What is Bipolar Disorder?
Bipolar disorder (BD) is a condition where someone has recurring periods of overwhelming excitement or extreme happiness (mania or hypomania) followed by depression. This disorder is often hard to identify correctly at first.
There are various types of this disorder, which include bipolar I disorder, bipolar II disorder, and cyclothymic disorder (a mild form of bipolar). Other diagnoses may also fall under the label of bipolar or similar disorders, defined by the specific circumstances. The term “bipolar affective disorders” used in the International Classification of Diseases 10th Revision (ICD-10) has been updated to “bipolar disorders” in ICD-11. The category for bipolar disorders in ICD-11 shares its title with the definition given in the Diagnosis and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
A study conducted by the World Health Organization discovered the occurrence, severity, effects, and related conditions of the bipolar spectrum disorder, which includes bipolar I and II, and subthreshold bipolar, are strikingly similar across the globe. It’s estimated that 2.4% of the world’s population experience bipolar spectrum disorders in their lifetime.
Bipolar disorder is challenging to identify because its symptoms are common with other psychiatric disorders. Alongside this, patients often experience additional mental and physical conditions and may not be fully aware of their condition, especially during hypomania phases. Treatment typically includes medication and support services to help manage the patient’s mood. However, it’s common for patients undergoing treatment to still experience mood relapses and incomplete response, especially during depression. Therefore, regular review and adjustment of treatment are often necessary. Managing any additional psychiatric and medical conditions might also be needed. This gives us an understanding of the cause, types, examination, and handling of bipolar disorder.
What Causes Bipolar Disorder?
Right now, we don’t exactly know what causes BD, or bipolar disorder, but it’s thought to come from a combination of genetic, environmental, brain chemistry, and lifestyle factors. We know that it can be passed down in families. In 1987, scientists found the first piece of DNA linked to the chance of developing BD. Since then, at least 30 other genes have been found to potentially increase the risk of this condition.
While it’s hard to link specific life events to the onset of BD, a history of child neglect or abuse, especially emotional abuse, can be connected to the development of this disorder later in life. Other stressful life events like having a baby, divorce, unemployment, disability, and the death of a parent at an early age can also contribute to its development. In fact, over 60% of adults with BD have reported experiencing a significant stressful event in the six months leading up to a period of mania or depression.
BD is also thought to be associated with imbalances in brain chemicals, particularly dopamine and serotonin, alongside disruptions in the systems within our cells that control mood. However, no single problem with these brain chemical systems has been definitively identified as causing BD.
Recently, the ENIGMA Bipolar Disorder Working Group stated in a review of brain imaging studies, “Overall, these studies point to a widespread pattern of changes in brain including smaller below-cortex volumes, thinner cortex, and disrupted white matter structure in bipolar disorder patients compared to healthy individuals.” This implies that brain scans have also found changes in how different regions of the brain connect and communicate in people with BD.
Risk Factors and Frequency for Bipolar Disorder
The World Mental Health Survey Initiative undertook a study on the use of mental health services for various bipolar disorders. Despite differences in prevalence rates across various locations, the severity, impact, and patterns of additional disorders were surprisingly similar worldwide.
- The lifetime prevalence was 0.6% for BD-I (Bipolar I Disorder), 0.4% for BD-II (Bipolar II Disorder), 1.4% for subthreshold BD (Bipolar Disorder not otherwise specified), and 2.4% for any kind of Bipolar Disorder.
- Most people with bipolar disorder show symptoms between the ages of 15-24 and 45-54.
- More than 70% show symptoms before the age of 25.
- Bipolar disorder is equally distributed across genders, ethnicities, and urban and rural locations.
- For Cyclothymia, a milder form of bipolar disorder, about 0.4-1% of people will experience it in their lifetime, with an even balance between males and females.
Signs and Symptoms of Bipolar Disorder
Bipolar disorder is a mental health condition that doctors diagnose based on a detailed patient examination, including talking to the patient and sometimes their relatives as well. They’ll look at how the condition evolved over time. It’s important to understand there’s no specific medical test like a blood test or brain imaging that can confirm bipolar disorder.
Puzzlingly, bipolar disorder often takes about 6 to 10 years to get diagnosed after patients first see a doctor, even though clear symptoms might be present. Misdiagnosis can happen particularly when a patient is initially diagnosed with major depressive disorder (MDD), another mental health condition. Up to 30% of these patients might transition to bipolar disorder within three years, so doctors must be open to this possibility. The same goes for patients who have MDD and show somewhat lesser signs of mania, a state of excessive energy; this happens in up to 40% of MDD patients.
To help in identifying bipolar disorder, doctors may use self-report tools. Two well-studied options are the Mood Disorders Questionnaire and the Hypomania Checklist 32; while not perfect, they can guide doctors towards a more comprehensive evaluation if results suggest bipolar disorder.
