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Bipolar disorder, formerly known as manic depression, is a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most bipolar individuals experience alternating episodes of mania and depression.
Bipolar disorder is characterized by alternating manic episodes in which the individual feels abnormally euphoric, optimistic, and energetic and depressive periods in which the individual feels sad, hopeless, guilty, and sometimes suicidal. Manic or depressive periods may last for days, weeks, or months and run the spectrum from mild to severe. These episodes may be separated by periods of emotional stability in which the individual functions normally.
Bipolar I disorder is characterized by at least one manic episode without a major depressive episode. Manic episodes are the "high" of the manic-depressive cycle. A person experiencing a manic episode often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of severe depression, although a few individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also may occur (e.g., racing thoughts of mania with the listlessness of depression). Also, dysphoric mania is common particularly in adolescents. It is mania characterized by anger and irritability.
Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. A bipolar depressive episode may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, slowed mental and physical processes, and more profound fatigue (for example, hypersomnia, a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.
Cyclothymia refers to the cycling of hypomanic episodes with less severe depression that does not reach major depressive proportions. Some people with cyclothymia develop bipolar I or II disorder later in life.
A phenomenon known as rapid cycling occurs in up to 20% of bipolar patients. In rapid cycling, at least four manic and depressive moods swings must occur within 12 months. In some cases of ultra-rapid cycling, the individual may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.
In the United States in 2005 about 5.7 million adults, or 2.6% of the adult population have been diagnosed with bipolar disorder. About 1% of adolescents and between 0.2% and 0.4% of children have been diagnosed with the bipolar disorder, although controversy exists about diagnosing the disorder in these groups. The average age of onset of bipolar disorder is 25. However, because of the complexity of the disorder, a correct diagnosis can be delayed, and between 20% and 30% of adults with bipolar disorder report having undiagnosed symptoms in childhood or adolescence. According to the World Health Organization, bipolar disorder is the sixth leading cause of disability worldwide.
Causes and symptoms
Although the source of bipolar disorder has not been clearly identified, a number of genetic and environmental factors appear to be involved in triggering episodes. Bipolar disorder has an inherited component; children who have at least one parent with bipolar disorder are more likely to develop the disorder. They are also more likely to be diagnosed with other psychiatric disorders such as attention deficit/hyperactivity disorder (ADHD). Several studies have uncovered possible genetic connections to the predisposition for bipolar disorder. A large study done in Sweden reported in 2009 that schizophrenia and bipolar disorder appeared to share similar genetic causes. Brain imaging studies suggest that there are physical changes in the brains of people with bipolar disorder. It is hypothesized that dopamine and other neurotransmitters involved in mood may be involved. The possible role of hormonal imbalances in bipolar disorder is another area of investigation. Investigators are also researching what, if any, environmental factors may trigger the disorder.
People with bipolar disorder tend to have other psychiatric disorders. Oppositional defiant disorder (ODD) and ADHD are among the most common. Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse. A high rate of association exists between cocaine abuse and bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression cycle of the bipolar patient, making the disorder difficult to diagnosis.
For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.
Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities).
Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, increased risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose illusions.
Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings. Laboratory tests for drug and alcohol may be done to rule out other causes of the behavior.
Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) published by the American Psychiatric Association to definitively diagnose bipolar disorder. The DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.
Although some clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). The DSM-IV-TR notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal-directed activities, often result in a positive outcome, and are perceived in a positive manner by the patient (e.g., as a time of heightened creativity or work output), bipolar II disorder can go undiagnosed.
Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic (ongoing), rather than acute (episodic). Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of ADHD. Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder. Complicating the picture is that ADHD and conduct disorders are often present concurrently in children with bipolar disorder.
Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.
Medication is the most effective treatment for bipolar disorder. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants may be used to regulate manic and depressive episodes.
Mood stabilizing agents are the most commonly prescribed drugs to treat bipolar disorder. Their function is to regulate the manic highs and lows of bipolar disorder. The following drugs are commonly used:
- Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use also may cause hyperthyroidism (a disorder in which the thyroid is overactive, which may cause heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)
- Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug often prescribed in conjunction with other mood stabilizing agents. The drug may be used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.
- Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate.
Risperidone (Risperdal) may be used for short-term (usually no more than 3 weeks) treatment of acute mania associated with bipolar disorder. It may be given in conjunction with lithium or valproate. Side effects include weight gain, sedation, and abnormally low blood pressure upon rising from lying down (orthostatic hypotension).
Quetiapine (Seroquel) is a newer antipsychotic that acts on neurotransmitters in the brain. It appears to have fewer side effects than some of the older antipsychotics.
Olanzapine (Zyprexa, Zydis) may be used to treat acute manic episodes in individuals with bipolar I. Its mechanism of action is not clear. Side effects include orthostatic hypotension.
