UNDERSTANDING BIPOLAR DISORDER

DEFINITION

Bipolar disorders are brain disorders that causes changes in a person’s mood, energy, and ability to function. People with bipolar disorder experience intense emotional states that typically occur during distinct periods of days to weeks, called mood episodes.

Like the name suggests, bipolar disorder is marked by polar opposite mood swings—at one point, you feel like you can conquer anything; at another, you can barely get your butt out of bed. Once called manic depression, bipolar disorder affects up to 5.7 million adults. It impacts both men and women equally and the typical onset of symptoms usually occurs between ages 15-25. Of course, those years are notoriously emotional ones—first loves, college, new careers! Throw wonky energy levels into the mix, and, things just got more complicated. After all, how hard is it to plan your schedule or navigate your life when you don’t know which “you” you’re getting that week?

Like many mental disorders, bipolar illness is genetic and tends to run in families, meaning oftentimes, one or more family members also have a form of bipolar disorder. (It’s important to note that the illness can start in early childhood or as late as the 40s-50s.)

DEFINITION AND DSM-5 DIAGNOSTIC CRITERIA

People who live with bipolar disorder experience periods of great excitement, overactivity, delusions, and euphoria (known as mania) and other periods of feeling sad and hopeless (known as depression). As such, the use of the word bipolar reflects this fluctuation between extreme highs and extreme lows. The diagnosis is frequently assigned to young patients presenting with a (first) major depressive episode. In these cases, diagnosis is exclusively based on psychiatric history provided by family and caregivers, not on the current psychopathological assessment by the psychiatrist.

Bipolar disorders are described by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a group of brain disorders that cause extreme fluctuation in a person’s mood, energy, and ability to function.

To be diagnosed with bipolar disorder, a person must have experienced at least one episode of mania or hypomania.

To be considered mania, the elevated, expansive, or irritable mood must last for at least one week and be present most of the day, nearly every day. To be considered hypomania, the mood must last at least four consecutive days and be present most of the day, almost every day.

During this period, three or more of the following symptoms must be present and represent a significant change from usual behavior:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Increased talkativeness
4. Racing thoughts
5. Distracted easily
6. Increase in goal-directed activity or psychomotor agitation
7. Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees

The depressive side of bipolar disorder is characterized by a major depressive episode resulting in depressed mood or loss of interest or pleasure in life. The DSM-5 states that a person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:

1. Depressed mood most of the day, nearly every day
2. Loss of interest or pleasure in all, or almost all, activities
3. Significant weight loss or decrease or increase in appetite
4. Engaging in purposeless movements, such as pacing the room
5. Fatigue or loss of energy
6. Feelings of worthlessness or guilt
7. Diminished ability to think or concentrate, or indecisiveness
8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt

Bipolar disorder includes three different types: bipolar I, bipolar II, and cyclothymic disorder:

• Bipolar I disorder is a manic-depressive disorder that can exist both with and without psychotic episodes
• Bipolar II disorder consists of depressive and manic episodes which alternate and are typically less severe and do not inhibit function
• Cyclothymic disorder is a cyclic disorder that causes brief episodes of hypomania and depression

People who live with bipolar disorder experience periods of great excitement, overactivity, delusions, and euphoria (known as mania) and other periods of feeling sad and hopeless (known as depression). As such, the use of the word bipolar reflects this fluctuation between extreme highs and extreme lows. The diagnosis is frequently assigned to young patients presenting with a (first) major depressive episode. In these cases, diagnosis is exclusively based on psychiatric history provided by family and caregivers, not on the current psychopathological assessment by the psychiatrist.

Bipolar disorder occurs in up to 2.5% of the population, but the prevalence is much higher among first-degree relatives of individuals with bipolar or schizophrenia disorder. Individuals with bipolar disorder experience mood swings that are less severe in intensity. During what is known as a hypomanic episode, a person may experience elevated mood, increased self-esteem, and a decreased need for sleep. Unlike a manic episode, these symptoms are not so severe as to impact daily functioning or cause psychotic symptoms.

What’s more, in some cases, a bipolar episode can include symptoms of both mania and depression; this is what’s known as an episode with mixed features. People experiencing an episode with mixed features may feel extreme sadness, guilt, and worthlessness, while at the same experiencing high energy, racing thoughts and speech, and overactivity. It is not uncommon during a mixed episode for a person to go from being exuberantly happy to be expressing suicidal thoughts in a matter of moments.

