What is bipolar disorder

Bipolar disorder, formerly known as manic depression or manic-depressive illness, is a serious mental illness that affects your moods, which can swing from one extreme to another ¹⁾. People with bipolar disorder go through unusual mood changes. Sometimes they feel very happy and “up,” and are much more energetic and active than usual. This is called a manic episode. Sometimes people with bipolar disorder feel very sad and “down,” have low energy, and are much less active. This is called depression or a depressive episode.

Anyone can develop bipolar disorder. It often starts in a person’s late teen or early adult years. But children and older adults can have bipolar disorder too. The illness usually lasts a lifetime.

Symptoms of bipolar disorder depend on which mood you’re experiencing. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer), and some people may not experience a “normal” mood very often.

People who have it go through unusual mood changes. They go from very happy, “up,” and active to very sad and hopeless, “down,” and inactive, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

The causes of bipolar disorder aren’t always clear. It runs in families. Abnormal brain structure and function may also play a role.

Bipolar disorder often starts in a person’s late teen or early adult years. But children and adults can have bipolar disorder too. The illness usually lasts a lifetime.

If you think you may have it, tell your health care provider. A medical checkup can rule out other illnesses that might cause your mood changes.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy).

If not treated, bipolar disorder can lead to damaged relationships, poor job or school performance, and even suicide. However, there are effective treatments to control symptoms: medicine and talk therapy. A combination usually works best.

Who’s affected?

Bipolar disorder is fairly common and one in every 100 adults will be diagnosed with the condition at some point in their life.

Bipolar disorder can occur at any age, although it often develops between the ages of 15 and 19 and rarely develops after 40. Men and women from all backgrounds are equally likely to develop bipolar disorder.

The pattern of mood swings in bipolar disorder varies widely between people. For example, some people only have a couple of bipolar episodes in their lifetime and are stable in between, while others have many episodes.

Types of bipolar disorder

There are four basic types of bipolar disorder; all of them involve clear changes in mood, energy, and activity levels ²⁾. These moods range from periods of extremely “up,” elated, and energized behavior (known as manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

Bipolar I Disorder

Bipolar I Disorder is defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible.

Bipolar II Disorder

Bipolar II Disorder is defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes described above.
Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

Cyclothymic disorder

In cyclothymic disorder (also called cyclothymia), you’ve had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

Other Specified and Unspecified Bipolar and Related Disorders

Other Specified and Unspecified Bipolar and Related Disorders— defined by bipolar disorder symptoms that do not match the three categories listed above. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing’s disease, multiple sclerosis or stroke.

Bipolar disorder signs and symptoms

Bipolar “mood episodes” include unusual mood changes along with unusual sleep habits, activity levels, thoughts, or behavior. People may have manic episodes, depressive episodes, or “mixed” episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that last a week or two or sometimes longer. During an episode, the symptoms last every day for most of the day.

Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels.

People having a manic episode may:

• Feel very “up” or “high”
• Feel “jumpy” or “wired”
• Have trouble sleeping
• Become more active than usual
• Talk really fast about a lot of different things
• Be agitated, irritable, or “touchy”
• Feel like their thoughts are going very fast
• Think they can do a lot of things at once
• Do risky things, like spend a lot of money or have reckless sex

People having a depressive episode may:

• Feel very “down” or sad
• Sleep too much or too little
• Feel like they can’t enjoy anything
• Feel worried and empty
• Have trouble concentrating
• Forget things a lot
• Eat too much or too little
• Feel tired or “slowed down”
• Have trouble sleeping
• Think about death or suicide.

Other features of bipolar disorder:

• Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as anxious distress, melancholy, psychosis or others. The timing of symptoms may include diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during pregnancy or change with the seasons.

Depression

You may initially be diagnosed with clinical depression before having a future manic episode (sometimes years later), after which you may be diagnosed with bipolar disorder.

