At the lower levels of mania, such as hypomania, individuals may appear energetic and excitable. At a higher level, individuals may behave erratically and impulsively, often making poor decisions due to unrealistic ideas about the future, and may have great difficulty with sleep. At the highest level, individuals can show psychotic behavior, including violence. Individuals who experience manic episodes also commonly experience depressive episodes, or symptoms, or a mixed state in which features of both mania and depression are present at the same time. These events are usually separated by periods of "normal" mood; but, in some individuals, depression and mania may rapidly alternate, which is known as rapid cycling. Severe manic episodes can sometimes lead to such psychotic symptoms as delusions and hallucinations.
Current research suggests that about 4% of people experience some of the characteristic symptoms at some point in their life. Prevalence is similar in men and women and, broadly, across different cultures and ethnic groups. Genetic factors contribute substantially to the likelihood of developing bipolar disorder, and environmental factors are also implicated. Bipolar disorder is often treated with mood stabilizing medications and psychotherapy. In serious cases, in which there is a risk of harm to oneself or others, involuntary commitment may be used. These cases generally involve severe manic episodes with dangerous behavior or depressive episodes with suicidal ideation. There are widespread problems with social stigma, stereotypes, and prejudice against individuals with a diagnosis of bipolar disorder. People with bipolar disorder exhibiting psychotic symptoms can sometimes be misdiagnosed as having schizophrenia.
The current term bipolar disorder is of fairly recent origin and refers to the cycling between high and low episodes (poles). The term "manic-depressive illness" or psychosis was coined by German psychiatrist Emil Kraepelin in the late nineteenth century, originally referring to all kinds of mood disorder. German psychiatrist Karl Leonhard split the classification in 1957, employing the terms unipolar disorder (major depressive disorder) and bipolar disorder.
Signs and symptoms
Bipolar disorder is a condition in which people experience abnormally elevated (manic or hypomanic) mood states, to a degree that interferes with the functions of ordinary life. Many people with bipolar disorder also experience periods of depressed mood, but this is not universal. There is no simple physiological test to confirm the disorder. Diagnosing bipolar disorder is often difficult, even for mental health professionals. In particular, it can be difficult to distinguish depression caused by bipolar disorder from pure unipolar depression.
The younger the age of onset, the more likely the first few episodes are to be depressive. Because a bipolar diagnosis requires a manic or hypomanic episode, many patients are initially diagnosed and treated as having major depression.
Manic episodes
Mania is the defining feature of bipolar disorder. Mania is a distinct period of elevated or irritable mood, which can take the form of euphoria, and lasts for at least a week (less if hospitalization is required). People with mania commonly experience an increase in energy and a decreased need for sleep, with many often getting as little as three or four hours of sleep per night. Some can go days without sleeping. A manic person may exhibit pressured speech, with thoughts experienced as racing. Attention span is low, and a person in a manic state may be easily distracted. Judgment may be impaired, and sufferers may go on spending sprees or engage in risky behavior that is not normal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive, intolerant, or intrusive. They may feel out of control or unstoppable, or as if they have been "chosen" and are "on a special mission", or have other grandiose or delusional ideas. Sexual drive may increase. At more extreme levels, a person in a manic state can experience psychosis, or a break with reality, where thinking is affected along with mood. Some people in a manic state experience severe anxiety and are irritable (to the point of rage), while others are euphoric and grandiose. The severity of manic symptoms can be measured by rating scales such as the Altman Self-Rating Mania Scale and clinician-based Young Mania Rating Scale.
The onset of a manic episode is often foreshadowed by sleep disturbances. Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.
Hypomanic episodes
Hypomania is a mild to moderate level of elevated mood, characterized by optimism, pressure of speech and activity, and decreased need for sleep. Generally, hypomania does not inhibit functioning as mania does. Many people with hypomania are actually more productive than usual, while manic individuals have difficulty completing tasks due to a shortened attention span. Some hypomanic people show increased creativity, although others demonstrate poor judgment and irritability. Many experience hypersexuality. Hypomanic people generally have increased energy and increased activity levels. They do not, however, have delusions or hallucinations.
Hypomania may feel good to the person who experiences it. Thus, even when family and friends recognize mood swings, the individual often will deny that anything is wrong. What might be called a "hypomanic event", if not accompanied by depressive episodes, is often not deemed as problematic, unless the mood changes are uncontrollable, volatile or mercurial. If left untreated, an episode of hypomania can last anywhere from a few days to several years. Most commonly, symptoms continue for a few weeks to a few months.
Depressive episodes
Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal thoughts. In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.
Mixed affective episodes
In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and depression occur simultaneously. Typical examples include weeping during a manic episode or racing thoughts during a depressive episode. Individuals may also feel very frustrated in this state, for example thinking grandiose thoughts while at the same time feeling like a failure. Mixed states are often the most dangerous period of mood disorders, during which the risks of substance abuse, panic disorder, suicide attempts, and other complications increase greatly.
