Bipolar Disorder

Bipolar Disorder
(Mania)

Medical Author:

Roxanne Dryden-Edwards, MD 

Medical Editor:

Melissa Conrad Stöppler, MD 

• Bipolar disorder facts
• What is bipolar disorder?
• What is the history of bipolar disorder?
• What are the types of bipolar disorder?
• What are bipolar disorder causes and risk factors?
• What are bipolar disorder symptoms and signs in adults, teenagers, and children?
• How is bipolar disorder diagnosed?
• What illnesses coexist with bipolar disorder?
• What are bipolar disorder medications and other treatments? Are there any home remedies or alternative treatments for bipolar disorder?
• How is bipolar disorder treated during pregnancy and the postpartum period?
• What are complications and the prognosis/effects over time of bipolar disorder?
• Can bipolar disorder be prevented?
• Where can people find more information about bipolar disorder?
• Where can people find support to help them or someone they know cope with bipolar disorder?
• Bipolar Disorder (Mania) FAQs

Bipolar disorder facts

• Bipolar disorder, also commonly called manic depression, is characterized by mood swings and repeated episodes of depression with at least one episode of mania.
• Bipolar disorder afflicts up to 4 million people in the United States and is the fifth leading cause of disability worldwide.
• The suicide rate for people with bipolar disorder is 60 times higher than in the general public.
• Bipolar disorder was conceptualized by Emil Kraeplin more than 100 years ago, but its symptoms were first described as long ago as 200 A.D.
• Bipolar disorder has a number of types, including bipolar I and bipolar II disorder based on the severity of symptoms, and may be described as mixed or rapid cycling based on the duration and frequency of episodes.
• As with most other mental disorders, bipolar disorder is not directly passed from one generation to another genetically but is thought to be the result of a complex group of genetic, psychological, and environmental factors.
• The adolescent with bipolar disorder is more likely to exhibit depression and mixed episodes, with rapid changes in mood.
• Symptoms of bipolar disorder in women tend to include more depression and anxiety as well as a rapid-cycling pattern compared to symptoms in men.
• Since there is no one test that definitively indicates that someone has bipolar disorder, health-care professionals diagnose this disease by gathering comprehensive medical, family, and mental-health information in addition to performing physical and mental-health evaluations.
• Treatment of bipolar disorder with medications tends to relieve already existing symptoms of mania or depression and prevent symptoms from returning.
• Talk therapy (psychotherapy) is an important part of helping individuals with bipolar disorder achieve the highest level of functioning possible.
• When treating individuals with bipolar disorder who are pregnant or nursing, health-care professionals take great care to balance the need to maintain the person's stable mood and behavior while minimizing the risks that medications used to treat this disorder may present.

What is bipolar disorder?

Bipolar disorder, also called manic depression, is a mental illness that is characterized by severe mood swings, repeated episodes of depression, and at least one episode of mania. Bipolar disorder is one kind of mood disorder that afflicts more than 1% of adults in the United States, up to as many as 4 million people. Here are some additional statistics about bipolar disorder:

• Bipolar disorder is the fifth leading cause of disability worldwide.
• Bipolar disorder is the ninth leading cause of years lost to death or disability worldwide.
• The number of individuals with bipolar disorder who commit suicide is 60 times higher than that of the general population.
• People who have bipolar disorder are at a higher risk of also suffering from substance abuse such as alcoholism as well as other mental-health problems.
• Males may develop bipolar disorder earlier in life compared to females.
• Blacks are sometimes diagnosed more often with bipolar disorder compared to whites.

What is the history of bipolar disorder?

This disease was formally conceptualized by Emil Kraeplin more than 100 years ago, at which time he described it as manic-depressive insanity. However, mood problems that include depression alternating with symptoms that are now understood to be manic have been referenced in history as long ago as 200 A.D. At that time, this illness, like unipolar depression, was thought to be the result of bad blood, called black bile. In the 19th century, this illness was referred to by terms like biphasic illness, circular insanity, and dual-form insanity. Despite such unfortunate terminology for this disease, bipolar disorder is also known to be associated with significant achievement in some individuals. Many historical figures and current luminaries suffer from this disorder, whose creativity and accomplishments can therefore be an inspiration for current sufferers of bipolar disorder.

What are the types of bipolar disorder?

