CONDITIONS

Bipolar

What Is Bipolar

Bipolar disorder, sometimes called manic-depressive illness, is a serious mental illness characterized by extreme shifts in mood and energy levels-resulting in episodes of mania to depression. The National Institute of Mental Health reports that the disorder affects an estimated 5.7 million American adults (2.6% of the population), and it affects all ages, races, ethnic groups, and social classes. The World Health Organization reports that bipolar disorder is the sixth leading cause of disability worldwide and can lead to a 9.2 year reduction in lifespan. If left untreated, bipolar disorder can cause relationship problems, job loss, and erratic behavior that may be life threatening. People with bipolar disorder alternate between periods of depression and mania, which are both characterized by vastly different behaviors.


Depressive episodes are defined by the following behaviors:

  • Contemplation of suicide, death, or suicide attempts
  • Prolonged feelings of apathy, sadness, or hopelessness
  • Restlessness/irritability
  • Fatigue
  • Changes in eating and sleeping habits
  • Memory loss
  • Inability to concentrate

Manic behaviors include:

  • Overly outgoing, happy, or “high” feelings
  • Irritability
  • Rapid speech, racing thoughts, and erratic thought patterns
  • Extreme over-confidence
  • Excess energy levels with little need for sleep
  • Engagement in impulsive behaviors, especially pleasurable or high-risk behaviors
  • Overall increased activity level

It is also possible to have episodes of mixed mania or hypomania. Mixed mania episodes are characterized by both manic and depressive behaviors occurring simultaneously. Hypomania episodes include all of the same behaviors of manic episodes; only the behaviors are less severe.


There are four types of Bipolar Disorder:

  • Bipolar 1 Disorder. With Bipolar 1 Disorder, manic and depressive symptoms must be significantly different from a person’s normal behavior in order to classify the condition as Bipolar 1. This disorder is characterized by any of the following:
    • Manic or mixed episodes lasting seven or more days
    • Manic behaviors requiring immediate hospitalization
    • Depressive episodes lasting at least 2 weeks
  • Bipolar 2 Disorder is characterized by a pattern of depressive episodes alternating with milder periods of elation called hypomania.
  • Cyclothymic Disorder is characterized by alternating periods of especially high and especially low moods that last for months or years without letting up. The behavior in these episodes is not extreme enough to be called manic or depressive.
  • Rapid-Cycling Bipolar Disorder is characterized by more rapid alternations between manic and depressive episodes. Sufferers have four or more episodes of major depression, mania, hypomania, or mixed symptoms per year. Approximately three times as many women as men experience this form of the disease.

What Causes Bipolar

The precise cause of bipolar disorder is not known. The most common belief is that it is a biological disorder that occurs in a specific part of the brain due to the misfiring of neurotransmitters such as norepinephrine and serotonin. The misfiring of neurotransmitters is thought to be caused by a genetic predisposition, in combination with a triggering event. To learn more about what makes you more likely to develop bipolar disorder, read about the disorder’s risk factors.

Risk Factors For Bipolar

While the cause of bipolar disorder is unknown, there are known factors that influence the development of the disease.

Risk factors for bipolar disorder include:

  • Genetics. Between 80 to 90 percent of people with bipolar disorder have a relative with bipolar disorder or depression. When one parent has bipolar disorder, children have a 15-30% chance of developing the disorder (as compared to a 2-5% chance in the general population)
  • Stress. Stressful life events can cause emotional changes that exacerbate already existing predispositions to erratic moods.
  • Substance abuse. Depressants like alcohol and stimulants such as cocaine, MDMA (street name Molly), and Methamphetamine can cause intense mood swings and often send abusers into episodes of mania or depression.
  • Brain structure. Certain studies have shown a similar pattern of brain development in children with bipolar disorder and other disorders that cause similar symptoms. This suggests that there is a link between brain structure and susceptibility to bipolar disorder.
  • Sex. A study published in the Journal of Clinical Psychology found that an equal number of men and women are affected by bipolar disorder, however women are approximately three times more likely to develop the rapid-cycling form of the disorder than men. Similar studies also found that women may be more likely to suffer from depressive episodes.
  • Age. Bipolar disorder can develop at any age, but the median age of onset is 25 years old and the disease rarely develops after age 50.
  • Existing depressive or anxiety disorders. According to the Depression and Bipolar Support Alliance (DBSA), 20% of adolescents with major depression develop bipolar disorder within 5 years of the depression onset. The DBSA also reports that about one third of children with major depression are actually exhibiting early symptoms of bipolar disorder

Diagnosing Bipolar

Bipolar disorder can be a challenging condition to diagnose. According to The Depression and Bipolar Support Alliance (DBSA), people with bipolar disorder may face up to ten years of coping with symptoms before getting an accurate diagnosis. Only one in four receive an accurate diagnosis in less than three years. The DBSA also reports that a gender bias exists in the diagnosis of bipolar disorder – women are far more likely to be misdiagnosed with depression and men are far more likely to be misdiagnosed with schizophrenia.

