What Is Bipolar Disorder?
Bipolar disorder is a chronic psychiatric disorder characterized by episodes of elevated mood, typically alternating with episodes of depression. For most people, bipolar disorder is a lifelong condition requiring ongoing treatment. The American Psychiatric Association (APA) recognizes three primary types of bipolar disorder, which all involve distinct changes in mood, energy and activity levels. Although the different types have specific defining characteristics, there are some basic similarities. Bipolar mania manifests in manic episodes in which people feel exuberantly joyful or uncomfortably irritable. Bipolar depression manifests in depressive episodes in which people experience desperate sadness or hopelessness. The three types are as follows:
Bipolar I disorder: This is characterized by one or more manic episodes or mixed episodes (symptoms of both mania and depression) lasting at least seven days. Typically, a person will also experience periods of depression with episodes lasting at least two weeks. It is common for episodes to be so severe that immediate hospitalization is warranted.1
Bipolar II disorder: This is characterized by a pattern of one or more major depressive episodes and at least one hypomanic episode. Individuals do not experience the full-blown manic episodes that are indicative of bipolar 1. This type is sometimes misdiagnosed as major depression if hypomanic episodes go unrecognized or unreported.1
Cyclothymic disorder: This is a milder type defined by numerous alternating periods of hypomanic and depressive symptoms. The episodes generally have a duration of at least two years in adults and one year in children and adolescents. The severity of this type may change over time.1
There are several other terms commonly used to further define bipolar disorder. Cases that do not follow the above patterns are known as “not otherwise specified.” The term “rapid cycling” is used to describe four or more manic, hypomanic, or depressive episodes in any 12-month period. Rapid cycling produces unusually frequent shifts in mood, can affect individuals with any of the three types and may be temporary.1 While mixed bipolar disorder is not a type, the term is often used to indicate people who have episodes of mania with additional symptoms of depression — or, conversely, episodes of depression with additional symptoms of mania. The APA changed its official diagnostic term from “mixed episodes” to “mixed features” in 2013.2
Bipolar Facts and Stats
- Bipolar disorder affects an estimated 5.7 million people ages 18 and older, or about 2.6% of the U.S. population.3
- The median age of onset for bipolar disorder is 25, although the illness can start in early childhood or as late as one’s 40s to 50s.3
- More than 50% of people diagnosed with bipolar disorder have comorbid alcohol use disorders, which further increases the risk of suicide.4
- The lifetime risk of suicide among individuals with bipolar disorder is estimated at 10% to 15%.5
- A 2016 study indicated 27.7% of people with bipolar disorder attempted two or more suicide attempts. This number jumped to 74.7% when individuals had a history of psychiatric hospitalization.5
- More than two-thirds of people with bipolar disorder have at least one close relative with the illness or with unipolar major depression. When one parent is affected, every child has a 15% to 30% risk of developing the disease. This increases to 50% to 75% if both parents have it.6
Bipolar Symptoms and Signs
People with bipolar disorder experience mood episodes, unusually intense periods of emotion, changes in sleep patterns and activity levels and unusual behaviors. Symptoms are classified under manic and depressive episodes.
Manic Episode Symptoms
- Heightened sense of self-importance
- Exaggerated positive outlook
- Significantly decreased need for sleep
- Poor appetite and weight loss
- Racing speech, flight of ideas and impulsiveness
- Thoughts and ideas that move quickly from one topic to the next
- Poor concentration and high distractibility
- Increased activity level
- Excessive involvement in pleasurable activities
- Poor financial choices (e.g. impulsive spending sprees)
- Excessive irritability
- Aggressive behavior7
Depressive Episode Symptoms
- Feelings of sadness or hopelessness
- Loss of interest in pleasurable or usual activities
- Difficulty sleeping (e.g. waking up early in the morning)
- Loss of energy and constant lethargy
- Sense of guilt or low self-esteem
- Difficulty concentrating
- Negative thoughts about the future
- Weight gain or weight loss
- Talk of suicide or death7
Like other mental illnesses, there is no single physical or lab test used to diagnosis bipolar disorder. Written guidelines exist to document the severity and number of symptoms, but a thorough clinical interview with a mental health professional is necessary for accurate diagnosis.
Recent Findings About Bipolar Disorder
The latest news updates on bipolar disorder seem to be aimed at furthering our understanding of its complexity, and indicate that the medical community and advocacy groups are working toward earlier and more accurate diagnoses as well as improved and more individualized bipolar disorder treatments.
#1 Bipolar Disorder Exists on a Spectrum, and the Distinctions Are Important
A 2017 article from the National Alliance on Mental Illness (NAMI) highlights the importance of recognizing that bipolar disorder has three types that exist on a spectrum, with very individualized symptoms and experiences.
