Bipolar disorders are mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function. These periods, lasting from days to weeks, are called mood episodes. Mood episodes are categorized as manic/hypomanic episodes when the predominant mood is intensely happy or irritable, or depressive episodes, when there is an intensely sad mood or the ability to experience joy or pleasure disappears. People with bipolar disorder generally have periods of neutral mood as well. When treated, people with bipolar disorder can lead full and productive lives.

While people without bipolar disorder may also experience mood fluctuations, mood changes that are part of commonly lived experience typically last hours rather than days and are not accompanied by extreme changes in behavior or changes in functioning, such as difficulties with daily routines and social interactions. Bipolar disorder can disrupt a person’s relationships with loved ones and cause difficulty in working or going to school.

Bipolar disorder is a category that includes three main diagnoses: bipolar I, bipolar II, and cyclothymic disorder.

Bipolar disorder commonly runs in families: 80 to 90 percent of individuals with bipolar disorder have a relative with bipolar disorder or depression. Environmental factors such as stress, sleep disruption, and drugs and alcohol may trigger mood episodes in vulnerable people. Though the specific causes of bipolar disorder are unclear, there are both biological factors, including a family history of mood disorders, psychotic disorders, and substance misuse, and environmental factors that increase the risk for bipolar disorder. The average age of onset is in the mid-20s.

People with bipolar I disorder frequently have other mental disorders such as anxiety disorders, substance use disorders, and/or attention-deficit/hyperactivity disorder (ADHD). The risk of suicide is significantly higher among people with bipolar I disorder than among the general population.

Bipolar I disorder is diagnosed when a person experiences a manic episode. During a manic episode, people with bipolar I disorder experience an extreme increase in energy and mood changes, including feeling extremely happy or uncomfortably irritable. Some people with bipolar I disorder also experience depressive or hypomanic episodes, and most people with bipolar I disorder also have periods of neutral mood.

Symptoms of Bipolar I Disorder

Manic Episode

A manic episode is a period of at least one week when a person is extremely high-spirited or irritable most of the day for most days, possesses more energy than usual, and experiences at least three of the following changes in behavior:

• Decreased need for sleep (e.g., feeling energetic despite significantly less sleep than usual.
• Increased or faster speech.
• Uncontrollable racing thoughts or quickly changing ideas or topics when speaking.
• Distractibility.
• Increased activity (e.g., restlessness, working on several projects at once).
• Increased risky or impulsive behavior (e.g., reckless driving, spending sprees, sexual promiscuity).

These behaviors must represent a change from the person’s usual behavior and be clear to friends and family. Symptoms must be severe enough to cause dysfunction in work, family, or social activities and responsibilities. Symptoms of a manic episode commonly require hospital care to ensure safety.

During severe manic episodes, some people also experience disorganized thinking, false beliefs, and/or hallucinations, known as psychotic features.

Hypomanic Episode

A hypomanic episode, or hympomania, is characterized by less severe manic symptoms that need to last only four days in a row rather than a week. Hypomanic symptoms do not lead to the major problems in daily functioning that manic symptoms commonly cause.

Major Depressive Episode

A major depressive episode is a period of at least two weeks in which a person experiences intense sadness or despair or a loss of interest in acivities the person once enjoyed and at least four of the following symptoms:

• Feelings of worthlessness or guilt.
• Fatigue.
• Increased or decreased sleep.
• Increased or decreased appetite.
• Restlessness (e.g., pacing) or slowed speech or movement.
• Difficulty concentrating.
• Frequent thoughts of death or suicide.

Treatment and Management

Bipolar disorder symptoms commonly improve with treatment. Medication is the cornerstone of bipolar disorder treatment, though talk therapy (psychotherapy) can help many patients learn about their illness and adhere to medications, helping prevent future mood episodes.

Medications known as “mood stabilizers” (e.g., lithium, atypical antipsychotics) are the most commonly prescribed type of medications for bipolar disorder. While it is not completely understood how these medications work, some are known to change the brain cells' excitability (e.g. lithium), while others alter the neurotransmitters signaling in the brain (e.g., atypical antipsychotics). Because bipolar disorder is a chronic illness in which mood episodes typically recur, ongoing preventive treatment is recommended. Bipolar disorder treatment is individualized; people with bipolar disorder may need to try different medications before finding what works best for them.

In some cases, when medication and psychotherapy have not helped, an effective treatment known as electroconvulsive therapy (ECT) may be used. ECT consists of several rounds of a brief electrical current applied to the scalp while the patient is under anesthesia, leading to a short, controlled seizure. ECT-induced seizures are believed to change the brain signaling pathways.

Since bipolar disorder can cause serious disruptions in a person’s daily life and create stressful family situations, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies for coping, participating actively in the treatment, and obtaining support.

To diagnose bipolar II disorder in an individual, they must have at least one major depressive episode and at least one hypomanic episode (see above). With bipolar II, it is common that people return to their usual functioning between episodes. People with bipolar II disorder often first seek treatment as a result of their depressive episodes, since hypomanic episodes often feel pleasurable and can even increase performance at work or school.

People with bipolar II disorder frequently have other mental illnesses such as an anxiety disorder or substance use disorder, the latter of which can exacerbate symptoms of depression or hypomania.

Treatment

Treatments for bipolar II are similar to those for bipolar I: medication and psychotherapy. The most commonly used medications are mood stabilizers. Antidepressants are used cautiously for the treatment of bipolar-associated depression and continued ony for a short time after the depression gets better as they increase the risk of switching depression into hypomania and mania. If depressive symptoms are severe and medication is not effective, ECT (see above) may be used. Each person's treatment is individualized.

Cyclothymic disorder is a milder form of bipolar disorder involving many "mood swings," with hypomania and depressive symptoms that occur frequently. People with cyclothymia experience emotional ups and downs but with less severe symptoms than bipolar I or II disorder.

Cyclothymic disorder symptoms include the following:

• For at least two years, many periods of hypomanic and depressive symptoms, but the symptoms do not meet the criteria for hypomanic or depressive episodes.
• During the two-year period, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months.

Treatment

Treatment for cyclothymic disorder can involve medication and talk therapy. For many people, talk therapy can help with the stresses of mood swings. Keeping a mood journal can be an effective way to observe patterns in mood fluctuation. People with cyclothymia may start and stop treatment over time.

Physician Review

Adrian Preda, M.D.

Editor in Chief, Psychiatric News

April 2024