Bipolar disorder is a mental disorder that causes unusual shifts (highs and lows) in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. A person with bipolar disorder may experience periods of an extremely elevated or irritable mood (called manic episodes) and episodes of depression. Both the manic and depressive periods can be brief, from just a few hours to a few days. However, the cycles can also be much longer, lasting up to several weeks or months, even years, in depressive periods. The disorder was previously known as manic depression or manic-depressive illness. However, the term “manic” led to the patients being called “maniacs,” a stigmatizing label. As a result, the term “bipolar” was introduced in 1980 in the 3rd revision of the DSM to describe the illness in a more fraught-upon way. Unfortunately, there is no cure for bipolar disorder at the moment, but bipolars can still live normal lives as medication and therapy can effectively treat bipolar disorder. This post will discuss the symptoms, causes, manifestations, and the recommended treatment of the bipolar disorder.
The Biology of Bipolar Disorder
Bipolar disorder is primarily a biological disorder that occurs in a specific area of the brain due to the dysfunction of certain neurotransmitters, or chemical messengers, in the brain. These chemicals may involve neurotransmitters like norepinephrine, serotonin, and probably many others. As a biological disorder, it may lie dormant and be activated on its own, or it may be triggered by external factors such as psychological stress and social circumstances.
We still don't know the exact etiology of bipolar disorder. However, the overall heritability of bipolar approximately 79%-93% and first-degree relatives of bipolar probands have a relative risk of developing bipolar with a 7:10 ratio. While the heritability is high, no specific genes have been conclusively associated with bipolar yet, and several hypotheses have been proposed to explain it.
“The polygenic common rare variant” hypothesis model suggests that a large number of risk-inducing genes are carried in a population and that the disease manifests in cases where a person has a sufficient number of these genes.
On the other hand, the “multiple rare variant” model suggests that multiple genes that are rare in the population are capable of causing disease and that carrying one or a few can lead to disease.
Meanwhile, the familial transmission of mania and depression are largely independent of each other. This raises the possibility that bipolar disorder is, in fact, two biologically distinct but highly comorbid conditions.
Environmental factors also play a key role in the development of bipolar disorder.
Sleep deprivation can produce manic episodes in around 30% of people with bipolar disorder. While not all people with bipolar disorder demonstrate seasonality of affective symptoms, it is a consistently reported feature that supports theories of circadian dysfunction in people who have bipolar disorder.
Risk factors for bipolar include obstetric complications, abuse, drug use, and major life stressors. Studies estimate that around 60% of individuals with bipolar disorder are dependent on drugs or alcohol. People with seasonal depression or anxiety disorders may also be susceptible to developing bipolar disorder.
The “kindling model” of mood disorders suggests that major environmental stressors trigger initial mood episodes, but as mood episodes occur, weaker and weaker triggers can precipitate an affective episode.
Functional magnetic resonance imaging (fMRI) and positron emission technology (PET) are two types of scans that provide brain images. Certain findings on brain scans of bipolars are possibly associated with bipolar disorder. Regardless, more research is needed to see how these findings specifically impact bipolar disorder and its means for treatment and diagnosis.
The Symptoms of Bipolar Disorder
The symptoms of the disorder vary by the type of bipolar disorder that the person has. For instance, individuals with bipolar I disorder must experience a manic episode. The manic episode may be preceded or followed by a depressive episode, but a depressive episode is not required to diagnose bipolar I disorder.
To be diagnosed with bipolar II disorder, a person must have had a major depressive disorder following or preceded by a hypomanic episode. Sometimes, psychosis is involved. This is when the person sees or hears things that are not there or has delusional thoughts. For instance, a person may develop delusions of grandeur.
Symptoms of the manic or hypomanic state include:
- rapid speech
- racing thoughts, lack of focus
- high sex drive
- decreased need for sleep yet increased energy
- increase in impulsivity (e.g., reckless driving, unsafe sex)
- drug or alcohol abuse
Symptoms of the depressive state include:
- loss of energy
- lack of concentration
- irritability, agitation
- insomnia or hypersomnia
- appetite changes (e.g., from bulimic to anorexic)
- recurring thoughts of death or suicide
- attempting suicide
Different Types of Bipolar Disorder
Each disorder type is identified by the pattern of episodes of mania and depression. The treatment that is best for you may differ depending on the type of bipolar disorder you have.
Bipolar I disorder
This bipolar disorder is diagnosed when manic episodes last at least seven days and are accompanied by psychotic features. The manic symptoms are severe enough to require immediate hospitalization to prevent harm to oneself or others. Depressive episodes, typically lasting at least two weeks, also often occur. A person may have manic episodes with some depressive features or depressive episodes with some manic features.