During an episode of depression, you may have overwhelming feelings of worthlessness, difficulty in day-to-day activities, such as work, school, social activities or relationships, which can potentially lead to thoughts of suicide.

A major depressive episode includes five or more of these symptoms:

• Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
• Marked loss of interest or feeling no pleasure in all — or almost all — activities
• Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)
• Either insomnia or sleeping too much
• Either restlessness or slowed behavior
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Decreased ability to think or concentrate, or indecisiveness
• Thinking about, planning or attempting suicide

If you’re feeling suicidal or having severe depressive symptoms, contact your healthcare provider or your local mental health emergency services as soon as possible.

Mania

During a manic phase of bipolar disorder, you may feel very happy and have lots of energy, ambitious plans and ideas. You may spend large amounts of money on things you can’t afford and wouldn’t normally want.

Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common characteristics of this phase.

You may feel very creative and view the manic phase of bipolar as a positive experience. However, you may also experience symptoms of psychosis, where you see or hear things that aren’t there or become convinced of things that aren’t true.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work, school and social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

• Abnormally upbeat, jumpy or wired
• Increased activity, energy or agitation
• Exaggerated sense of well-being and self-confidence (euphoria)
• Decreased need for sleep
• Unusual talkativeness
• Racing thoughts
• Distractibility
• Poor decision-making — for example, going on buying sprees, taking sexual risks or making foolish investments.

Symptoms in children and teens

Symptoms of bipolar disorder can be difficult to identify in children and teens. It’s often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.

Children and teens may have distinct major depressive or manic or hypomanic episodes, but the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift during episodes. Some children may have periods without mood symptoms between episodes.

The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

Can someone have bipolar disorder along with other problems?

Yes. Sometimes people having very strong mood episodes may have psychotic symptoms. Psychosis affects thoughts and emotions as well as a person’s ability to know what is real and what is not. People with mania and psychotic symptoms may believe they are rich and famous, or have special powers. People with depression and psychotic symptoms may believe they have committed a crime, they have lost all of their money, or that their lives are ruined in some other way.

Sometimes behavior problems go along with mood episodes. A person may drink too much or take drugs. Some people take a lot of risks, like spending too much money or having reckless sex. These problems can damage lives and hurt relationships. Some people with bipolar disorder have trouble keeping a job or doing well in school.

Bipolar Disorder and Other Illnesses

Some bipolar disorder symptoms are similar to other illnesses, which can make it hard for a doctor to make a diagnosis. In addition, many people have bipolar disorder along with another illness such as anxiety disorder, substance abuse, or an eating disorder. People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.

Psychosis

Sometimes, a person with severe episodes of mania or depression also has psychotic symptoms, such as hallucinations or delusions. The psychotic symptoms tend to match the person’s extreme mood. For example:

• Someone having psychotic symptoms during a manic episode may believe she is famous, has a lot of money, or has special powers.
• Someone having psychotic symptoms during a depressive episode may believe he is ruined and penniless, or that he has committed a crime.

As a result, people with bipolar disorder who also have psychotic symptoms are sometimes misdiagnosed with schizophrenia.

Anxiety and ADHD

Anxiety disorders and attention-deficit hyperactivity disorder (ADHD) are often diagnosed among people with bipolar disorder.

Substance Abuse

People with bipolar disorder may also misuse alcohol or drugs, have relationship problems, or perform poorly in school or at work. Family, friends and people experiencing symptoms may not recognize these problems as signs of a major mental illness such as bipolar disorder.

What causes bipolar disorder

Doctors do not know what causes bipolar disorder, but several things may contribute to the illness.

Genetics

Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.

Family genes may be one factor because bipolar disorder sometimes runs in families. However, it is important to know that just because someone in your family has bipolar disorder, it does not mean other members of the family will have it as well.

Biological differences

Another factor that may lead to bipolar disorder is the brain structure or the brain function of the person with the disorder. The significance of these changes is still uncertain but may eventually help pinpoint causes.

