Bipolar disorder

Answer 1

Definition

Bipolar disorder involves periods of elevated or irritable mood (mania), alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.

Alternative Names

Manic depression; Bipolar affective disorder

Causes, incidence, and risk factors

Bipolar disorder affects men and women equally. It usually appears between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.

Types of bipolar disorder:

• People with bipolar disorder type I have had at least one fully manic episode with periods of major depression. In the past, bipolar disorder type I was called manic depression.
• People with bipolar disorder type II have never experienced full-fledged mania. Instead they experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of depression.
• A mild form of bipolar disorder called cyclothymia involves less severe mood swings with alternating periods of hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be misdiagnosed as having depression alone.

In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people who are vulnerable to the illness:

• Life changes such as childbirth
• Medications such as antidepressants or steroids
• Periods of sleeplessness
• Recreational drug use

Symptoms

The manic phase may last from days to months and can include the following symptoms:

• Agitation or irritation
• Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
• Little need for sleep
• Noticeably elevated mood
  • Hyperactivity
  • Increased energy
  • Lack of self-control
  • Racing thoughts
• Over-involvement in activities
• Poor temper control
• Reckless behavior
  • Binge eating, drinking, and/or drug use
  • Impaired judgment
  • Sexual promiscuity
  • Spending sprees
• Tendency to be easily distracted

These symptoms of mania are seen with bipolar disorder I. In people with bipolar disorder II, hypomanic episodes involve similar symptoms that are less intense.

The depressed phase of both types of bipolar disorder includes the following symptoms:

• Daily low mood
• Difficulty concentrating, remembering, or making decisions
• Eating disturbances
  • Loss of appetite and weight loss
  • Overeating and weight gain
• Fatigue or listlessness
• Feelings of worthlessness, hopelessness and/or guilt
• Loss of self-esteem
• Persistent sadness
• Persistent thoughts of death
• Sleep disturbances
  • Excessive sleepiness
  • Inability to sleep
• Suicidal thoughts
• Withdrawal from activities that were once enjoyed
• Withdrawal from friends

There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can make the symptoms worse.

Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.

Signs and tests

A diagnosis of bipolar disorder involves consideration of many factors. The health care provider may do some or all of the following:

• Ask about your family medical history, particularly whether anyone has or had bipolar disorder
• Ask about your recent mood swings and for how long you've experienced them
• Observe your behavior and mood
• Perform a thorough examination to identify or rule out physical causes for the symptoms
• Request laboratory tests to check for thyroid problems or drug levels
• Speak with your family members to discuss their observations about your behavior
• Take a medical history, including any medical problems you have and any medications you take

Note: Use of recreational drugs may be responsible for some symptoms, though this does not rule out bipolar affective disorder. Drug abuse may itself be a symptom of bipolar disorder.

Treatment

Spells of depression or mania return in most patients, in spite of treatment. The major goals of treatment are to:

• Avoid cycling from one phase to another
• Avoid the need for a hospital stay
• Help the patient function as best as possible between episodes
• Prevent self-destructive behavior, including suicide
• Reduce the severity and frequency of episodes

The doctor will first try to determine what may have triggered the mood episode, and identify any medical or emotional problems that might interfere with or complicate treatment.

Drugs called mood stabilizers are considered to be the first-line treatment. The following are commonly used mood stabilizers:

• Carbamazepine
• Lamotrigine
• Lithium
• Valproate (valproic acid)

Other antiseizure drugs may also be tried.

Other drugs used to treat bipolar disorder include:

• Antipsychotic drugs and anti-anxiety drugs (benzodiazepines), which can be used to stabilize mood
• Antidepressant medications can be added to mood-stabilizing drugs to treat depression. People with bipolar disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, an antidepressant is only used in people who are also taking a mood stabilizer.

Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar disorder that does not respond to medication.

• ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia.
• ECT is the most effective treatment for depression that is not relieved with medications.

Transcranial magnetic stimulation (TMS) uses high frequency magnetic pulses that target affected areas of the brain. It is most often used as a second-line treatment after ECT.

Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stabilized and their behaviors are under control.

Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the potential risks and benefits of treatment for their children.

SUPPORT PROGRAMS AND THERAPIES

Family treatments that combine support and education about bipolar disorder (psychoeducation) appear to help families cope and reduce the odds of symptoms returning. Programs that emphasize outreach and community support services can help people who lack family and social support.

Important skills include:

• Coping with symptoms that are present even while taking medications
• Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
• Learning to take medications correctly and how to manage side effects
• Learning to watch for early signs of a relapse, and knowing how to react when they occur

Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients seek out proper support services, and help make sure the patient follows medication therapy.

Getting enough sleep is extremely important in bipolar disorder, because a lack of sleep can trigger a manic episode. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones.

• A patient with bipolar disorder cannot always reliably tell the doctor about the state of the illness. Patients often have difficulty recognizing their own manic symptoms.
• Mood variations in bipolar disorder are not predictable, so it is sometimes difficult to tell whether a patient is responding to treatment or naturally emerging from a bipolar phase.
• Treatment strategies for children and the elderly have not been well-studied, and have not been clearly defined.