Bipolar II disorder
Bipolar II disorder does not involve mania. Instead, the illness involves recurring episodes of major depression and hypomania, a milder form of mania. To be diagnosed with bipolar II disorder, the patient must have experienced at least one hypomanic episode and one major depressive episode in your lifetime. In bipolar I disorder, a major depressive episode (one or more) usually occurs, but it is not a requirement. Bipolar II disorder involves one or more major depressive episodes. Common symptoms that occur in a major depressive episode include:
- insomnia or hypersomnia
- unexplained or uncontrollable crying
- severe fatigue
- loss of interest in things the person typically enjoys.
- recurring thoughts of death or suicide
Cyclothymia is a milder form of bipolar disorder. Like bipolar disorder, cyclothymia consists of cyclical mood swings. However, the highs and lows are not severe enough to qualify as either mania or major depression.
The condition usually develops in adolescence. People with the disease often appear to function normally, although they may seem “moody” or “difficult” to others. People will often not seek treatment because the mood swings do not seem severe. Untreated cyclothymia can increase the risk of developing bipolar disorder.
Bipolar disorder due to another medical or substance abuse disorder
Some bipolar disorders don’t have a specific pattern. They also don’t match the other three disorders. Yet, they still have to meet the criteria for abnormal mood changes.
For example, a person may experience mild depressive or hypomanic symptoms that last less than the two years specified for cyclothymia. Another example is if a person has depressive episodes, but their mood elevation symptoms are too mild or brief to be diagnosed as mania or hypomania.
Since there is no cure, yet bipolar disorder is a lifelong condition. Treatment aims to manage symptoms during the patient's whole life and is best guided by a psychiatrist, who should specialize in bipolar or similar disorders. So how do we treat bipolar disorder?
Treatment may include:
- Medication. On many occasions, it is necessary to start taking medications to balance the mood swings right away.
- Continued treatment. Bipolar disorder requires lifelong treatment with medications, even during periods when you feel better. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
- Day treatment programs. These programs provide the support and counseling you need while you get symptoms under control.
- Substance abuse treatment. In cases of substance or alcohol, it must be treated in parallel with bipolar disorder.
- Hospitalization. Your doctor may recommend hospitalization if you're behaving dangerously, you feel suicidal, or you become detached from reality (psychotic). Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you have a manic or major depressive episode.
The primary treatments for bipolar disorder include medication and psychological counseling (psychotherapy) to control symptoms and may include education and support groups. It's also important for the patients to come to terms with their actions during a (hypo)manic or depressive episode.
The treatment of bipolar disorder includes several medications. There is not a single answer on how to treat bipolar disorder. The particular symptoms of the patient's bipolar disorder dictate the types and doses of the prescribed medications.
Medications may include:
- Mood stabilizers. You'll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium, valproic acid, divalproex sodium, carbamazepine, and lamotrigine.
- Antipsychotics. If symptoms of depression or mania persist despite treatment with other medications, adding an antipsychotic drug may help.
- Antidepressants. Treatment may include an antidepressant to help manage depression. Because an antidepressant can sometimes trigger a manic episode, it's usually prescribed along with a mood stabilizer or antipsychotic.
- Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep but are usually used on a short-term basis.
Medication – No One Size Fits All Solution
Finding the right medication or medications for will likely take some trial and error. If one doesn't work well for, there are several others to try.
Of course, this process requires patience, as some medications need several weeks or months to take full effect. Generally, only one medication is changed at a time so that your doctor can identify which medications work to relieve the symptoms with the least bothersome side effects.
The therapist may need to adjust the medication as the symptoms change. Different medications or different episodes may be necessary when you go through a (hypo)manic or depressive episode due to environmental/social conditions. So, how you treat bipolar disorder depends on the current phase of the cycle of symptoms.
Mild side effects often improve as you find the right medications and doses that work for you, and your body adjusts to the medications. You need to talk to your doctor or mental health professional if you have bothersome side effects.
Don't make changes or stop taking your medications. If you stop your medication, you may experience withdrawal effects, or your symptoms may worsen or return. You may become very depressed, feel suicidal, or go into a manic or hypomanic episode. If you think you need to make a change, call your doctor. Once again, there is no 100% accurate approach on how to treat bipolar disorder. Patience and cooperation are required.
Psychotherapy is a vital part of bipolar disorder treatment and can be provided in individual, family or group settings. Several types of therapy may be helpful. These include:
- Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on stabilizing daily rhythms, such as sleeping, waking, and mealtimes, to treat bipolar disorder. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet, and exercise.
- Cognitive-behavioral therapy (CBT). The focus is on identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. CBT can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
- Psychoeducation. Learning about bipolar disorder (psychoeducation) can help you, and your loved ones understand the condition. Knowing what's going on can help you get the best support, identify issues, make a plan to prevent relapse, and stick with treatment.
- Family-focused therapy. Family support and communication can help you stick with your treatment plan and help you and your loved ones recognize and manage warning signs of mood swings.