Bipolar Disorder 1

Bipolar I require symptoms to meet the full criteria for what is known as a manic episode. You do not have to experience depression to be diagnosed with bipolar 1, but many people with the diagnosis experience both kinds of mood episodes.

Mania

A manic episode must include at least three of the following symptoms:

• Increased talkativeness
• Increased self-esteem or grandiosity
• Decreased need for sleep
• Increase in goal-directed activity, energy level, or irritability
• Racing thoughts
• Poor attention
• Increased risk-taking (spending money, risky sexual behaviors, etc.)

Mania is much more extreme than a sudden burst in energy or motivation or a happy mood. It often results in problems in work, school, and relationships, and it some cases it may require hospitalization. A manic episode is also just as frequently characterized by an irritable mood as an elevated one for people with bipolar 1, so never assume a manic episode is not present because a person doesn’t not appear happy or enthusiastic.

Psychosis

More than half of those with bipolar will develop symptoms of psychosis during their lifetimes. Often associated more with schizophrenia, psychosis can look the same in bipolar disorder.

Psychotic symptoms can include hallucinations, delusions, and hearing voices, and are more frequent during manic episodes than during depressive ones.

Bipolar Disorder II

To qualify for a diagnosis of bipolar II, a person has to have experienced a depressive episode and a less severe form of mania known as hypomania. A person experiencing mania will exhibit manic symptoms but is able to continue with day-to-day responsibilities and may even see an increase in job performance or other goal-directed activity. The elevated mood, however, is not so severe that the person requires hospitalization or experiences significant disruption at home or work.

Bipolar Depression

To meet the criteria for a depressive episode, a person must experience five or more of the following symptoms:

• Depressed mood
• Changes in sleep
• Changes in eating
• Fatigue or lack of energy
• Loss of pleasure in activities once enjoyed
• Restlessness or slowing down
• Feelings of guilt or worthlessness
• Indecision or difficulty concentrating
• Thoughts of suicide

Many people with bipolar II are diagnosed with depression because they fail to report the elevated mood symptoms of hypomania to their doctor. People with bipolar II also may be at higher risk for substance misuse and eating disorders. They are also more likely to have a relative in their immediate family with a psychiatric illness.

Some people with bipolar disorder also meet the criteria for rapid cycling, which requires four mood episodes of depression, mania, or hypomania in a 12-month period. Rapid cycling can occur with bipolar 1 and II.

Cyclothymic Disorder

 

If you’ve experienced manic and depressive symptoms for several years without meeting the requirements for a full manic or depressive episode, your doctor may diagnose you with what is known as cyclothymic disorder. Treatment typically consists of cognitive behavioral therapy, but not usually medication.

A bipolar diagnosis can affect the course treatment and medication recommended, so it’s important to report all mood symptoms to your doctor. Because drugs and alcohol can trigger episodes of mania or depression, you may have to complete detoxification from substances before you are given a diagnosis.

 

Keeping track of your mood, energy level, attention span, and behaviors every day can help you receive the most accurate diagnosis. Staying informed and staying patient with the diagnostic process also gives you the best chance for managing symptoms and reducing the frequency and intensity of mood changes. With the right team of support and the right tools for keeping track of your symptoms, it is possible to manage mental illness and live a full and goal-directed life.

 

Unspecified bipolar disorder

This diagnosis may be given when there is clinically significant abnormal mood elevation that doesn’t match the full criteria for the other three disorders. These disorders can be substance-induced or associated with other conditions.

What Causes Bipolar Disorder?

Like most mental illnesses, researchers haven’t pinpointed a single cause, but it seems that a combination of genes and environmental factors can awaken bipolar. Scientists have learned that a number of genes are associated with the disorder, meaning it’s about 80 percent genetic. If you have a first-degree relative with the disorder, you’re at higher risk for developing it, and if you have relatives with other mental health conditions, you may have increased risk as well. But not everyone who has bipolar disorder in their family will get the illness.

Scientists have learned that a number of genes are associated with the disorder, meaning it’s about 80% genetic. If you have a first-degree relative with the disorder, you’re at higher risk for developing it, and if you have relatives with other mental health conditions, you may have increased risk as well. But not everyone who has bipolar disorder in their family will get the illness.

Environmental factors also play a role in developing bipolar. And these interact with genetic predispositions to trigger the onset of the disorder. These include diet, sleep, substance use and abuse, the stability of your relationships, the atmosphere in the home if you’re an adolescent, stress, and early childhood trauma. This means is that if you’re living with bipolar disorder, it was probably a mixture of genes and environmental factors or life events that triggered the disorder to present itself.