Bipolar disorder has a number of types, including bipolar I and bipolar II disorder. Depending on how rapidly the mood swings occur, the episodes of bipolar disorder can also be classified as having mixed (mood disordered episodes that last less than the usual amount of time required for the diagnosis) features or rapid cycling (four or more mood disordered episodes per year) features. About two-fifths of people with bipolar disorder have at least one period of rapid cycling over the course of their lifetime. For every type and duration of the illness, the sufferer experiences significant problems with his or her functioning at school, at work, or socially, may require hospitalization, or may have psychotic symptoms (for example, delusions or hallucinations). The diagnosis of bipolar I disorder requires that the individual has at least one manic episode but does not require a history of major depression. Bipolar II disorder is diagnosed if the person has experienced at least one episode of major depression and at least one episode of hypomania (a milder form of mania).

Mixed features are defined as meeting full diagnostic criteria for a manic episode while also suffering from at least three symptoms of a depressive episode, or meeting full diagnostic criteria for a major depressive episode while also suffering from at least three symptoms of a manic or hypomanic episode. People who suffer from significant, debilitating seasonal mood changes year after year may be classified as having a seasonal pattern to their bipolar disorder.

What are bipolar disorder causes and risk factors?

One frequently asked question about bipolar disorder is if it is hereditary. As with most other mental disorders, bipolar disorder is not directly passed from one generation to another genetically. Rather, it is the result of a complex group of genetic, psychological, and environmental factors. Genetically, bipolar disorder and schizophrenia have much in common, in that the two disorders share a number of the same risk genes. However, both illnesses also have some genetic factors that are unique.

Stress has been found to be a significant contributor to the development of most mental illnesses, including bipolar disorder. For example, gay, lesbian, and bisexual people are thought to experience increased emotional struggles associated with the multiple social stressors that are linked to coping with societal reactions to their homosexuality or bisexuality.

What are bipolar disorder symptoms and signs in adults, teenagers, and children?

In order to qualify for the diagnosis of bipolar disorder, a person must experience at least one manic episode. Characteristics of manic episodes must last at least a week (unless it is part of mixed features) and include

• elevated, expansive, or irritable mood;
• racing thoughts;
• pressured speech (rapid, excessive speech);
• decreased need for sleep;
• grandiose beliefs (for example, feeling like one has super powers or superlative talents or faults);
• tangential speech (repeatedly changing conversational topics to topics that are hardly related);
• increased goal-directed activity;
• impulsivity and poor judgment (like spending sprees or promiscuity).

Symptoms of the manic episode of early onset bipolar disorder tend to include outbursts of anger and rage, as well as irritability, as opposed to the expansive, excessively elevated mood seen in adults. The adolescent with bipolar disorder is more likely to exhibit depression and mixed episodes with rapid changes in mood. Despite differences in the symptoms of bipolar disorder in teens and children compared to adults, many who are diagnosed with certain kinds of pediatric bipolar disorder continue to have those symptoms as adults. Symptoms of bipolar disorder in women tend to include more depression and anxiety and a rapid cycling pattern compared to symptoms in men.

Although a major depressive episode is not required for the diagnosis of bipolar disorder, such episodes often alternate with manic episodes. In fact, persistent sadness occurs more often than mania in many people with bipolar disorder. Characteristics of depressive episodes include a number of the following symptoms: persistently depressed or irritable mood; decreased interest in previously pleasurable activities; change or problems in appetite, weight, or sleep; agitation or lack of activity; fatigue; feelings of worthlessness; trouble concentrating; thoughts of death or suicidal thoughts, plans, or actions.

How is bipolar disorder diagnosed?

As is true with virtually any mental-health diagnosis, there is no one test that definitively indicates that someone has bipolar disorder. Therefore, health-care professionals diagnose this disease by gathering comprehensive medical, family, and mental-health information. The health-care professional will also either perform a physical examination or request that the individual's primary-care doctor perform one. The medical examination will usually include lab tests to evaluate the person's general health and to explore whether or not the individual has mental-health symptoms like euphoria, depression, and rarely psychosis that are associated with a medical condition.

In asking questions about mental-health symptoms, mental-health professionals are often exploring if the individual suffers from depression and/or manic symptoms but also anxiety, substance abuse, hallucinations or delusions, as well as some personality and behavioral disorders. Health-care professionals may provide the people they evaluate with a quiz or self-test as a screening tool for bipolar disorder and other mood disorders. Since some of the symptoms of bipolar disorder can also occur in other mental illnesses, the mental-health screening is to determine if the individual suffers from bipolar disorder, an anxiety disorder like panic disorder, generalized anxiety disorder, or posttraumatic stress disorder (PTSD). The examiner also explores whether the person with bipolar disorder suffers from other mental illnesses like schizophrenia, schizoaffective disorder, and other psychotic disorders, or a substance abuse, personality, or behavior disorder like attention deficit hyperactivity disorder (ADHD). Any disorder that is associated with sudden changes in behavior, mood, or thinking, like a psychotic disorder, borderline personality disorder, or multiple personality disorder (MPD), may be particularly challenging to distinguish from bipolar disorder. In order to assess the person's current emotional state, health-care professionals perform a mental-status examination as well.