Diagnostic criteria for bipolar disorder have been flexible over the years, changing to accommodate new findings from research and data. For example, with the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the criteria for manic and hypomanic episodes now includes an emphasis on changes in energy level and activity instead of only mood.


When making a diagnosis, your physician will take the following into account:

  • Psychological assessment. You will be asked what your symptoms are, how long you’ve had them, the severity of symptoms, family history, your mental health history, and prior mental health treatment if any. Other questions can concern your memory, thought patterns, ability to express yourself, and to maintain relationships.
  • Physical exam to rule out other possible causes for your symptoms.
  • Blood and urine tests. These also help rule out other possible causes for your symptoms such as hypothyroidism.

Symptoms of Bipolar

Symptoms of bipolar disorder can vary greatly as some people are more prone to depression or mania, while others alternate these conditions or experience both at the same time. The severity and frequency of symptoms can vary as well.


The following may be signs of bipolar disorder in varying forms:

Manic Episodes

  • Heightened energy
  • Racing thoughts
  • Fast talking
  • Euphoria
  • Lack of sleep
  • Feeling invincible and thus often indulging in rash behavior
  • Lack of focus
  • Delusions

Hypomania

Symptoms for hypomania are similar to those for mania, but less severe. You can still function day to day, however hypomania can escalate to full mania or cycle into major depression.

Bipolar Depression

  • Feeling hopeless, empty
  • Irritability
  • Appetite or weight changes
  • Lack of energy
  • Difficulty feeling pleasure
  • Difficulty focusing
  • Suicidal ideation
  • Feeling worthless

Bipolar disorder in children and adolescents

According to the National Institute of Mental Health, when children and adolescents are manic they are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. When depressed, the youngsters may headaches, stomachaches, fatigue, irritability, social isolation, and extreme sensitivity to rejection or failure. Poor performance in school is common.

Prognosis

The disease can be severe and long term in some and less severe and infrequent in others. However, all sufferers should be able to lead normal lives with medication, therapy, and self-management skills including learning to recognize triggers such as irregular sleep, stressors, and changes in medication dosage.

 

Living With Bipolar

Living with bipolar disorder can be challenging. Changes in moods and behaviors can put stress on your job, relationships, and family life. Luckily, there are things you can do to help manage your disorder. These include:

  • Finding a good treatment team. This typically means a psychiatrist to work with you to find the right medications and dosages for you, as well as a therapist to help you manage your symptoms, impulses, and mood changes. The Depression and Bipolar Support Alliance reports that people with bipolar disorder who have high levels of satisfaction with their treatment and treatment provider maintain a much more positive outlook about their illness and their ability to cope with it.
  • Having a consistent routine. Don’t indulge in a 24-7, go, go, go lifestyle and do make sure you have a regular sleep schedule.
  • Talking to family and friends. Your family and closest friends should be aware of your condition, supportive of your treatment and – very important – aware of triggers indicating that you are on the brink of an episode. Family-Focused therapy can be helpful.
  • Joining a support group. Connecting with others who have your condition can help you feel less isolated, and may help you learn more about yourself and your condition. The Depression and Bipolar Support Alliance reports that patients who participate in patient-to-patient support groups may improve
  • Taking your medication as prescribed. It can be tempting to stop your medication or take more if you feel it isn’t working properly, but you shouldn’t make changes to your medication routine without first talking to your doctor. Some medications may take longer than others to be fully effective, and prematurely stopping usage can stop progress or even worsen your condition.
  • Staying away from drugs and alcohol. These can exacerbate erratic moods and leave you in a heightened depressive or manic state.
  • Eating a healthy diet and stay away from foods that you notice worsen your mood. A dietitian or self-kept food journal may help you keep track of what does and does not make you feel well.

Screening

Bipolar disorder affects over 2.5 million adult Americans annually. It is a serious disorder and if you have some of the symptoms – i.e.: extreme mood swings, reckless behavior, euphoria – you should go to a doctor for a psychological assessment, a physical exam, and blood and urine tests.