While some people who have bipolar have suffered from some type of early traumatic event, abuse, or a troubling and/or stressful episode, many others cannot link to anything specific in their past.

With those differences, it’s not surprising that bipolar disorder is frequently misidentified and mistreated. “Research shows that nearly two-thirds of people with bipolar have been misdiagnosed at least one time in their lives and will have suffered nearly 10 years of untreated symptoms before receiving proper care

This gap in treatment is usually the result of misunderstanding bipolar illness, how it presents itself in episodes that can come and go, and the stigma of having a chronic mental illness, especially when symptoms are present in a young person.

And sometimes, other issues are simply masking the bipolar. Many patients will be diagnosed with the condition only after they seek sobriety for alcohol or drug abuse. Why the link? People often like how they feel when they are manic and think that level of creativity, productivity, and euphoria is helpful to their life so they try to replace it with substances like drugs and alcohol. On the flipside, manic people with bipolar disorders may use substances to help them relax, sleep, and calm down.

What’s important is if you suspect you may have bipolar disorder, see your doctor so you can manage the condition and live a productive life without the ups and downs of extreme mood swings.

What’s Going On In The Brain?

Up until recently, researchers hadn’t been able to distinguish a person with bipolar’s brain from a person without the disorder on a scan. But science is making some tracks. A 2019 study that looked at the brains of people with bipolar and those with depression on functional MRI scans correctly differentiated their brains about 80% of the time.

The findings suggest differences in the amygdala, the emotion center of the brain, of people with bipolar when they process emotions like sadness, anger, fear, and joy, and could become a marker to help identify bipolar disorder on brain scans. Likewise, bipolar affects brain biochemistry and neurotransmitters in the brain that produce chemical variations such as oxytocin, GABA, dopamine, and serotonin. These chemicals may be unbalanced in the brains of people with bipolar disorders. But as of yet, researchers aren’t clear on how too little GABA or too many oxytocin-active neurons play a role in the disorder or whether measuring them can help.

Bipolar disorders are most common in older adolescents and teens, but children can also be diagnosed with the disorder at a younger age. While not nearly as common in children as it is in adults, research studies have revealed that bipolar disorder affects as many as 3% of all children and up to 7% of children receiving outpatient psychiatric care. (The numbers are even higher in children hospitalized for inpatient psychiatric treatment.) Bipolar disorder has been diagnosed in children as young as 5. When young children experience symptoms, this is called early-onset bipolar disorder.

Bipolar disorder is more likely to affect the children of parents who have the disorder. When one parent has bipolar disorder, the risk to each child is 15 to 30%. When both parents have bipolar disorder, the risk increases to 50 to 75% according to the National Institute of Mental Health.

Bipolar in kids also causes distinct mood episodes from mania or hypomania to depression. However, because kids and adolescents can act out, have difficulty in school or at home, and display some of the symptoms of bipolar disorders, like restlessness, impulsivity, risky behaviors, and an inflated view of capabilities, even when they don’t have the disorder, it can be difficult to diagnose.

It is important to note that a number of other childhood disorders cause bipolar-like symptoms, including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, anxiety disorders, and major depression. Arriving at the correct diagnosis presents challenges because these and other mental health conditions often occur along with bipolar disorder.

If your child is struggling with behaviors like a depressed mood, loss of interest in activities, negative thinking, suicidal thoughts, or a decreased need for sleep, impulsivity, or aggressive or socially inappropriate behavior, they should see a mental health professional that specializes in children. And for kids with a family history of bipolar, parents should be vigilant about watching for symptoms and looking for help early. Getting diagnosed and treated earlier can prevent serious consequences and help kids keep their moods in check and manage symptoms from a younger age.

How is Bipolar Disorder Diagnosed?

There is no simple “test” you can take to determine bipolar disorder. Instead, you’ll need to meet with a provider who specializes in mental health disorders and discuss your specific symptoms.

Your doctor will give you a full physical to rule out any underlying medical conditions, such as hyper and hypothyroidism, that could cause manic or depressive states. If none are found, you’ll undergo a series of psychological assessments to gather additional information about your condition and determine which type of bipolar disorder you may be suffering from. Your provider will talk with you to determine your symptoms, their duration, intensity, and frequency, and gauge how your symptoms impair daily life, school, work, and relationships.