Associated features of bipolar disorder
Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria. In adults with the condition, bipolar disorder is often accompanied by changes in cognitive processes and abilities. These include reduced attentional and executive capabilities and impaired memory. How the individual processes the world also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states. Some studies have found a significant association between bipolar disorder and creativity. Some patients may have difficulty in maintaining relationships.
There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder. These include mood abnormalities, full major depressive episodes, and ADHD.
Causes
The causes of bipolar disorder likely vary between individuals. Twin studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. For bipolar I, the (probandwise) concordance rates in modern studies have been consistently put at around 40% in monozygotic twins (same genes), compared to 0 to 10% in dizygotic twins. A combination of bipolar I, II and cyclothymia produced concordance rates of 42% vs 11%, with a relatively lower ratio for bipolar II that likely reflects heterogeneity. The overall heritability of the bipolar spectrum has been put at 0.71. There is overlap with unipolar depression and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67% in monozigotic twins and 19% in dizigotic. The relatively low concordance between dizygotic twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.
Genetic
Genetic studies have suggested many chromosomal regions and candidate genes appearing to relate to bipolar disorder's development, but the results are not consistent and often not replicated.
Although the first genetic linkage finding for mania was in 1969, the linkage studies have been inconsistent. Meta-analyses of linkage studies detected either no significant genome-wide findings or, using a different methodology, only two genome-wide significant peaks, on chromosome 6q and on 8q21.
Neither have genome-wide association studies brought a consistent focus — each has identified new loci.
Findings point strongly to heterogeneity, with different genes being implicated in different families. A review seeking to identify the more consistent findings suggested several genes related to serotonin (SLC6A4 and TPH2), dopamine (DRD4 and SLC6A3), glutamate (DAOA and DTNBP1), and cell growth and/or maintenance pathways (NRG1, DISC1 and BDNF), although noting a high risk of false positives in the published literature. It was also suggested that individual genes are likely to have only a small effect and to be involved in some aspect related to the disorder (and a broad range of "normal" human behavior) rather than the disorder per se.
Advanced paternal age has been linked to a somewhat increased chance of bipolar disorder in offspring, consistent with a hypothesis of increased new genetic mutations.
Physiological
The causes of bipolar disorder have yet to be fully uncovered, but there is strong evidence that brain structure anomalies play a role.
Abnormalities in the structure and/or function of certain brain circuits could underlie bipolar. Meta-analyses of structural MRI studies in bipolar disorder report an increase in the volume of the lateral ventricles, globus pallidus and increase in the rates of deep white matter hyperintensities. Functional MRI findings suggest that abnormal modulation between ventral prefrontal and limbic regions, especially the amygdala, likely contribute to poor emotional regulation and mood symptoms.
According to the "kindling" hypothesis, when people who are genetically predisposed toward bipolar disorder experience stressful events, the stress threshold at which mood changes occur becomes progressively lower, until the episodes eventually start (and recur) spontaneously. There is evidence of hypothalamic-pituitary-adrenal axis (HPA axis) abnormalities in bipolar disorder due to stress.
Other brain components which have been proposed to play a role are the mitochondria, and a sodium ATPase pump, causing cyclical periods of poor neuron firing (depression) and hypersensitive neuron firing (mania). This may only apply for type one, but type two apparently results from a large confluence of factors.[citation needed] Circadian rhythms and melatonin activity also seem to be altered.
Environmental
Evidence suggests that environmental factors play a significant role in the development and course of bipolar disorder, and that individual psychosocial variables may interact with genetic dispositions. There is fairly consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for onsets and recurrences of unipolar depression. There have been repeated findings that between a third and a half of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a worse course, and more co-occurring disorders such as PTSD. The total number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior.
Prevention
Prevention of bipolar has focused on stress (such as childhood adversity or highly conflictual families) which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness. There has been considerable debate regarding the causal relationship between usage of cannabis and bipolar disorder.
Diagnosis
Diagnosis is based on the self-reported experiences of an individual as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a clinical assessment. There are lists of criteria for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in Europe and other regions while the DSM criteria are used in the USA and other regions, as well as prevailing in research studies. The DSM-V, to be published in 2013, will likely include further and more accurate sub-typing.
An initial assessment may include a physical exam by a physician. Although there are no biological tests which confirm bipolar disorder, tests may be carried out to exclude medical illnesses such as hypo- or hyperthyroidism, metabolic disturbance, a systemic infection or chronic disease, and syphilis or HIV infection. An EEG may be used to exclude epilepsy, and a CT scan of the head to exclude brain lesions. Investigations are not generally repeated for relapse unless there is a specific medical indication.