The use of antidepressants in bipolar disorder, once common, is as of 2009 controversial. Because antidepressants may stimulate manic episodes in some bipolar patients, their use typically is short-term. In 2004, the first drug to specifically be approved to treat bipolar administration was approved by the U.S. Food and Drug Administration (FDA). This drug, Symbyax, is a combination of olanzipine and fluoxetine.
Other antidepressants, although not specifically approved for treating depression associated with bipolar disorder, may be prescribed off-label. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) may be prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.
- SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
- MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.
- Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.
ECT, or electroconvulsive therapy, has been successful in treating both unipolar and bipolar depression and mania. However ECT usually is employed after all pharmaceutical treatment options have been explored in patients with severe depression and suicidal thoughts. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.
Adjunct treatments that may be used in conjunction with a long-term pharmaceutical treatment plan include:
- Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) may be used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood-stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
- Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) also may be used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
- Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.
- Psychotherapy and counseling. Because bipolar disorder is thought to be biological in nature, therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family.
General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise, and proper diet. Chinese herbs may soften mood swings. Biofeedback may help some patients control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.
While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic, recurrent illness in over 90% of people with the disorder. The disorder requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a high suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by ten years.
The ongoing medical management of bipolar disorder is critical to preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.
- A neurotransmitter and the precursor of norepinephrine.
- One of a group of chemicals secreted by a nerve cell (neuron) to carry a chemical message to another nerve cell, often as a way of transmitting a nerve impulse. Examples of neurotransmitters include acetylcholine, dopamine, serotonin, and norepinephrine.
- Off-label use
- Drugs in the United States are approved by the Food and Drug Administration (FDA) for specific uses, periods of time, or dosages based on the results of clinical trials. However, it is legal for physicians to administer these drugs for other "off label" or non-approved uses. It is not legal for pharmaceutical companies to advertise drugs for off-label uses.
- A severe mental disorder in which a person loses touch with reality and may have illogical thoughts, delusions, hallucinations, behavioral problems and other disturbances.
For Your Information
- Mondimore, Francis M. Bipolar Disorder: A Guide for Patients and Families, 2nd ed. Baltimore: Johns Hopkins University Press, 2006.
- "Bipolar Disorder." MedlinePlus. January 19, 2009 [cited January 28, 2009]. http://www.nlm.nih.gov/medlineplus/bipolardisorder.html.
- "Bipolar Disorder." National Institute of Mental Health. April 2, 2008 [cited January 28, 2009]. http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.
- American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, D.C.20016-3007. Telephone: (202) 966-7300 Fax: (202) 966-2891 http://www.aacap.org.
- American Psychiatric Association (APA). 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-3901. (888) 35-PSYCH or (703) 907-7300. Email: firstname.lastname@example.org http://www.psych.org.
- Depression and Bipolar Support Alliance. 730 N. Franklin Street, Suite 501, Chicago, Illinois 60654-7225. Telephone (800) 826-3632. Fax: (312) 642-7243. .
- Mental Health America (formerly National Mental Health Association). 2000 North Beauregard Street, 6th Floor, Alexandria, VA 22311. Telephone: (703) 684-7722 or (800) 969-6642. TTY: (800) 433-5959. Fax: (703) 684-5968. http://www.nmha.org.
an affective disorder characterized by the occurrence of alternating manic, hypomanic, or mixed episodes and with major depresive episodes. The DSM specifies the commonly observed patterns of bipolar I and bipolar II disorder and cyclothymia.
See also: manic episode, cyclothymia.
See also: manic episode, cyclothymia.
Synonym(s): manic-depressive psychosis
A mood disorder characterized by manic or hypomanic episodes typically alternating with depressive episodes. Also called manic-depressive disorder.
a major mental disorder characterized by episodes of mania, depression, or mixed mood. One or the other phase may be predominant at any given time, one phase may appear alternately with the other, or elements of both phases may be present simultaneously. Characteristics of the manic phase are excessive emotional displays, such as excitement, elation, euphoria, or in some cases irritability accompanied by hyperactivity, boisterousness, impaired ability to concentrate, decreased need for sleep, and seemingly unbounded energy. In extreme mania, a sense of omnipotence and delusions of grandeur may occur. In the depressive phase, marked apathy and underactivity are accompanied by feelings of profound sadness, loneliness, guilt, and lowered self-esteem. Causes of the disorder are multiple and complex, often involving biological, psychological, interpersonal, and social and cultural factors. The disorder is a biological illness that can be precipitated or exacerbated by psychosocial stressors. See also major depressive disorder.
bipolar disorderA mental condition characterised by episodic mania (euphoria) alternating with bouts of depression, which affects 1% of the general population. Bipolar disorder (BD) is the term used by the American Psychiatric Association, and is an umbrella term that encompasses a variety of clinical subtypes. The synonym manic-depressive disorder is still popular.