Your physician will also consider your family history when diagnosing. If there are family members with bipolar or depression, that’s a red flag for genetic pre-disposition to developing a bipolar disorder. She also asks about any family history of completed suicide or suicide attempts, which is concerning because untreated bipolar disorder can result in suicide. In previous generations, often family members didn’t realize that they had a mental illness or went undiagnosed, misdiagnosed, or never sought treatment. So, when a family has any committed or attempted suicide in their history, it can be a red flag for bipolar.

On the flip side, your family might also play a role in helping you get a diagnosis. Oftentimes, your family, a significant partner, or co-workers are first to recognize signs and symptoms of bipolar disorder. If you’re suffering from this condition, you may be reluctant to seek help at first–mostly because you may not notice how disruptive the disorder is to your life or think it’s just part of your personality. And, you may enjoy feeling high or euphoric when you’re manic.

Whatever your symptoms, we can’t underscore this enough: If you believe you are experiencing signs and symptoms of mania or depression, see your doctor. Bipolar disorder won’t go away on its own, but with the right treatment plan, you can successfully manage it.

Medications and psychotherapy are the most commonly prescribed treatment plans for people suffering from bipolar disorder. And the success rate of these plans is very high if you follow them consistently.

Medications

Depending on how severe your symptoms are, your provider may prescribe medication to help get you out of a manic or depressive state. Avoiding drugs and alcohol and taking your medication as prescribed—even on days you feel fine—can help you lead a normal, productive life. The most common medications used to treat bipolar:

Mood stabilizers work to level your mood, so it won’t tip toward mania or depression. Lithium is one of the most well-known and effective mood stabilizers for people with bipolar disorder.

Antidepressants work for depressive states, so if that is your most severe symptom, you may also benefit from one of many types of antidepressants prescribed to treat bipolar disorders.

Atypical antipsychotics may be used if your bipolar disorder symptoms include hallucinations, delusions, or severe mania. There are a number of antipsychotics also used in the treatment of bipolar disorders.

Often, the first course of drug therapy is the prescription of mood stabilizers. You may also be prescribed an anticonvulsant for use as a mood stabilizer. Atypical antipsychotics are sometimes combined with antidepressants to treat the disorders.

Because the use of antidepressants can trigger hypomanic or manic states, you will likely take an antidepressant with a mood stabilizer to even out your emotions.

Most patients respond very well to medicine, some just with a minimum dose. Other times doses need to be increased or a second medication added. Some meds can take up to six weeks to kick in, so if yours isn’t working by then, your physician might need to tweak it.

Psychotherapy

Psychotherapy Studies show psychotherapy has also been an effective tool for people living with bipolar disorder. Cognitive behavioral therapy helps you learn how to change negative or harmful thoughts or behaviors.

Family-focused therapies involve family members and focus on teaching you coping strategies, communication, and problem-solving techniques.

Interpersonal and social rhythm therapy (IPSRT) is often used in treating bipolar disorder as well, as this form of psychotherapy focuses on the stabilization of daily rhythms—sleep, wake, mealtimes—to introduce consistent routines to better manage moods.

Dialectical behavior therapy, (DBT) is also an effective treatment for bipolar disorders. DBT concentrates on regulating your emotions better so when you’re manic, you can have tools to help cope, English explains. She says you may do sensory type activities like breath work to calm down or put your feet in water or hold a frozen object to help bring you back to reality and teach you to live in the moment.

Psychoeducation has also been a powerful therapeutic tool to teach those living with bipolar disorder about their condition and how to treat it. This education allows you to notice triggers and impending mood swings so you can seek treatment before a full-blown episode happens.

Other Bipolar Disorder Treatment

Most patients respond very well to medication and various psychotherapies but there are some outliers who don’t respond as well. In this case, you may want to explore other options.

Transcranial Magnetic Stimulation

Medication-resistant patients can benefit from other treatments such as transcranial magnetic stimulation (TMS). This non-invasive treatment works by using magnetic fields to stimulate nerve cells in the brain and improve depressive symptoms. The treatment delivers repetitive magnetic pulses via an electromagnetic coil placed against your scalp. Though the mechanism for how it works isn’t well understood, it’s thought to impact how the brain works, which in turn can alleviate depressive episodes. TMS is well tolerated, doesn’t include much downtime, and has only some side effects such as headache, tingling, and lightheadedness. There are some rare side effects such as seizure and hearing loss.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) involves brief electrical stimulation while the patient is sedated and can be effective for those with severe symptoms that haven’t responded well to medication and psychotherapies. Though, it gets a bad rap thanks to movies and TV from the 40s and 50s, which showed it more like a torture device used on wide-awake patients. But today’s treatment is a lot more civilized and uses electro currents that pass through the brain, which intentionally trigger micro seizures. It’s these micro seizures which may reset the brain’s circuitry and help alleviate symptoms of depression. Though it’s generally safe, side effects can include confusion and memory loss as well physical problems like headache and jaw pain.