It can be particularly challenging for doctors to distinguish between regular (or unipolar) depression and bipolar disorder, as both conditions involve periods of depression. This makes it essential for doctors to ask about previous episodes of mania, hypomania, and depression when a patient reports symptoms of a depressive episode. For young patients, those who’ve had many instances of depression, and those with a family history of bipolar disorder, any past experience with mania or hypomania can increase the likelihood of a bipolar diagnosis.
Additionally, certain factors can indicate a shift in diagnosis from MDD to bipolar disorder. These include the occurrence of psychosis, a lack of response to antidepressants, onset of mania by antidepressant treatment, and having three or more co-existing conditions.
Testing for Bipolar Disorder
According to the American Psychiatric Association’s 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Bipolar and Related Disorders are diagnosed based on specific criteria. Here’s what those criteria could look like:
Bipolar I (BD-I): The individual has experienced at least one manic episode, which could have been surrounded by a less severe manic episode (hypomanic) or a major depressive episode (neither of which is necessary for the diagnosis).
Bipolar II (BD-II): The individual has experienced at least one hypomanic episode in their past or currently, and a major depressive episode; but no manic episodes.
Cyclothymic disorder: The individual experiences hypomanic symptoms and depressive symptoms that don’t meet all the criteria for hypomanic and major depressive episodes. These symptoms occur frequently for at least two years (or one year for those aged 18 and under). The individual has never met the full criteria for major depressive, manic, or hypomanic episodes.
Specified and Unspecified bipolar and related disorders: These are categories for bipolar-like symptoms that don’t fit BD-I, BD-II, or cyclothymic disorder due to being insufficient in duration or severity or due to other significant difficulties in everyday activities. Any related symptoms or episodes should not be related to the effects of a substance or a general medical condition.
BD-I and BD-II can be further detailed with subtypes like rapid cycling or seasonal patterns and the presence of psychosis, extreme anxiety, melancholic features, or onset around childbirth.
Mood-related delusions may be present in either a major depressive or manic episode, including feelings of extreme guilt or grandiose notions of power and wealth. “Mixed features” involving both mania and depression are accounted for with specific criteria.
The criteria discussed here are taken from the DSM-5’s diagnostic guidelines for Bipolar I Disorder, Bipolar II Disorder, and a major depressive episode. The precise criteria involve particular measures of mood, energy, activity, self-esteem, sleep, talkativeness, distractibility, and risk-taking—in combination with duration and impact on daily functioning—to distinguish manic, hypomanic, and depressive episodes. It’s also crucial to exclude the effects of substances, a general medical condition, or psychosis, when applicable.
Additional tests may be required if a secondary cause of bipolar disorder is suspected. This includes cases where an individual first shows symptoms after age 50, shows unusual vital signs or neurological exam results, has a recent change in health or medications that aligns with symptom onset, responds unusually or not at all to typical treatments, or has no personal or family history of psychiatric disorder. These tests may include a urine drug screen, complete blood count, comprehensive metabolic panel, thyroid function tests, and checks for vitamin B and folate levels.
Treatment Options for Bipolar Disorder
Although there are many guidelines for treating and managing bipolar disorder, their recommendations are not always consistent, making it difficult to form a standard treatment plan. Various guidelines from organizations including the National Institute for Health and Care Excellence (NICE), British Association for Psychopharmacology, International College of Neuro-Psychopharmacology (CINP), Canadian Network for Mood and Anxiety Treatments (CANMAT), International Society for Bipolar Disorders (ISBD), and Indian Psychiatric Society (IPS), have been taken into consideration.
In bipolar disorder, a manic episode is treated as a medical emergency and often requires staying in a psychiatric hospital. The first goal is to stabilize the patient to reduce distress, prevent harmful behavior, and allow for patient assessment. In this phase, it can be helpful to provide a calm environment and use medication such as benzodiazepines along with mood stabilizers and antipsychotic drugs to induce calm and promote sleep.
During mania, it’s important to review current medications. If the patient is only taking lithium, another drug is usually added. Antidepressants are often phased out. First-line treatments involve mood stabilizers, like lithium or valproate, or antipsychotic drugs such as aripiprazole, asenapine, cariprazine, quetiapine, or risperidone.
If symptoms can’t be controlled or mania is severe, extra medication is considered. This could mean combining lithium or valproate with certain antipsychotic drugs. Electroconvulsive therapy (ECT) might be chosen for very severe or treatment-resistant cases.
Hypomanic episodes, by their definition, are less severe without causing psychosis. Thus, they can be managed outside the hospital. The medications used are similar to those for mania, but higher doses may be required for mania.
When dealing with acute bipolar depression, the primary immediate concern is the risk of suicide or self-harm. In this phase, patients may need to be hospitalized. Medications for patients not already on long-term drugs for bipolar disorder include quetiapine, olanzapine, or lurasidone with additional treatments considered in consultation with a healthcare provider. Cognitive behavioral therapy (CBT) can complement pharmacotherapy, but studies show it’s not as effective as a standalone treatment.
