Bipolar disorder

Definition

Bipolar disorder is characterized by periods of excitability (mania) alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.

Causes, incidence, and risk factors

Bipolar disorder results from disturbances in the areas of the brain that regulate mood. During manic periods, a person with bipolar disorder may be overly impulsive and energetic, with an exaggerated sense of self. The depressed phase brings overwhelming feelings of anxiety, low self-worth, and suicidal thoughts.

There are two primary types of bipolar disorder. People with bipolar disorder I have had at least one fully manic episode with periods of major depression. (In the past, bipolar disorder I was called manic depression.)

People with bipolar disorder II seldom experience 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 major depression.

A mild form of bipolar disorder called cyclothymia involves periods of hypomania and mild depression, with less severe mood swings. People with bipolar disorder II or cyclothymia may be misdiagnosed as having depression alone.

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

Symptoms

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

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

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 involves very serious symptoms of major depression:

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

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

Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession 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:

• Observe your behavior and mood
• Obtain your medical history, including any medical problems you have and any medications you take
• Ask about your recent mood swings and how long you've experienced them
• Ask about your family medical history, particularly whether anyone has or had bipolar disorder
• 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

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

Bipolar disorder is often treated with mood-stabilizing medications such as valproic acid, lithium, and carbamazepine. These are effective for treating both the manic and depressive phases, as well as preventing future symptoms.

Antidepressant drugs may be useful during the depressive phase IF the antidepressants are used with a mood stabilizer. Mood stabilizers are very important in people with bipolar disorder. Without a mood stabilizer, antidepressants may trigger mania in people with bipolar disorder. (Keep in mind that people with bipolar disorder II may be misdiagnosed with depression only because they do not experience full-fledged mania. If these patients take antidepressants without mood stabilizers, it can trigger a manic episode.)

Anti-psychotic drugs can help a person who has lost touch with reality. Anti-anxiety drugs, such as benzodiazepines, may also help. The patient may need to stay in a hospital until his or her mood has stabilized and symptoms are under control.

Electroconvulsive therapy (ECT) may be used to treat bipolar disorder. 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. Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications.

Getting enough sleep helps keep a stable mood in some patients. 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.

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 lead to symptoms coming back and the following complications:

• Alcohol and/or drug abuse may be used as a strategy to "self-medicate."
• Personal relationships, work, and finances may suffer as a result of mood swings.
• Suicidal thoughts and behaviors are a very real complication of bipolar disorder.

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

Illustrations

Bipolar disorder

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