Lifestyle and Integrative Treatments

Lifestyle habits such as consistent sleep, regular exercise, a nutritious diet and mindfulness practices such as yoga, meditation have been shown to help improve symptoms of bipolar disorders. Integrative treatments are also something many patients with bipolar disorders may want to explore. For example, melatonin or magnesium can aid sleep. If you’re interested in exploring integrative treatments for bipolar disorders, talk with your mental health provider, or find an integrative specialist.

HOW TO LIVE BETTER WITH BIPOLAR DISORDER

1. Stay Connected

#1. Stay Connected – The more you isolate yourself, the more you increase the risk of mood changes going unnoticed and jeopardizing your health. Lack of connection to others can also put you at risk for a depressive episode. So don’t hesitate to assemble of team of professionals to provide guidance and insight. Doctors, counselors, and others can be a part of your support system, and many people find that attending a support group for people with bipolar disorder can be invaluable. Staying engaged with friends, family, and members of your community can also play an important role in keeping you energized and providing support.

2. Educate Yourself

#2, Educate Yourself – Education starts with learning the symptoms of manic and depressive episodes and getting up-to-date on research-driven treatment options for bipolar disorder. Share your questions and concerns with your doctor or psychiatrist, and ask them what resources they recommend for you to read or gather. Understanding the illness can help it feel more manageable and assist you in identifying symptoms before they get worse.

3. Track Symptoms

#3. Track Symptoms – Many people with bipolar disorder find it useful to keep a daily log of their mood, thinking, and behaviors. If you are able to catch small changes in these arenas, then you may be able to stop or decrease the intensity of a mood episode before it worsens. You should can also track stressors or behaviors which may trigger a mood episode, such as lack of sleep, relationship conflict, school or work stress, substance use, or seasonal changes. The more accurately you can report these changes to yourself and your doctor, the greater chance of stabilizing your mood.

4. Engage Coping Skills

4. Engage Coping Skills – In addition to alerting your counselor or doctor, you can utilize coping skills to control symptoms or reduce your risk for a mood episode. Different coping techniques work for different people, but they typically involve activities that help you feel calm, stay connected to others, practice healthy habits, and engage interests. Having a list of coping skills available to you can be useful, as it might prove difficult to generate your own ideas when you feel a lack of control.

5. Establish A Routine

#5. Establish a Routine – Perhaps the greatest coping skill for preventing mania or depression is the establishment of a healthy, daily routine. You should be taking medication consistently and accurately. Getting consistent and sufficient sleep every night can reduce the risk of mania.² Getting healthy and exercising can help improve and stabilize your mood as well. Schedule regular times to dedicate to family and friends, attend all doctor’s appointments, and carve out time to relax and unwind from life’s stressors.

6. Develop a Crisis Plan

#6. Develop a Crisis Plan – There are times when even the best routine and set of coping skills may fail to prevent a mood episode from escalating. It’s important, even while you’re feeling good, to go ahead and develop a crisis plan you can activate when you feel out of control. Create a written plan with a list of people that you or others can contact in emergency as well as information about your medications and warning signs and symptoms. Also, include a list hotline numbers that you can call if you experience suicidal thoughts or psychotic symptoms. Finally, leave a reminder to yourself that you can always call 911, walk into an emergency room, or ask a loved one to get you help if other measures fail.

If you’re not sure where to start, mental health professionals are trained to help you develop a treatment plan that can engage all of these actions steps. Having a concrete plan can help you feel more in control of your bipolar disorder, and over time you can tailor or alter this plan as needed. Bipolar disorder doesn’t have to be a lonely experience, so think about who you can recruit today to help you build up resilience and thrive in all arenas of life.

REFERENCE

• https://dsm.psychiatryonline.org/
• https://www.psycom.net/depression/bipolar-depression
• https://www.psychiatry.org/patients-families/bipolar-disorders#:~:text=Bipolar-disorders-are-brain-disorders,to-weeks-called-mood-episodes.