Bipolar disorder is often screened for in primary practice through the use of the mood disorder questionnaire (MDQ). The MDQ was developed by psychiatrists and researchers to accurately detect bipolar disorder in patients visiting their primary care physicians. It consists of about 15 questions regarding mood irregularity, energy levels, and sporadic behaviors. The MDQ has been found to be effective in identifying individuals with mood-related disorders, though its questions may not accurately distinguish bipolar disorder from other mood conditions in those who respond positively to the questionnaire; further testing may be required before a diagnosis is reached.

Prevention

There are no proven ways to prevent bipolar disorder. If you have been diagnosed and are in treatment, stay on your medications to lessen your chances of recurrence. Note that even small changes in mood, energy, sleep, and focus can be signs of an imminent episode. If you have had two or three full-blown episodes, you will most likely be advised to indefinitely continue the medication.

Medication And Treatment

Bipolar disorder is most commonly treated with mood stabilizers. Antipsychotics and antidepressants can be prescribed along with mood stabilizers to help further control symptoms.


Medication

Mood stabilizers have been clinically shown to successfully reduce the severity of manic/depressive symptoms. They work by affecting communication within the nervous system to limit brain activity that leads to manic/depressive behaviors. Mood stabilizers often take several weeks for their full effects to be observed. They are most effective when distributed throughout the body at an optimal level, which can take several weeks of close blood monitoring to arrive at. Do not alter your medication regimen without first talking to your doctor. These include:

Lithium (Eskalith, Eskalith CR, Lithobid). After being approved by the FDA in the 1970s for the treatment of both manic episodes and depressive episodes, lithium established itself as a primary medication for the treatment of bipolar disorder. Researchers are still unsure of why this naturally occurring element works as an effective treatment for bipolar disorder. The effects of lithium typically do not begin to take effect until about two weeks after the initial dose, with full effects emerging three to six weeks after the initial dose. It works best for those who experience euphoric mania (as opposed to mixed mania or anxious mania), and about 50% of the patients who take lithium notice an improvement in their condition. The FDA warns that because lithium toxicity can occur at therapeutic doses, lithium therapy must be monitored with blood tests. Women who are pregnant or breastfeeding should not take lithium due to the risk of birth defects. According to researchers at the University of South Florida, a safer form of lithium called lithium salicylate is on the horizon. Findings on the new drug were published in the March 2014 issue of RSC Advances, the journal of the Royal Society of Chemistry.

Side effects of lithium include:

  • Excessive thirst
  • Loss of coordination
  • Frequent urination
  • Blackouts
  • Seizures
  • Slurred speech
  • Fast, slow, irregular, or pounding heartbeat
  • Hallucinations (seeing things or hearing voices that do not exist)
  • Changes in vision
  • Itching, rash
  • Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

Anticonvulsant medications were originally developed to treat seizures but were found to help control moods as well. These include:

  • Valproic acid, also called divalproex sodium (Depakote)
  • Carbamazepine (Tegretol)
  • Lamotrigine (Lamictal)
    • Oxcarbazepine (Trileptal).

Anticonvulsants can have serious side effects, including:

  • Changes in weight
  • Nausea
  • Stomach pain
  • Vomiting
  • Anorexia
  • Drowsiness
  • Insomnia
  • Loss of appetite
  • Loss of vision
  • Loss of coordination
  • Damage to the liver or pancreas
  • Increased risk of suicidal thoughts and behaviors.
  • An increase in testosterone levels in teenage girls leading to a condition called polycystic ovarian syndrome disease that can affect fertility and make the menstrual cycle become irregular (Valproic acid ONLY)
  • Increased risk for ovarian cysts
  • A rare but serious skin rash that can cause permanent disability or be life-threatening. (Lamotrigine ONLY)

If you experience any increased symptoms of depression or suicidal thoughts or behaviors, talk to your doctor as soon as possible. If you are contemplating suicide, call 1-800-273-TALK for immediate support.


Atypical antipsychotics can be used in combination with mood stabilizers to treat symptoms of bipolar disorder. Initially, these were thought only to treat psychosis, a symptom of other mental disorders such as schizophrenia. Atypical antipsychotics used to treat bipolar disorder include:

  • Olanzapine (Zyprexa)
  • Aripiprazole (Abilify)
  • Risperidone (Risperdal)
  • Ziprasidone (Geodon)
  • Clozapine (Clorazil)
  • Lurasidone (Latuda)

Mild side effects of atypical antipsychotics include:

  • Weight gain is an almost certain side effect of atypical antipsychotics. Individuals taking atypical antipsychotics should be careful to monitor their diet and exercise regularly.
  • Drowsiness is the second most common side effect.