Patients undergoing long-term medication are closely assessed during depressive episodes. Healthcare providers make sure that their current treatment can prevent a manic relapse. It’s crucial to check factors such as dosage, drug interactions, and stressors that might affect the effectiveness of the treatment.
Antidepressant medications should never be the only treatment for most patients with bipolar disorder, given the risk of destabilization or a shift to mania. Antidepressants can be combined with mood stabilizers and second-generation antipsychotics.
Maintenance treatment is a continuous, long-term strategy aimed at preventing the recurrence of bipolar disorder episodes. This usually involves medication that had proven effective during the acute phase. Mood stabilizers and atypical antipsychotics are the go-to drugs for maintenance. Long-term lithium mono-therapy has been particularly effective in preventing manic, depressive, and mixed relapses and reducing the risk of suicide. Regular monitoring of serum lithium concentrations is standard practice during lithium therapy. In addition, treatment success can be improved by prioritizing medication adherence, avoiding and treating comorbidities, considering psychotherapy, and maintaining regular assessments for suicide risk.
What else can Bipolar Disorder be?
When a doctor is trying to diagnose bipolar disorder, they’ll also consider other conditions that might cause similar symptoms. These conditions may include:
- Major depressive disorder (MDD)
- Schizophrenia
- Anxiety disorders
- Substance abuse issues
- Borderline personality disorder
In children, a doctor might also consider:
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Oppositional Defiant Disorder (ODD)
The doctor will carefully consider all these possibilities when making a diagnosis. They’ll use their understanding of the patient’s symptoms and condition to guide their decisions and provide suitable treatment.
What to expect with Bipolar Disorder
Bipolar disorder is among the top 10 disabilities globally that cause significant health impacts. Recent studies indicate that people with bipolar disorder often live about 13 years less than the average population. Interestingly, this reduction in lifespan is higher in people with bipolar disorder compared to those with common mental health issues like anxiety and depression. Also, men with bipolar disorder generally have a lower lifespan compared to women with the same condition.
A different study revealed that the overall mortality rate for people with bipolar disorder is twice that of the average population. Natural death rates are about 1.5 times higher, primarily driven by nearly double the risk of death from circulatory illnesses like heart attacks or strokes, and three times the danger of death from respiratory diseases like COPD or asthma.
Furthermore, unnatural deaths occur about seven times more in people with bipolar disorder, with the suicide risk being about 14 times higher and the threat of other violent deaths approximately four times higher. Both men and women with bipolar disorder have a similar increase in death rates from all studied causes. Another recent study showed that the suicide rate in those with bipolar disorder is about 20 to 30 times greater than in the average population.
Possible Complications When Diagnosed with Bipolar Disorder
People with bipolar disorder are at a significantly higher risk of dying early due to suicide and other health issues, including heart, respiratory, and hormonal disorders. It’s also noted that a majority of individuals with this disorder have weight-related issues, either being overweight or obese. This weight problem is not necessarily linked to medications that may cause weight gain. Additionally, about one-third of patients with bipolar disorder also have what’s known as metabolic syndrome, a condition that heightens the risks of heart disease and stroke. Furthermore, this syndrome is linked to higher instances of attempted suicide.
Numerous other health problems can coincide with bipolar disorder. Migraine headaches, for instance, are a commonplace occurrence. Regarding psychological health issues, 50 to 70% of patients with bipolar disorder also have other conditions. Anxiety disorders, including generalized and social anxiety and panic disorder, are found in 70 to 90% of individuals with bipolar disorder. On top of that, 30 to 50% struggle with alcohol and substance abuse.
These co-occurring mental health issues can make bipolar disorder even more challenging to manage. They’re often associated with more severity in symptoms, frequent mood swings, and reduced quality of life. Up to half of the patients may additionally suffer from a personality disorder, particularly borderline personality disorder, and 10 to 20% may have a binge eating disorder. These conditions contribute to higher rates of mood episodes, suicidality, and substance abuse problems.
The presence of so many overlapping health concerns makes the management of bipolar disorder complex and delicate. Remember, it is crucial to seek and maintain appropriate medical care if you or someone you know has bipolar disorder.
Preventing Bipolar Disorder
It’s recommended for patients and their families to receive psychoeducation, either individually or in a group setting. This can include teaching them how to identify and manage signs of depression and mania, encouraging them to take their medication regularly, and offering tips for making healthier lifestyle choices. Patients are advised to stay away from stimulants like caffeine, cut down on alcohol, exercise frequently, and maintain good sleep habits.
Healthcare providers, on the other hand, are urged to build strong, supportive relationships with their patients, show empathy, involve patients in their treatment decisions, and always keep an eye on patient symptoms. Doing these have been found to lessen thoughts of suicide, improve the effectiveness of treatments, and boost patients’ overall satisfaction with their care.
Also, patients might find case management or care coordination services beneficial. These services link them with resources in their community, like support groups, mental health centers, and programs aimed at addressing substance use problems.