BD first appears by age 30; half of patients have 2–3 episodes during life, each from 4–13 months in duration.
Mood swings in BD may be dramatic and rapid, but more often are gradual; manic episodes are characterised by disordered thought, judgment and social behaviour; unwise business or financial decisions may be made when an individual is in a manic phase.
Lithium prevents or attenuates manic and depressive episodes, maintained at 0.8–1.0 mmol/L; if the manic episode is unresponsive, electroconvulsive therapy may be effective.
Bipolar disorder, DSM-IV subtypes
Bipolar I disorder—characterised by an occurrence of one or more manic episodes or mixed episodes, and one or more major depressive episodes, and an absence of episodes better accounted for by schizoaffective, delusional or psychotic disorders.
Bipolar II disorder—recurrent major depressive episodes with hypomanic episodes, characterised by one or more major depressive episodes, one or more hypomanic episodes, and an absence of manic or mixed episodes or other episodes better accounted for by schizoaffective, delusional or psychotic disorders. Bipolar II patients suffer from greater psychomotor agitation, guilt, shame and suicidal ideation, attempts and success.
0.5% prevalence in the general population; a familial tendency; more common in women.
10–15% die from suicide
Cyclothymia—a mild form of bipolar II disorder, consisting of recurrent mood disturbances between hypomania and dysthymic mood. A single episode of hypomania is sufficient to diagnose cyclothymia, but most people with it also have dysthymic periods. The diagnosis of cyclothymic disorder is not made if there is a history of mania or major depressive episode or mixed episode.
Bipolar disorder, NOS (Sub-threshold bipolar disorder)—bipolar disorder, NOS, is a waste-paper basket category used to indicate bipolar illness that does not fit into any of the above three formal DSM-IV bipolar diagnostic categories. The patient is so labeled if he or she manifests part of the bipolar spectrum symptoms (e.g. some manic and depressive symptoms) but does not meet the criteria for one of the above subtypes.
bipolar disorderBipolar disease, bipolar illness, manic-depressive disease/illness, manic depression Psychiatry A condition characterized by episodic mania-euphoria, alternating with bouts of depression, which affects 1% of the general population; BD first appears by age 30;1⁄2 of Pts have 2-3 episodes during life, each from 4-13 months in duration Clinical Mood swings in BD may be dramatic and rapid, but more often are gradual; manic episodes are characterized by disordered thought, judgment, and social behavior, unwise business or financial decisions may be made when an individual is in a manic phase Treatment Lithium; if manic episode is unresponsive, electroconvulsive therapy may be effective
- Bipolar I disorder
- is characterized by a occurrence of one or more manic episodes or mixed episodes, and one or more major depressive episodes, and an absence of episodes better accounted for by schizoaffective, delusional, or psychotic disorders
- Bipolar II disorder
- Recurrent major depressive episodes with hypomanic episodes Bipolar II is characterized by one or more major depressive episodes, one or more hypomanic episodes, and an absence of manic or mixed episodes or other episodes better accounted for by schizoaffective, delusional, or psychotic disorders
bi·po·lar dis·or·der(bī-pō'lăr dis-ōr'dĕr)
An affective disorder characterized by the occurrence of alternating periods of euphoria (mania) and depression.
Synonym(s): manic-depressive psychosis.
Synonym(s): manic-depressive psychosis.
bipolar disorderFormerly called manic-depressive psychosis, this is a severe psychiatric disorder featuring extreme alternations of mood from euphoria and hyperactivity to depression and apathy.
manic-depressive psychosis; bipolar disorder major, often remissive/recurrent mental illness, characterized by severe mood changes
bi·po·lar dis·or·der(bī-pō'lăr dis-ōr'dĕr)
Affective disorder characterized by occurrence of alternating manic, hypomanic, or mixed episodes and with major depresive episodes.
Patient discussion about bipolar disorder
Q. Why is there bipolar disorder?
A. Why is there Cancer? Why is there all kinds of illnesses. Some spiritual people may say that it is a test of your spirit. But why is often a victom frame of mind. Why me? Why my loved one? The trouth is there is no answer to the question, there are only solutions. The solution to bipolar disorder are diagnosis and treatments.
Q. is Bipolar genetic?
A. Bipolar disorder has a very strong genetic background: The approximate lifetime risk of this disease in relatives of a bipolar patient is 40 to 70 percent for a monozygotic (identical) twin and 5 to 10 percent for a first degree relative, compared with 0.5 to 1.5 percent for an unrelated person.
Q. why do you call Bipolar ... Bipolar? i mean what does it mean?
A. Bipolar disorder is called this way because it is charecterized by two types of obvious mood disorders- depression on the one side, and mania, or hypomania (a manic state, or 'high'), on the other side.More discussions about bipolar disorder