Serious side effects of atypical antipsychotics include:

  • Diabetes
  • Increased risk for heart disease
  • High cholesterol
  • Muscular dysfunction (i.e. inability to move muscles, involuntary muscle spasms)
  • Sexual dysfunction (low libido, erectile dysfunction, inability to orgasm)
  • Increased risk for cataracts

SSRI Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder, however people with bipolar disorder should not take an antidepressant on its own because doing so can cause the person to switch rapidly from depression to mania. Doctors typically prescribe an antipsychotic along with an antidepressant for patients with bipolar disorder. Recent studies suggest that antidepressants are not as effective in treating individuals with bipolar as initially thought. A study funded by the National Institute of Mental Health found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. Use of antidepressants as treatment for bipolar disorder is therefore controversial, however doctors may still choose to prescribe SSRI anti-depressants including:

  • Gluoxetine (Prozac)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)

Serious side effects of antidepressants are among the reasons why their use for bipolar disorder treatment is controversial. These include:

  • Weight loss
  • Fatigue
  • Apathy
  • Insomnia
  • Sexual dysfunction (low libido, erectile dysfunction, inability to orgasm)
  • Suicidal thoughts or behaviors

Women who are pregnant should not take these medications, as SSRI antidepressants have been shown to cause birth defects.


Psychotherapy

In addition to medications, various types of psychotherapy may be helpful in treating and managing your bipolar symptoms.

These include:

  • Cognitive-Behavioral Therapy (CBT), which helps you learn techniques to manage your stress and erratic emotions. Therapy sessions are typically conversational between the therapist and the patients. Patients learn how to identify their problem and work through it carefully, avoiding rash or impulsive responses. CBT is typically used in combination with medicine to control symptoms, though it may be used as an alternative to medicine if a patient has shown to be unresponsive to all drugs.
  • Single, couple, group, or family therapy. These types of psychotherapy can be effective in helping bipolar disorder patients and their loved ones effectively manage relationships, which can be put under stress by the disorder’s effect on mood and energy levels.
  • Psychoeducation, which can teach bipolar disorder patients and their loved ones more about the disorder and help them better understand how to live with it.
  • Interpersonal and Social Rhythm Therapy (IPSRT) can help patients identify and maintain daily routines in order to minimize stressful situations and help prevent erratic behavior.

Complementary and Alternative Treatment

In addition to medications and therapies, alternative treatments may help reduce bipolar disorder symptoms. Keep in mind that most of these treatments are only backed by anecdotal evidence that has not been validated by statistical data and are therefore not endorsed by the FDA as official treatments for bipolar disorder.


The following alternative medicines may be helpful in treating bipolar disorder:

Nutritional supplementation. Certain supplements may be useful in controlling high and low moods associated with bipolar disorder.These include:

  • Omega-3 fatty acids. The National Center for Complimentary and Alternative Medicine published studies suggesting omega-3 fatty acids may be helpful in treating bipolar disorder. These anti-depressant, mood-stabilizing fatty acids are found in fish, flaxseeds, eggs, green vegetables, and olive oil, among other sources. However, they “strongly recommend that patients with psychiatric disorders should not elect supplementation with omega-3 [fatty acids] in lieu of established psychiatric treatment options.”
  • 5-hydroxytryptophan (5-HTP). 5-HTP is a chemical your body naturally makes that is a pre-cursor to serotonin, a mood-boosting neurotransmitter. 5-HTP supplements have been shown in a few studies to increase serotonin levels in the brain, regulating the mood of the patient and relieving depression.
  • 5-Dehydroepiandrosterone (DHEA). DHEA is a natural steroid produced in the adrenal glands that is thought to have antidepressant and mood regulating properties. Because of its natural interactions with hormones, DHEA may have severe hormonal side effects and its use as a supplement is therefore controversial

Herbal supplements. Certain herbal supplements may also be helpful in lessening bipolar disorder symptoms.Possibly beneficial herbal supplements include:

  • St. John’s Wort is thought to have antidepressant properties, but its interaction with the following drugs may serious and even life-threatening side effects:
    • oral contraceptives
    • selective serotonin reuptake inhibitors (SSRIs)
    • blood thinners
    • chemotherapy medicines
    • digoxin
    • statins
    • immunosuppressants
    • HIV medications
  • Ginseng is thought to boost the immune system, improve moods, and regulate energy levels. However like St. John’s Wort, Ginseng can cause life-threatening side effects as a result of drug interactions and can cause serious complications if taken in a high doses. Individuals with heart disease or at an elevated risk for heart conditions should not take Ginseng, as it can affect heart rate.