Expectations (prognosis)

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.

Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.

Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with bipolar affective disorder require immediate emergency attention.

Complications

Stopping or improperly taking medication can cause your symptoms to come back, and lead to the following complications:

• Alcohol and/or drug abuse as a strategy to "self-medicate"
• Personal relationships, work, and finances suffer
• Suicidal thoughts and behaviors

This illness is challenging to treat. Patients and their friends and family must be aware of the risks of neglecting to treat bipolar disorder.

Calling your health care provider

Call your health provider or an emergency number right way if:

• You are having thoughts of death or suicide
• You are experiencing severe symptoms of depression or mania
• You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms

References

Moore DP, Jefferson JW. Bipolar disorder. In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier;2004:chap 80.

Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 420.

Benazzi F. Bipolar disorder -- focus on bipolar II disorder and mixed depression. Lancet. 2007;369:935-945.

Morriss RK, Faizal MA, Jones AP, Williamson PR, Bolton C, McCarthy JP. Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database Syst Rev. 2007;24;(1):CD004854.

Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722.

Answer 2

Bipolar disorder is a serious mental health disorder. Those who suffer from bipolar disorder should seek the help of a mental healthcare professional for treatment. Treatment often involves a combination of medication and psychotherapy. Some sufferers may feel that they are "cured" of their illness, and they may be tempted to stop treatment. It is important to remember that though symptoms may sometimes appear to vanish, there is no cure for the disorder.

Answer 3

Bipolar disorder is a mental disorder that presents as extreme mood swings. It typically arises at around 15 to 25 years of age and appears to have some link to genes. Bipolar disorder does not affect one sex more than the other. There can be triggers for the up and down moods in people with bipolar disorder, but they may also appear with no apparent cause. There is treatment for this unpredictable and sometimes debilitating disorder for those who seek medical attention and get a diagnosis.

The symptoms of bipolar disorder run a range unlike most other mental disorders because sufferers present with symptoms on both ends of the spectrum. Symptoms on the manic or "up" end of the disorder include extreme energy, distracted behavior, extreme happiness or anger, binging in any area, high sex drive, promiscuity and talkativeness. These symptoms are more pronounced in individuals with bipolar disorder type I.

The other end of the bipolar spectrum is depression. As with the manic phases of bipolar, the depression phases are more pronounced in people with bipolar disorder type I. Symptoms are identical to symptoms of people with depression. They include lack of interest, weight loss or gain, suicidal thoughts, sleeping difficulty, excessive crying and general deep sadness. In some cases, manic and depressive phases of bipolar disorder occur simultaneously creating a barrage of symptoms and behaviors.

Because bipolar disorder falls into two extremes, it may be difficult to treat. However, there are treatment options that include medicine, therapy or both. Patients may be given anti-anxiety medication, mood stabilizers, anti-psychotics, antidepressants and/or electroconvulsive therapy. Therapies for bipolar disorder include individual and group therapies of various kinds, depending on the behaviors of the sufferer. They may include illicit drug or alcohol cessation therapy as bipolar individuals tend to self-medicate.

Treatment is essential to a normal lifestyle for people with prominent bipolar disorder. It can interfere with work, everyday life and relationships if it goes untreated. While treatment may result in hospitalization, it helps protect bipolar individuals who are at risk for suicide. All treatment should be undergone with the help of a medical professional for this reason.

Answer 4

Definition

Bipolar disorder is a condition in which people go back and forth between periods of a very good or irritable mood and depression. The "mood swings" between mania and depression can be very quick.

Alternative Names

Manic depression; Bipolar affective disorder

Causes, incidence, and risk factors

Bipolar disorder affects men and women equally. It usually starts between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.

Types of bipolar disorder:

• People with bipolar disorder type I have had at least one manic episode and periods of major depression. In the past, bipolar disorder type I was called manic depression.
• People with bipolar disorder type II have never had full mania. Instead they experience periods of high energy levels and impulsiveness that are not as extreme as mania (called hypomania). These periods alternate with episodes of depression.
• A mild form of bipolar disorder called cyclothymia involves less severe mood swings. People with this form alternate between hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be wrongly diagnosed as having depression.

In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people with bipolar disorder:

• Life changes such as childbirth
• Medications such as antidepressants or steroids
• Periods of sleeplessness
• Recreational drug use

Symptoms

The manic phase may last from days to months. It can include the following symptoms:

• Easily distracted
• Little need for sleep
• Poor judgment
• Poor temper control
• Reckless behavior and lack of self control
  • Binge eating, drinking, and/or drug use
  • Poor judgment
  • Sex with many partners (promiscuity)
  • Spending sprees
• Very elevated mood
  • Excess activity (hyperactivity)
  • Increased energy
  • Racing thoughts
  • Talking a lot
  • Very high self-esteem (false beliefs about self or abilities)
• Very involved in activities
• Very upset (agitated or irritated)

These symptoms of mania occur with bipolar disorder I. In people with bipolar disorder II, the symptoms of mania are similar but less intense.