Scientists are finding out more about the disorder by studying it. This research may help doctors do a better job of treating people. Also, this research may help doctors to predict whether a person will get bipolar disorder. One day, doctors may be able to prevent the illness in some people.

Risk factors for developing bipolar disorder

Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first episode include:

• Having a first-degree relative, such as a parent or sibling, with bipolar disorder
• Periods of high stress, such as the death of a loved one or other traumatic event
• Drug or alcohol abuse.

Complications of bipolar disorder

Left untreated, bipolar disorder can result in serious problems that affect every area of your life, such as:

• Problems related to drug and alcohol use
• Suicide or suicide attempts
• Legal or financial problems
• Damaged relationships
• Poor work or school performance

Co-occurring conditions

If you have bipolar disorder, you may also have another health condition that needs to be treated along with bipolar disorder. Some conditions can worsen bipolar disorder symptoms or make treatment less successful. Examples include:

• Anxiety disorders
• Eating disorders
• Attention-deficit/hyperactivity disorder (ADHD)
• Alcohol or drug problems
• Physical health problems, such as heart disease, thyroid problems, headaches or obesity

Prevention of bipolar disorder

There’s no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.

If you’ve been diagnosed with bipolar disorder, some strategies can help prevent minor symptoms from becoming full-blown episodes of mania or depression:

• Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you’re falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.
• Avoid drugs and alcohol. Using alcohol or recreational drugs can worsen your symptoms and make them more likely to come back.
• Take your medications exactly as directed. You may be tempted to stop treatment — but don’t. Stopping your medication or reducing your dose on your own may cause withdrawal effects or your symptoms may worsen or return.

Bipolar disorder diagnosis

Some people have bipolar disorder for years before the illness is diagnosed. This is because bipolar symptoms may seem like several different problems. Family and friends may notice the symptoms but not realize they are part of a bigger problem. A doctor may think the person has a different illness, like schizophrenia or depression.

People with bipolar disorder often have other health problems as well. This may make it hard for doctors to recognize the bipolar disorder. Examples of other illnesses include substance abuse, anxiety disorders, thyroid disease, heart disease, and obesity.

To determine if you have bipolar disorder, your evaluation may include:

• Physical exam. Your doctor may do a physical exam and lab tests to identify any medical problems that could be causing your symptoms.
• Psychiatric assessment. Your doctor may refer you to a psychiatrist, who will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms.
• Mood charting. You may be asked to keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.
• Criteria for bipolar disorder. Your psychiatrist may compare your symptoms with the criteria for bipolar and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Diagnosis of bipolar disorder in children

Although diagnosis of children and teenagers with bipolar disorder includes the same criteria that are used for adults, symptoms in children and teens often have different patterns and may not fit neatly into the diagnostic categories.

Also, children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems, which can make diagnosis more complicated. Referral to a child psychiatrist with experience in bipolar disorder is recommended.

Bipolar disorder treatment

Right now, there is no cure for bipolar disorder, but treatment can help control symptoms. Most people can get help for mood changes and behavior problems. Steady, dependable treatment works better than treatment that starts and stops.

Treatment is best guided by a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist) who is skilled in treating bipolar and related disorders. You may have a treatment team that also includes a psychologist, social worker and psychiatric nurse.

Bipolar disorder is a lifelong condition. Treatment is directed at managing symptoms. Depending on your needs, treatment may include:

Medication

There are several types of medication that can help. People respond to medications in different ways, so the type of medication depends on the patient. Sometimes a person needs to try different medications to see which works best.

Bipolar disorder requires lifelong treatment with medications, even during periods when you feel better. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.

Medications can cause side effects. Patients should always tell their doctors about these problems.

Also, patients should not stop taking a medication without a doctor’s help. Stopping medication suddenly can be dangerous, and it can make bipolar symptoms worse.

A number of medications are used to treat bipolar disorder. The types and doses of medications prescribed are based on your particular symptoms.