Acupuncture. Acupuncture is a form of ancient Chinese medicine that focuses on replenishing the bodily flow of energy though the placement of small needles in acupuncture points around the body. Anecdotal evidence suggests that acupuncture can help raise energy levels, regulate moods, and alleviate stress, though there is little statistical evidence suggesting it as an effective treatment for bipolar disorder.

Mind/body practices such as yoga, tai chi, and meditation can help individuals concentrate on finding a bodily rhythm that reduces stress and anxiety levels.

Care Guide

If you have been diagnosed with bipolar disorder, the following tips can help you manage your symptoms and lead a more balanced, happier lifestyle:

  • Educate your family and friends about bipolar disorder. Tell your loved ones about your triggers and teach them how to recognize when you are on the brink of an episode so that they can help you keep on track. For example, if they see that you are showing signs of an episode, they can ask if you have been adhering to your medication schedule.
  • Avoid drugs, alcohol, and situations that might compromise your self-control.
  • Know that the right treatment plan can help you. There are many medications out there. Your doctor can help you find the best approach. Even if you feel like your medications aren’t working, don’t make any changes without first talking to your doctor. Additionally, if you are not happy with your doctor(s), find ones that better suit your needs.
  • Try to avoid stress. Know your triggers and have a plan to keep stress at a minimum.
  • Learn to manage stress. Avoiding stressful situations won’t always be possible. Learn techniques of how to identify problems and think through them in a rational manner to help prevent the likelihood of a stressful event triggering a manic or depressive episode.

When To Contact A Doctor

If you suspect you have bipolar disorder, track your emotions for at least two weeks. Pay special attention to what affects your emotions and look for possible triggers. This will be helpful when you see a mental health professional, which is definitely a good step to take so that you can figure out what is going on.

If you have suicidal thoughts, call 911 or the suicide helpline at 1-800-273-TALK immediately.

If you have already been diagnosed with bipolar disorder and experience any of the following, contact your doctor immediately:

  • Vomiting
  • Excessive weight loss
  • Abdominal or chest pain
  • Changes in vision
  • Irregular heartbeat
  • Slurred speech
  • Hallucinations

These could be signs of serious complications with your medications.

Questions For Your Doctor

Your care team for your bipolar disorder will most likely have several members. You may wish to include:

  • Psychiatrist or pharmacologist to give a mental assessment and prescribe medications.
  • Therapist for behavioral, psychological, and relationship counseling.
  • Dietitian to help design a diet plan that avoids foods that worsen moods.

Finding the right members for your team can be a difficult task. Here are some suggestions to help make the process easier:

  • Ask trusted friends for referrals to mental health professionals. Choosing healthcare professionals that are respected and trusted by those you know can help you respect and trust them, facilitating the necessary environment for the treatment process.
  • Call the Department of Psychiatry of your local university to ask for recommendations.
  • Contact your insurance company for a list of mental health care providers to avoid costly medical bills.
  • Contact the local chapter of the Depression and Bipolar Support Alliance for information about bipolar disorder treatment and access to support groups and networks of emotional support. You can get recommendations from the group and have emotional support as well.

Questions For A Doctor

It is best to be as pro-active as possible in your treatment. Asking your doctor questions can help you better understand your condition, and communication can help make treatment more effective and efficient.

Here are some good questions to ask:

  • What kind of bipolar disorder do I have? How severe is it?
  • How will bipolar disorder affect me over the long term?
  • What are some key components to successfully manage this disease?
  • Are there other types of medical or mental health experts who should be involved in my treatment?
  • What should I do if I am in crisis?

Resources

For more information about bipolar disorder:

For information on support groups and suicide helplines, visit:

  • American Foundation for Suicide Prevention is devoted to helping prevent suicide. It includes pages on the relationship between depressive disorders and suicide, steps for prevention, help for survivors, and related resources.
  • Depression and Bipolar Support Association provides information on mood disorders, such as a list of support groups with chapters, personal stories, programs, publications, resources, and advocacy.

If contemplating suicide, please call 1-800-273-TALK