The depressed phase of both types of bipolar disorder includes the following symptoms:

• Daily low mood or sadness
• Difficulty concentrating, remembering, or making decisions
• Eating problems
  • Loss of appetite and weight loss
  • Overeating and weight gain
• Fatigue or lack of energy
• Feeling worthless, hopeless, or guilty
• Loss of pleasure in activities once enjoyed
• Loss of self-esteem
• Thoughts of death and suicide
• Trouble getting to sleep or sleeping too much
• Pulling away from friends or activities that were once enjoyed

There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances, which can make the symptoms and suicide risk worse.

Sometimes the two phases overlap. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.

Signs and tests

Many factors are involved in diagnosing bipolar disorder. The health care provider may do some or all of the following:

• Ask about your family medical history, such as whether anyone has or had bipolar disorder
• Ask about your recent mood swings and for how long you've had them
• Perform a thorough examination to look for illnesses that may be causing the symptoms
• Run laboratory tests to check for thyroid problems or drug levels
• Talk to your family members about your behavior
• Take a medical history, including any medical problems you have and any medications you take
• Watch your behavior and mood

Note: Drug use may cause some symptoms. However, it does not rule out bipolar affective disorder. Drug abuse may be a symptom of bipolar disorder.

Treatment

Periods of depression or mania return in most patients, even with treatment. The main goals of treatment are to:

• Avoid moving from one phase to another
• Avoid the need for a hospital stay
• Help the patient function as well as possible between episodes
• Prevent self-injury and suicide
• Make the episodes less frequent and severe

The health care provider will first try to find out what may have triggered the mood episode. The provider may also look for any medical or emotional problems that might affect treatment.

The following drugs, called mood stabilizers, are usually used first:

• Carbamazepine
• Lamotrigine
• Lithium
• Valproate (valproic acid)

Other antiseizure drugs may also be tried.

Other drugs used to treat bipolar disorder include:

• Antipsychotic drugs and anti-anxiety drugs (benzodiazepines) for mood problems
• Antidepressant medications can be added to treat depression. People with bipolar disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, antidepressants are only used in people who also take a mood stabilizer.

Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar disorder if it does not respond to medication. ECT uses an electrical current to cause a brief seizure while the patient is under anesthesia. ECT is the most effective treatment for depression that is not relieved with medications.

Transcranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain. It is most often used after ECT.

Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stable and their behavior is under control.

Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the possible risks and benefits of treatment for their children.

SUPPORT PROGRAMS AND THERAPIES

Family treatments that combine support and education about bipolar disorder (psychoeducation) may help families cope and reduce the odds of symptoms returning. Programs that offer outreach and community support services can help people who do not have family and social support.

Important skills include:

• Coping with symptoms that are present even while taking medications
• Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
• Learning to take medications correctly and how to manage side effects
• Learning to watch for the return of symptoms, and knowing what to do when they return
• Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients find the right support services, and make sure the patient takes medication correctly.

Getting enough sleep is very important in bipolar disorder. A lack of sleep can trigger a manic episode. Therapy may be helpful during the depressive phase. Joining a support group may help bipolar disorder patients and their loved ones.

• A patient with bipolar disorder cannot always tell the doctor about the state of the illness. Patients often have trouble recognizing their own manic symptoms.
• Changes in mood with bipolar disorder are not predictable. It it is sometimes hard to tell whether a patient is responding to treatment or naturally coming out of a bipolar phase.
• Treatments for children and the elderly are not well-studied.

Expectations (prognosis)

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to make sure that mania and depression are treated as early as possible.

Some people stop taking the medication as soon as they feel better or because the mania feels good. Stopping medication can cause serious problems.

Suicide is a very real risk during both mania and depression. People with bipolar disorder or think or talk about suicide need immediate emergency attention.

Complications

Stopping medication or taking it the wrong way can cause your symptoms to come back, and lead to the following complications:

• Alcohol and/or drug abuse
• Problems with relationships, work, and finances
• Suicidal thoughts and behaviors

This illness is hard to treat. Patients, their friends, and family must know the risks of not treating bipolar disorder.

Calling your health care provider

Call your health provider or an emergency number right way if:

• You are having thoughts of death or suicide
• You are experiencing severe symptoms of depression or mania
• You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms

References

Beynon S, Soares-Weiser K, Woolacott N, Duffy S, Geddes JR. Pharmacological interventions for the prevention of relapse in bipolar disorder: a systematic review of controlled trials. J Psychopharmacol. 2009; 23(5):574-591.

Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 420.

Benazzi F. Bipolar disorder -- focus on bipolar II disorder and mixed depression. Lancet. 2007;369:935-945.

Morriss RK, Faizal MA, Jones AP, Williamson PR, Bolton C, McCarthy JP. Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database Syst Rev. 2007;24;(1):CD004854.

Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722.

Reviewed By

Review Date: 03/29/2011

Fred K. Berger, MD, Addiction and Forensic Psychiatrist, Scripps Memorial Hospital, La Jolla, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.