Several rating scales for the screening and evaluation of bipolar disorder exist, such as the Bipolar spectrum diagnostic scale. The use of evaluation scales can not substitute a full clinical interview but they serve to systematize the recollection of symptoms. On the other hand instruments for the screening of bipolar disorder have low sensitivity[clarification needed] and limited diagnostic validity.
Criteria and subtypes
There is no clear consensus as to how many types of bipolar disorder exist. In DSM-IV-TR and ICD-10, bipolar disorder is conceptualized as a spectrum of disorders occurring on a continuum. The DSM-IV-TR lists three specific subtypes and one for non-specified:
Bipolar I disorder
One or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode.[49] A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.
Bipolar II disorder
No manic episodes, but one or more hypomanic episodes and one or more major depressive episode. However, a bipolar II diagnosis is not a guarantee that they will not eventually suffer from such an episode in the future.[citation needed] Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression.
Cyclothymia
A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. There is a low-grade cycling of mood which appears to the observer as a personality trait, and interferes with functioning.
Bipolar disorder NOS (not otherwise specified)
This is a catchall category, diagnosed when the disorder does not fall within a specific subtype. Bipolar NOS can still significantly impair and adversely affect the quality of life of the patient.
The bipolar I and II categories have specifiers that indicate the presentation and course of the disorder. For example, the "with full interepisode recovery" specifier applies if there was full remission between the two most recent episodes.
Rapid cycling
Most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months. Rapid cycling, however, is a course specifier that may be applied to any of the above subtypes. It is defined as having four or more episodes per year and is found in a significant proportion of individuals with bipolar disorder. The definition of rapid cycling most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period. Ultra-rapid (days) and ultra-ultra rapid or ultradian (within a day) cycling have also been described.
Differential diagnosis
There are several other mental disorders which may involve similar symptoms to bipolar disorder. These include schizophrenia, attention deficit hyperactivity disorder (ADHD), and some personality disorders, including borderline personality.
It has been noted that the bipolar disorder diagnosis is officially characterised in historical terms such that, technically, anyone with a history of (hypo)mania and depression has bipolar disorder whatever their current or future functioning and vulnerability. This has been described as "an ethical and methodological issue", as it means no one can be considered as being recovered (only "in remission") from bipolar disorder according to the official criteria. This is considered especially problematic given that brief hypomanic episodes are widespread among people generally and not necessarily associated with dysfunction.
Comorbid conditions
The diagnosis of bipolar disorder can be complicated by coexisting (comorbid) psychiatric conditions such as obsessive-compulsive disorder, social phobia, panic disorder and attention-deficit hyperactivity disorder. Substance abuse may predate the appearance of bipolar symptoms, further complicating the diagnosis. A careful longitudinal analysis of symptoms and episodes, enriched if possible by discussions with friends and family members, is crucial to establishing a treatment plan where these comorbidities exist.
Management: Treatment of bipolar disorder
Light therapy is one of several approaches to treating bipolar disorder. No one method is universally successful and most persons suffering from the illness need several forms of support.
There are a number of pharmacological and psychotherapeutic techniques used to treat bipolar disorder. Individuals may use self-help and pursue recovery.
Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (if mental health legislation allows and varying state-to-state regulations in the USA) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although these can still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups, intensive outpatient programs. These are sometimes referred to partial-inpatient programs.
Psychosocial
Psychotherapy is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and, practicing the factors that lead to maintenance of remission Cognitive behavioural therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioural therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge. Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.
Medication
Sodium valproate is a common mood stabilizer
Medications used to treat bipolar disorder are known as mood stabilizers; these work by reversing manic or depressive episodes and preventing relapses.The first known and "gold standard" mood stabilizer is lithium carbonate, which is effective in treating acute manic episodes, and preventing relapses, more so for manic than for depressive episodes. Treatment with lithium carbonate has been strongly linked to a reduced risk of suicide, self-harm, and death in people with bipolar disorder. Initially used as an anticonvulsant, sodium valproate has become a commonly prescribed treatment, and is effective in treating manic episodes. Three other anticonvulsants are used in to treat bipolar disorder. Carbamazepine became widely used to treat bipolar disorder in the late 1980s and early 1990s, but was displaced by sodium valproate in the 1990s. Carbamazepine is effective in treating manic episodes, with some evidence it has greater benefit in rapid-cycling bipolar disorder, or those with more psychotic manic symptoms or a more schizoaffective clinical picture. It is less effective in preventing relapse than lithium. Lamotrigine has been shown to have some efficacy in treating bipolar depression, and this benefit is greatest in more severe depression. It has also been shown to have some benefit in preventing further episodes, though there are concerns about the studies done, and is of no benefit in rapid cycling disorder. The effectiveness of topiramate is unknown. Depending on the severity of the case, anti-convulsants may be used in combination with lithium-based products or on their own.