The three types of bipolar disorder recognized by the American Psychiatric Association (APA) are: Bipolar type I, the most severe type, which in a 12-month period typically involves one or more manic episodes (or episodes that include mixed symptoms of mania and depression) that last at least seven days, and depressive periods that last about two weeks. Bipolar type II is not as severe as type I, because manic episodes are less pronounced. People with type II typically have one or more major depressive episodes per year and at least one hypomanic episode — the hypomania cycles can be so subtle that they are overlooked or unreported, leading to a bipolar II person being misdiagnosed with major depression.
Cyclothymic disorder, the mildest type of bipolar, is characterized by numerous alternating periods of less pronounced hypomanic and depressive symptoms. The episodes for this type last longer — at least two years in adults and one year in children and adolescents, with severity sometimes increasing over time.
According to NAMI, recent studies further support the distinctions between the types, underlining how grouping all types under a generalized “bipolar disorder” umbrella is problematic, often leading to misdiagnosis, and thus, delayed or incorrect treatment.
#2 Delayed Diagnosis and Delayed/Incorrect Treatment Worsen Outcomes in Bipolar Disorder
It has only recently been recognized that there is a lot of variability among people with bipolar disorder, which has led to misdiagnosis and ineffective treatment. Bipolar people who are misdiagnosed with depression or another disorder often receive the wrong medication, resulting in a worsening condition. In 2017, efforts are being made to improve the criteria used for diagnosis — for one, focusing on recognizing the more subtle signs of hypomania in younger patients with the aim of correctly distinguishing between bipolar disorder, major depression, and other disorders.
#3 There Has Been a Paradigm Shift in Definitions of “Mixed Episodes”
Views regarding the phenomenon of “mixed episodes” that can occur in patients with bipolar disorder — where features of depression, mania and hypomania can co-occur or “rapid cycle” in quick succession — have undergone a shift in the medical community. This is now referred to as “mixed features” as doctors have come to understand that mixed states can occur in all types of bipolar, not just in bipolar type I as once believed. A 2017 analysis of research studies revealed that mixed states also occur in patients with major depressive disorder and other mood disorders, and that the phenomenon stems from disturbances or fluctuations in the brain’s neurotransmitter systems (i.e., circadian, dopamine). Further, while understanding of mixed features has progressed at the research level, effective treatments at the clinical level have not yet caught up.
#4 Understanding Bipolar Disorder Helps Improve Relationships and Quality of Life
A February 2017 article from NAMI provides updated guidelines to help loved ones navigate their relationship with a bipolar individual to avoid problems. Open communication, recognition of signs of stress and signals to triggers for mood cycles are addressed in the article, along with tips for how to respond to the mood cycles, practice good self-care, and support the person with bipolar.
#5 Biggest Risk Factor for Bipolar Disorder Is a Parent With Any Mental Disorder
We have long known that bipolar disorder has a hereditary component — it runs in families. What we have learned only recently is that the highest risk factor for a child to develop bipolar disorder later in life is having a parent with any type of mental disorder — not just bipolar. In other words, if a child’s parent has a condition that is seemingly unrelated to bipolar, such as obsessive compulsive disorder (OCD), there is a higher likelihood that the child could develop bipolar disorder as an adult. While researchers have looked at other contributing factors, such as adverse events during childhood, non-genetic factors have not been found to be as significant as each parent’s mental health
Bipolar Disorder Treatment
Untreated bipolar disorder can result in devastating consequences for the individual and those closest to them. Treatment serves multiple purposes including:
- Helping the individual understand the disorder and learn ways to manage it
- Reducing symptoms
- Preventing or reducing the occurrence of future manic and depressive episodes
- Stabilizing current mood symptoms
- Keeping the individual and others safe
It is common for episodes to be so severe that immediate hospitalization is warranted. There are several advantages to inpatient treatment, including:
Guarding the safety of the individual and others while stabilizing the disorder
Enabling 24/7 observation and the following benefits:
Ensures an accurate diagnosis
Provides the attending psychiatrist with the opportunity to analyze the effectiveness and side effects of medication
Gives the individual a break from outside stressors, helping to facilitate stabilization and recovery
Provides intensive treatment over a short period of time, including both group and individual therapy
Although depression, anxiety and many other psychiatric disorders can often be effectively treated with psychotherapy alone, bipolar disorder treatment generally requires medication. Mood stabilizers play a key role in preventing or reducing the risk of recurring episodes. Antipsychotics and antidepressants are also commonly used in treatment.