Medications may include:

• Mood stabilizers. You’ll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).
• Antipsychotics. If symptoms of depression or mania persist in spite of treatment with other medications, adding an antipsychotic drug such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may help. Your doctor may prescribe some of these medications alone or along with a mood stabilizer.
• Antidepressants. Your doctor may add an antidepressant to help manage depression. Because an antidepressant can sometimes trigger a manic episode, it’s usually prescribed along with a mood stabilizer or antipsychotic.
• Antidepressant-antipsychotic. The medication Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer.
• Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep, but are usually used on a short-term basis.

Finding the right medication

Finding the right medication or medications for you will likely take some trial and error. If one doesn’t work well for you, there are several others to try.

This process requires patience, as some medications need weeks to months to take full effect. Generally only one medication is changed at a time so that your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. Medications also may need to be adjusted as your symptoms change.

Side effects

Mild side effects often improve as you find the right medications and doses that work for you, and your body adjusts to the medications. Talk to your doctor or mental health professional if you have bothersome side effects.

Don’t make changes or stop taking your medications. If you stop your medication, you may experience withdrawal effects or your symptoms may worsen or return. You may become very depressed, feel suicidal, or go into a manic or hypomanic episode. If you think you need to make a change, call your doctor.

Medications and pregnancy

A number of medications for bipolar disorder can be associated with birth defects and can pass through breast milk to your baby. Certain medications, such as valproic acid and divalproex sodium, should not be used during pregnancy. Also, birth control medications may lose effectiveness when taken along with certain bipolar disorder medications.

• Discuss treatment options with your doctor before you become pregnant, if possible. If you’re taking medication to treat your bipolar disorder and think you may be pregnant, talk to your doctor right away.

Psychotherapy

Psychotherapy or “talk” therapy is a vital part of bipolar disorder treatment can help people with bipolar disorder. Psychotherapy can be provided in individual, family or group settings. Therapy can help them change their behavior and manage their lives. It can also help patients get along better with family and friends. Sometimes therapy includes family members.

Several types of therapy may be helpful.

These include:

• Interpersonal and social rhythm therapy. Interpersonal and social rhythm therapy focuses on the stabilization of daily rhythms, such as sleeping, waking and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise.
• Cognitive behavioral therapy (CBT). The focus is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. CBT can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
• Psychoeducation. Learning about bipolar disorder (psychoeducation) can help you and your loved ones understand the condition. Knowing what’s going on can help you get the best support, identify issues, make a plan to prevent relapse and stick with treatment.
• Family-focused therapy. Family support and communication can help you stick with your treatment plan and help you and your loved ones recognize and manage warning signs of mood swings.

Other treatment options

Some people do not get better with medication and psychotherapy. Depending on your needs, other treatments may be added to your depression therapy.

During electroconvulsive therapy (ECT), sometimes called “shock” therapy where electrical currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can reverse symptoms of certain mental illnesses. ECT may be an option for bipolar treatment if you don’t get better with medications, can’t take antidepressants for health reasons such as pregnancy or are at high risk of suicide.

Transcranial magnetic stimulation (TMS) is being investigated as an option for those who haven’t responded to antidepressants.

Treatment in children and teenagers

Treatments for children and teenagers are generally decided on a case-by-case basis, depending on symptoms, medication side effects and other factors. Generally, treatment includes:

• Medications. Children and teens with bipolar disorder are often prescribed the same types of medications as those used in adults. There’s less research on the safety and effectiveness of bipolar medications in children than in adults, so treatment decisions are often based on adult research.
• Psychotherapy. Initial and long-term therapy can help keep symptoms from returning. Psychotherapy can help children and teens manage their routines, develop coping skills, address learning difficulties, resolve social problems, and help strengthen family bonds and communication. And, if needed, it can help treat substance abuse problems common in older children and teens with bipolar disorder.
• Psychoeducation. Psychoeducation can include learning the symptoms of bipolar disorder and how they differ from behavior related to your child’s developmental age, the situation and appropriate cultural behavior. Understanding about bipolar disorder can also help you support your child.
  Support. Working with teachers and school counselors and encouraging support from family and friends can help identify services and encourage success.