Prognosis
For many individuals with bipolar disorder a good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder can have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar disorder can be a severely disabling medical condition. However, many individuals with bipolar disorder can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with bipolar disorder may have periods of normal or near normal functioning between episodes.
Functioning
A recent 20-year prospective study on bipolar I and II found that functioning varied over time along a spectrum from good to fair to poor. During periods of major depression or mania (in BPI), functioning was on average poor, with depression being more persistently associated with disability than mania. Functioning between episodes was on average good — more or less normal. Subthreshold symptoms were generally still substantially impairing, however, except for hypomania (below or above threshold) which was associated with improved functioning.
Another study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with bipolar disorder is increased approximately two-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States." Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes.
Recovery and recurrence
A naturalistic study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. Within two years, 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.
Symptoms preceding a relapse (prodromal), specially those related to mania, can be reliably identified by people with bipolar disorder. There have been intents to teach patients coping strategies when noticing such symptoms with encouraging results.
Mortality
Bipolar disorder can cause suicidal ideation that leads to suicidal attempts. One out of three people with bipolar disorder report past attempts of suicide or complete it, and the annual average suicide rate is 0.4%, which is 10 to 20 times that of the general population. The standardized mortality ratio from suicide in bipolar disorder is between 18 and 25.
Atypical antipsychotics have been found to be effective in managing mania associated with bipolar disorder. Olanzapine is effective in preventing relapses, although the evidence is not as solid as for lithium. Antidepressants have not been found to be of any benefit over that found with mood stabilizers.
Omega 3 fatty acids, in addition to normal pharmacological treatment, may have beneficial effects on depressive symptoms, although studies have been scarce and of variable quality.
Bipolar disorder in children
Lithium carbonate is the only medication approved for treating mania in children by the FDA
In the 1920s, Emil Kraepelin noted that mania episodes are rare before puberty. In general, bipolar disorder in children was not recognized in the first half of the twentieth century. This issue diminished with an increased following of the DSM criteria in the last part of the twentieth century.
While in adults the course of bipolar disorder is characterized by discrete episodes of depression and mania with no clear symptomatology between them, in children and adolescents very fast mood changes or even chronic symptoms are the norm. On the other hand pediactric bipolar disorder instead of euphoric mania commonly develops with outbursts of anger, irritability and psychosis, less common in adults.
The diagnosis of childhood bipolar disorder is controversial, although it is not under discussion that the typical symptoms of bipolar disorder have negative consequences for minors suffering them. The debate is mainly centered on whether what is called bipolar disorder in children refers to the same disorder as when diagnosing adults, and the related question of whether the criteria for diagnosis for adults are useful and accurate when applied to children. Regarding diagnosis of children some experts recommend following the DSM criteria. Others believe that these criteria do not correctly separate children with bipolar disorder from other problems such as ADHD, and emphasize fast mood cycles. Still others argue that what accurately differentiates children with bipolar disorder is irritability. The practice parameters of the AACAP encourage the first strategy. American children and adolescents diagnosed with bipolar disorder in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the 21st century, while in outpatient clinics it doubled reaching 6%. Studies using DSM criteria show that up to 1% of youth may have bipolar disorder.
Treatment involves medication and psychotherapy. Drug prescription usually consists in mood stabilizers and atypical antipsychotics. Among the formers lithium is the only compound approved by the FDA for children. Psychological treatment combines normally education on the disease, group therapy and cognitive behavioral therapy. Chronic medication is often needed.
Current research directions for bipolar disorder in children include optimizing treatments, increasing the knowledge of the genetic and neurobiological basis of the pediatric disorder and improving diagnostic criteria. The DSM-V has proposed a new diagnosis which is considered to cover some presentations currently thought of as childhood-onset bipolar.
In the elderly
There is a relative lack of knowledge about bipolar disorder in late life. There is evidence that it becomes less prevalent with age but nevertheless accounts for a similar percentage of psychiatric admissions; that older bipolar patients had first experienced symptoms at a later age; that later onset of mania is associated with more neurologic impairment; that substance abuse is considerably less common in older groups; and that there is probably a greater degree of variation in presentation and course, for instance individuals may develop new-onset mania associated with vascular changes, or become manic only after recurrent depressive episodes, or may have been diagnosed with bipolar disorder at an early age and still meet criteria. There is also some weak evidence that mania is less intense and there is a higher prevalence of mixed episodes, although there may be a reduced response to treatment. Overall there are likely more similarities than differences from younger adults. In the elderly, recognition and treatment of bipolar disorder may be complicated by the presence of dementia or the side effects of medications being taken for other conditions.