What illnesses coexist with bipolar disorder?

In addition to providing treatment that is appropriate to the diagnosis, determining the presence of mental illnesses that may co-occur (be co-morbid) with bipolar disorder is important in preventing bad outcomes. For example, people with bipolar disorder are at increased risk of committing suicide, particularly after engaging in previous episodes of cutting or other self-harm. Therefore, mental-health-care professionals will take care to examine for any warning signs that the person with bipolar disorder is thinking of harming himself or herself or others. Individuals who suffer from this illness, in addition to either alcohol or substance-abuse problems or borderline personality disorder, are also at particular risk of committing suicide. People with bipolar disorder are at higher risk of having an anxiety disorder like panic disorder, phobias, generalized anxiety disorder, or obsessive compulsive disorder (OCD).

What are bipolar disorder medications and other treatments? Are there any home remedies or alternative treatments for bipolar disorder?

Many people, whether they suffer from bipolar disorder or any medical or other mental illness, understandably wonder how they might help themselves to have the best outcome of treatment. While medications and psychotherapies remain mainstays of treatment of bipolar disorder, lifestyle improvements can be important complementary measures to care for this population. For example, aerobic exercise has been found to help alleviate some of the thinking problems, like memory and ability to pay attention, that are associated with bipolar disorder and other mental-health problems. While some home remedies or alternative treatments like St. John's wort have been found to help mild depression, they may induce a manic episode. There remains insufficient evidence that such treatments successfully treat manic symptoms. Although alternative medicine treatments for bipolar disorder like St. John's wort or ginkgo biloba are not recognized as standard care for bipolar disorder, as many as one-third of some patient groups being treated for this disorder report using them.

Medications

In terms of the overall approach to treatment, people with bipolar disorder can expect their mental-health professionals to utilize several medical interventions in the form of medications, psychotherapies, and lifestyle advice. Treatment of bipolar disorder with medications tends to address two aspects: relieving already existing symptoms of mania or depression and preventing symptoms from returning. Medications that are thought to be particularly effective in treating manic and mixed symptoms include olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris),iloperidone (Fanapt), and lurasidone (Latuda). These medications belong to a group of medications called neuroleptics and are known for having the ability to work quickly compared to many other psychiatric medications. For this group of medications, side effects that occur most often include sleepiness, dizziness, and increased appetite. Weight gain, which may be associated with elevated blood sugar, elevated lipid levels, and sometimes increased levels of a hormone called prolactin, may also occur. Although older medications in this class that were not mentioned here are more likely to cause muscle stiffness, shakiness, and very rarely uncoordinated muscle twitches (tardive dyskinesia) that can be permanent, health-care professionals appropriately monitor the people they treat for these potential side effects as well.

Mood-stabilizer medications like lithium (Lithobid), divalproex (Depakote), carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol), and lamotrigine (Lamictal) can be useful in treating active (acute) symptoms of manic or mixed episodes, as well as preventing the return of such symptoms. These medications may take a bit longer to work compared to the neuroleptic medications, some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, and some can be associated with birth defects when taken by pregnant women.

Antidepressant medications are the primary medical treatment for the depressive symptoms of bipolar disorder. Examples of antidepressants that are commonly prescribed for that purpose include serotonergic (selective serotonin reuptake inhibitor or SSRI) medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro); there are also combination serotonergic/adrenergic medications (SNRIs) like venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq), as well as bupropion (Wellbutrin), which is a dopaminergic antidepressant. While antidepressant medication remains a mainstay of treatment for the depression of bipolar disorder, the prescribing physician will remain watchful since there is some concern that antidepressants can induce a manic or near-manic (hypomanic) episode or rapid mood cycling pattern of symptoms.