Lifestyle and home remedies

You’ll probably need to make lifestyle changes to stop cycles of behavior that worsen your bipolar disorder. Here are some steps to take:

• Quit drinking or stop using recreational drugs. One of the biggest concerns with bipolar disorder is the negative consequences of risk-taking behavior and drug or alcohol abuse. Get help if you have trouble quitting on your own.
• Form healthy relationships. Surround yourself with people who are a positive influence. Friends and family members can provide support and help you watch for warning signs of mood shifts.
• Create a healthy routine. Having a regular routine for sleeping, eating and physical activity can help balance your moods. Check with your doctor before starting any exercise program. Eat a healthy diet. If you take lithium, talk with your doctor about appropriate fluid and salt intake. If you have trouble sleeping, talk to your doctor or mental health professional about what you can do.
• Check first before taking other medications. Call the doctor who’s treating you for bipolar disorder before you take medications prescribed by another doctor or any over-the-counter supplements or medications. Sometimes other medications trigger episodes of depression or mania or may interfere with medications you’re taking for bipolar disorder.
• Consider keeping a mood chart. Keeping a record of your daily moods, treatments, sleep, activities and feelings may help identify triggers, effective treatment options and when treatment needs to be adjusted.

Avoiding drugs and alcohol

Some people with bipolar disorder use alcohol or illegal drugs to try to take away their pain and distress. Both have well-known harmful physical and social effects and are not a substitute for effective treatment and good healthcare.

Some people with bipolar disorder find they can stop misusing alcohol and drugs once they’re using effective treatment.

Others may have separate but related problems of alcohol and drug abuse, which may need to be treated separately.

Avoiding alcohol and illegal drugs is an important part of recovery from episodes of manic, hypomanic or depressive symptoms, and can help you gain stability.

Alternative medicine

There isn’t much research on alternative or complementary medicine — sometimes called integrative medicine — and bipolar disorder. Most of the studies are on major depression, so it isn’t clear how these nontraditional approaches work for bipolar disorder.

If you choose to use alternative or complementary medicine in addition to your physician-recommended treatment, take some precautions first:

• Don’t stop taking your prescribed medications or skip therapy sessions. Alternative or complementary medicine is not a substitute for regular medical care when it comes to treating bipolar disorder.
• Be honest with your doctors and mental health professionals. Tell them exactly which alternative or complementary treatments you use or would like to try.
• Be aware of potential dangers. Alternative and complementary products aren’t regulated the way prescription drugs are. Just because it’s natural doesn’t mean it’s safe. Before using alternative or complementary medicine, talk to your doctor about the risks, including possible serious interactions with medications.

Coping and support

Coping with bipolar disorder can be challenging. Here are some strategies that can help:

• Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan and recognize mood changes. Help educate your family and friends about what you’re going through.
• Stay focused on your goals. Learning to manage bipolar disorder can take time. Stay motivated by keeping your goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
• Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn ways to relax and manage stress. Yoga, tai chi, massage, meditation or other relaxation techniques can be helpful.

Dealing with suicidal feelings

Having suicidal thoughts is a common depressive symptom of bipolar disorder. Without treatment, these thoughts may get stronger.

Some research has shown the risk of suicide for people with bipolar disorder is 15 to 20 times greater than the general population.

Studies have also shown that as many as 25-50% of people with bipolar disorder attempt suicide at least once.

The risk of suicide seems to be higher earlier in the illness, so early recognition and help may prevent it.

If you’re feeling suicidal or you’re having severe depressive symptoms, contact your doctor, care co-ordinator or the local mental health emergency services as soon as possible.