BD are two major behavioral episodes that may cycle in an individual; Mania and/or Depression. Mania episodes may present as reckless behavior (feel indestructible, full of energy, starts tasks but seldom finishes any, pressured speech, driving a car recklessly, stealing, an increase in sexual affairs, for example). Most persons in this phase of BD cause friends and relatives concern but the BD affected person denies any problems and refuses to see a medical caregiver. Over half of BD patients with a maniac episode will follow with a depressive episode (crying spells, sadness, guilt, forget about personal hygiene, become withdrawn from friends and family); some individuals contemplate suicide (a medical/psychiatric emergency).
The causes of Bipolar disorder are not fully understood; there are theories about multiple gene involvement and chemical imbalances in the brain. Currently, there is no definitive cause(s), only theories.
Bipolar Disorder Symptoms
Mania and depression are the opposing poles of bipolar disorder. Bipolar symptoms are related to these two types of episodes:
- 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, stealing, an increase in sexual affairs, or other reckless behavior, such as wild driving, also may occur.
- Disregard for the risks or dangers of these and other impulsive behaviors.
- A decreased want or need for sleep, different than insomnia (when a person wants to sleep, but can't, and feels tired).
- Increased goal-directed activity: starting lots of projects and tasks (but often not finishing any of them)
- 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, as if his or her mouth can't keep up with the rapid thoughts (flight of ideas).
- The person may be unable to respond to social cues to stop talking, and other people can't get a word in (pressured speech).
- Increased physical activity, including fidgeting, restlessness, or hyperactivity, 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 sense of self-confidence and may inappropriately believe they have increased self-importance and abilities.
- Decisions regarding business and finances are often made hurriedly and without careful consideration; this poor judgment may be the result of inappropriate optimism.
- 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): Over half of manic episodes will be followed by a major depressive episode. Although mania is the more characteristic phase of bipolar disorder, most people spend more time in depressive episodes than manic ones.
- Depressive symptoms in bipolar disorder are identical to those in major depression (or unipolar depression).
- 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.
- During depression, most people sleep too much (hypersomnolence) and/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 have an increased appetite, eat more, and gain weight.
- 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 (anhedonia).
- Depression brings feelings of hopelessness, helplessness, pessimism, and worthlessness.
- 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.
- In bipolar disorder, the manic or depressed episodes last weeks or months. When a person's mood swings quickly from one extreme to the other within a few days, or even a single day, this suggests a different diagnosis than bipolar disorder. This is one reason a careful psychiatric assessment is important.
- When a person with bipolar disorder has more than four episodes of mania or depression (each lasting weeks or months) in a single year, it is referred to as rapid cycling.
- Individuals who have bipolar disorder often have other psychiatric diagnoses too. Anxiety disorders (such as panic attacks or social anxiety) are the most common secondary diagnosis, in about three-fourths of people with bipolar. Additionally, over half of those with bipolar disorder also have alcohol or other substance use disorders. People often use alcohol or drugs to try to feel better when they are depressed or disregard consequences when they are manic. However, the use of drugs or alcohol can trigger or worsen mood episodes (mania or depression). Other psychiatric conditions that frequently co-occur with BD include impulse control and conduct disorders or attention-deficit/hyperactivity disorder (ADHD).
Bipolar Disorder Causes
As with most psychiatric diagnoses, we are learning more but still do not fully understand bipolar disorder. Most experts agree that an interaction between genetic and environmental factors (for example, stress, exposure to certain drugs or medical conditions, etc.) causes bipolar disorder. More and more genes are being identified with an association with bipolar disorder, but there is no single gene that causes this condition. It is likely that many genes are involved and that individuals with bipolar may each have different sets of genes related to their diagnosis. The genetic component to bipolar disorder is demonstrated by the pattern of bipolar disorder within families; when one person has bipolar disorder, their family members have a higher chance of also developing bipolar disorder. Close relatives have a higher risk, and the identical twin of a person with bipolar disorder is at the highest risk for developing the condition. However, genes alone are not enough, but interaction between genes and stress of some kind often is needed 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 -- for this reason, practices that support good mental health are important.
Bipolar disorder involves chemical imbalances within the brain. The brain's functions are controlled by chemicals called neurotransmitters. Like depression, bipolar disorder was thought to involve an imbalance in one family of neurotransmitters called monoamines. The monoamines include serotonin, norepinephrine, and dopamine. Increased dopamine activity is associated with mania (and psychosis). In contrast, decreased serotonin and norepinephrine activity are associated with major depression and may also have a role in the depressed episodes of bipolar disorder. However, we now know from medication treatment trials that bipolar depression is different than major depression (unipolar depression) and may involve other neurotransmitters. Another class of neurotransmitters, like brain derived neurotrophic factor (BDNF) are involved with strengthening connections between nerve cells in the brain -- a process known as plasticity. BDNF and other related brain chemicals are also involved with bipolar disorder, and much ongoing research is trying to understand this relationship and hopefully design new treatments.
Not everyone with severe mood swings or a change in personality has bipolar disorder. When a person first develops symptoms, it is important for their doctors to investigate all reasonable medical causes for any acute change in someone's mental health or behavior. Symptoms of either mania or depression can be caused by other medical conditions that need to be diagnosed and treated properly. Additionally, both prescription medications and drugs of abuse can also cause symptoms similar to bipolar disorder. Medical conditions or medications and drugs that could cause bipolar symptoms include the following:
- Head trauma (blood clot or bleeding in the brain)
- Thyroid problems (both underactive and overactive)
- Autoimmune disorders that can affect the brain, including systemic lupus erythematosus (SLE)
- Brain tumors
- Epilepsy (seizures)
- Sleep disorders, including severe insomnia or sleep apnea
- Frontotemporal dementia (particularly with new onset of symptoms in the 60s or 70s)
- Neurosyphilis (a form of the sexually transmitted disease, syphilis, that has spread to the brain because it went untreated too long; this is rare today)
- HIV (human immunodeficiency virus) or AIDS (acquired immunodeficiency syndrome) affecting the brain
- Delirium (a condition with abnormal brain function due to other medical issues, including infections, abnormal electrolyte levels, or other conditions)
- Certain prescription medications can trigger mania-like symptoms, including stimulants (ADHD medications like Ritalin or Adderall), corticosteroids (like prednisone), and others.
Other psychiatric conditions and drug abuse may also mimic bipolar disorder:
- Attention deficit/hyperactivity disorder (ADHD)
- Borderline personality disorder (BPD)
- Delusional disorder
- Eating disorders (including anorexia nervosa or bulimia nervosa)
- Post-traumatic stress disorder
- Schizoaffective disorder
- Substance use disorders (particularly stimulants such as cocaine or methamphetamine)
Bipolar disorder, formerly called manic depression, is a mental illness that involves the sufferer having at least one manic (overly excited or irritable mood) or nearly manic (hypomanic) episode. The mood swings of this condition can last for weeks at a time and cause significant work and relationship problems. This illness affects up to 5% of adults in the United States, afflicting men and women equally.
Bipolar Disorder (Mania) : Test Your Emotional Wellness IQ QuizQuestion
Another term that has been previously used for bipolar disorder is ___________________.See Answer
Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.