When using medicines to prevent symptoms of manic or mixed episodes, mood-stabilizer medications like lithium or lamotrigine (Lamictal) are often used. Health-care professionals who prescribe lithium monitor blood levels of the medication to be sure it is within a therapeutic, safe level. The functioning of other body systems is frequently followed to quickly address any abnormal changes that may be associated with the medication. When a neuroleptic like olanzapine is used in combination with lithium, symptoms of relapse may be prevented for a longer period of time compared to when lithium is used alone. While lamotrigine tends to cause few side effects, practitioners tend to question the people they treat closely about symptoms of persistent fever, rash, or sore throat that may be warning signs of a rare but potentially fatal side effect. Depakote is also associated with that rare but potentially dangerous side effect. Medications like topiramate (Topamax) are being researched as a potential treatment for people with bipolar disorder who engage in pedophilia, sexual addiction, or are otherwise considered sexually deviant. While oxcarbazepine (Trileptal) continues to be used by many in an attempt to manage the mood swings of both adult and pediatric bipolar disorder, its effectiveness remains a matter of debate.

Despite its stigmatized history, electroconvulsive therapy (ECT) can be a viable treatment for people whose bipolar disorder has inadequately responded to psychotherapies and a number of medication trials.

Psychotherapies

Talk therapy (psychotherapy) is an important part of helping individuals with bipolar disorder achieve the highest level of functioning possible by improving ways of coping with the illness. These interventions are therefore seen by some as being forms of occupational therapy for people with bipolar disorder. Psychotherapy may also engage people with bipolar disorder who prefer to receive treatment without medication. While medications can be quite helpful in alleviating and preventing overt symptoms, they do not address the many complex social and psychological issues that can play a major role in how the person with this disease functions at work, home, and in his or her relationships. Since about 60% of people with bipolar disorder take less than 30% of their medications as prescribed, any supports that can promote compliance with treatment and otherwise promote the health of individuals in this population are valuable.

Psychotherapies that have been found to be effective in treating bipolar disorder include family focused therapy, psycho-education, cognitive therapy, interpersonal therapy, and social rhythm therapy. Family focused therapy involves education of family members about the disorder and how to provide appropriate support (psycho-education) to their loved one. This intervention also includes communication-enhancement training, and teaching family members problem-solving skills training. Psycho-education involves teaching the person with bipolar disorder and their family members about the symptoms of full-blown depressive and manic symptoms, as well as warning signs (for example, change in sleep pattern or appetite, change in activity level or increased irritability) that the person is beginning to experience either mood episode. In cognitive behavioral therapy, the mental-health professional works to help the person with bipolar disorder identify, challenge, and decrease negative thinking and otherwise dysfunctional belief systems. The goal of interpersonal therapy tends to be identifying and managing problems the sufferers of bipolar disorder may have in their relationships with others. Social rhythm therapy encourages stability of sleep-wake cycles, with the goal of preventing or alleviating the sleep disturbances often associated with this disorder.

How is bipolar disorder treated during pregnancy and the postpartum period?

When treating pregnant or postpartum individuals with bipolar disorder, health-care professionals take great care to balance the need to maintain the person's stable mood and behavior while minimizing the risks that medications used to treat this disorder may present to the patient, developing fetus, or nursing infant. While many medications that treat bipolar disorder may carry risks to the fetus in pregnancy and during breastfeeding, careful monitoring of the amount of medication that is administered as well as the health of the fetus or infant and of the mother can go a long way toward protecting the fetus or infant from any such risks, while maximizing the chance that the fetus or infant will grow in the healthier environment inside or outside the womb afforded by an emotionally healthy mother.

What are complications and the prognosis/effects over time of bipolar disorder?

While the prognosis for bipolar disorder indicates that individuals with this disorder can expect to experience episodes of some sort of mood problem up to 60% of the time, those episodes can be well managed by comprehensive treatment. There are a number of potential complications of bipolar disorder, particularly if left untreated. This illness may be compounded by other mental-health problems including substance abuse and addiction, whether it be to legal substances like alcohol or tobacco, prescription medications like amphetamine and dextroamphetamine (Adderall) or hydrocodone/acetaminophen (Vicodin), or to illicit drugs like heroine or cocaine. The risk of committing suicide is 60 times higher for people with bipolar disorder compared to the general population. That may be partly due to the chronic emotional pain that some people with this disorder experience, in that they endure years of depressive and manic symptoms, the consequences of their actions during those disease states, as well as potentially longing for the increased energy and sense of well-being of mania that may be quelled by psychiatric medications. Bipolar disorder is the fifth leading cause of disability and the ninth leading cause of years lost to death or disability worldwide.

Can bipolar disorder be prevented?

While far more seems to be known about the prevention of symptoms of bipolar disorder following its diagnosis, there is emerging research about ways to attempt to decrease the development of the full-blown disease altogether. For example, when family focused therapy is provided to children who have more subtle symptoms preceding bipolar disorder and who have bipolar relatives, they may be less likely to develop the full-blown disorder as adults.

Source: http://www.medicinenet.com/script/main/art.asp?articlekey=22133