Mood stabilizers — Lithium is one of the most commonly prescribed mood stabilizers for the treatment of bipolar disorder. Anticonvulsants such as valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro and others) and lamotrigine (Lamictal) are often effective for controlling manic and depressive episodes.8
Antidepressants — Many individuals with bipolar I disorder are prescribed antidepressant medications, in particular selective serotonin reuptake inhibitors (SSRIs) such as Paxil, Zoloft and Prozac. An antidepressant can sometimes trigger a manic episode, so it is usually prescribed along with a mood stabilizer or antipsychotic.8
Antipsychotics — Atypical antipsychotics help reduce psychotic symptoms that often occur during a manic episode. Some antipsychotics have been approved specifically for the treatment of bipolar mania, while others primarily target bipolar depression. Antipsychotic medications such as olanzapine (Zyprexa), risperidone (Risperdal), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may be prescribed alone or in combination with a mood stabilizer. Quetiapine (Seroquel) is approved for mania and the “maintenance” treatment of bipolar disorder.8
Antidepressant-antipsychotic — Symbyax is a combination of the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer. It is approved by the Food and Drug Administration specifically for the treatment of depressive episodes associated with bipolar I disorder.8
A large scale study of 21,000 adults treated in the U.K. for major (unipolar) depression between 2006 and 2013 yielded evidence of unintentional consequences. In this group, the most commonly prescribed antidepressants were SSRIs (35.5%); mirtazapine (9.4%); venlafaxine (5.6%) and tricyclics (4.7%). Previous treatment with certain antidepressants was associated with a 1.3% to 1.9% risk of a subsequent diagnosis of bipolar disorder and/or mania. Although this was low, further analysis revealed a 34% to 35% increased risk in individuals taking SSRIs and venlafaxine.9
Psychotherapy is often done on an individual basis, although couples and family therapy can be extremely beneficial. Understanding the disorder helps family members be more supportive and intervene when episodes occur. Since stress is often a trigger for manic episodes, therapy can help individuals learn to manage stress and keep future episodes at bay or to a minimum. Therapy can also help individuals identify mood triggers and manage symptoms when they occur.
It is common for individuals with serious psychiatric disorders to feel misunderstood, stigmatized and isolated. Group therapy provides a sense of community, the opportunity to share similar experiences and additional support for each participant. All of these elements can be beneficial to people suffering from a serious mental illness such as bipolar disorder.
Electroconvulsive Therapy (ECT)
Electrical currents are passed through the brain, which are thought to affect levels of neurotransmitters. ECT may be used for immediate relief of severe treatment-resistant depression. ECT is typically used in people whose symptoms do not improve with medications, those who cannot take antidepressants for health reasons or people at high risk of suicide. Physical side effects include headache and temporary memory loss.8
Transcranial Magnetic Stimulation (TMS)
TMS may be an option for people who do not respond to antidepressants. The individual sits in a reclining chair with a treatment coil placed against the scalp. The coil sends brief magnetic pulses to stimulate nerve cells in the brain involved in mood regulation and depression. Typically, a person receives five treatments every week for up to six weeks.8
- Tai chi or qigong
- Deep breathing
- Relaxation techniques (e.g. guided imagery or progressive muscle relaxation)
Beneficial Lifestyle Tips
- Avoid alcohol and recreational (or non-prescribed) drugs
- Avoid high-stress jobs and relationships
- Get adequate sleep every night
- Eat a healthy diet
- Exercise regularly (consult with doctor first)
- Keep life balanced (e.g. do not overload schedule)
If you suspect you have undiagnosed bipolar disorder, talk to your doctor or set up an appointment with a psychiatrist for an evaluation as soon as possible. With proper treatment, good self-care and diligent stress management, many people with bipolar disorder live happy, fulfilling lives.
- Types of Bipolar Disorder. Depression and Bipolar Support Alliance website. http://www.dbsalliance.org/site/PageServer?pagename=education_bipolar_types Accessed December 12, 2016.
- Help With Bipolar Disorders. American Psychiatric Association website. https://www.psychiatry.org/individuals-families/bipolar-disorders Accessed December 12, 2016.
- Bipolar Disorder Statistics. Depression and Bipolar Support Alliance website. http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_bipolar_disorder Accessed December 12, 2016.
- Duarte W, Becerra R, Cruise K. The Relationship Between Neurocognitive Functioning and Occupational Functioning in Bipolar Disorder: A Literature Review. van der Stelt O, ed. Eur J Psychol. 2016;12(4):659-678. doi:10.5964/ejop.v12i4.909.
- Schizophrenia, Bipolar Disorder and Suicide. Treatment Advocacy Center. http://www.treatmentadvocacycenter.org/evidence-and-research/learn-more-about/3632-schizophrenia-bipolar-disorder-and-suicide Published September 2016. Accessed December 12, 2016.
- Bipolar Disorder Statistics. Bipolar Lives website. http://www.bipolar-lives.com/bipolar-disorder-statistics.html Accessed December 12, 2016.
- Bipolar Disorder Symptoms. Psych Central website. http://psychcentral.com/disorders/bipolar-disorder-symptoms/ Updated September 15, 2016. Accessed December 12, 2016.
- Bipolar Disorder: Treatment and Drugs. Mayo Clinic website. http://www.mayoclinic.org/diseases-conditions/bipolar-disorder/basics/treatment/con-20027544 Published July 06, 2016. Accessed December 12, 2016.
- Certain antidepressants linked to heightened risk of mania and bipolar disorder. Science Daily website. https://www.sciencedaily.com/releases/2015/12/151216082204.htm Published December 16, 2015. Accessed December 12, 2016.