What is Bipolar Disorder?
Manic depression, now named Bipolar Disorder, is characterized by mainly depression with a history of at least one manic episode. A combination of genes and stressful triggers can cause shifting between unipolar depression and mania. Mixed mood states may be present as well as euthymic states or normal mood. Moods may alternate or cycle quickly or slowly.
A recent survey found bipolar disorder had been misdiagnosed in 69% of individuals. Half of those misdiagnosed patients had at least ten years of symptoms before the disorder was accurately diagnosed. Women were misdiagnosed more often, assumed to have just depression.
Misdiagnosis leads to the wrong medications, possible worsening of symptoms, and more frustration for the patient. As more rigorous studies and treatment approaches proliferate, a more positive recovery is possible by combining medication and psychological treatment.
Prevalence of bipolar ranges between 1-3% of the population and exists worldwide in persons of any age, race or nationality. Only one quarter to one half of those afflicted, depending on income and access to health care, seek treatment. Chronically recurring mood swings with a predominantly depressive state, deprives the person of stability and confidence to achieve normal life stages. Significant risk of illness and early death can be found in all subtypes of bipolar disorder.
Bipolar Disorder Symptoms
Bipolar disorder is a psychiatric diagnosis, not a physical disease. It is a chronic state, not an acute instance but a long-term condition needing management. The person feels in a disordered state, going from the top of the mountain to the pits. The person may experience several mood states including feeling normal. Generally there are two impairments with 3 or 4 alternating mood periods:
- Depression – dysphoria, an impairment characterized by a lagging, unenthusiastic approach, low activity level, pessimistic attitude, hopelessness, and helplessness. Everyone has the blues or mild cases of sadness at times, however this impairment is defined by the time span of weeks, months and years of persistent disability. Displays of anger and psychotic symptoms may also be exhibited.
- Manic episodes – euphoria, an impairment that raises or elevates mood to dangerous and disruptive levels including, but not limited to irritability, distractibility, and hyperactivity. Persons may be out of touch with reality and have delusions of grandeur, engage in indiscretions, have a low need for sleep, and be very talkative. Mania is suspected when these symptoms last at least one week. This mood is more disruptive than hypomania.
- Hypomania – has milder symptoms that last less than 4 days. Episodes may include spending sprees, and financially or sexually risky behaviors. Hypomanias are more difficult to diagnose.
- Mixed – persons may have a mixed mood of mania, hypomania and depression, as well as periods of normal mood.
- Euthymic – normal mood, neither depressed nor elevated. Euthymia can be confirmed with saliva samples to profile basal cortisol secretion.
Dealing With Bipolar Disorder
Many people are struggling with this crippling mental disorder which is not particular as to who it strikes. Anyone can have or develop symptoms including the rich and poor and the young and old. Some interpret the disorder in a positive light, seeing it as a capacity to experience a broader range of emotions than others. Famous and accomplished people with bipolar include musicians, poets, actors, and entrepreneurs.
The roller coaster of life can send anyone into maladaptive coping measures, but those with Bipolar Disorder may not have the skills necessary to manage their heightened senses. Many have been misdiagnosed or never diagnosed at all and see their special situation as an illness. Lowering expectations about what may be achieved, may not be helpful for long-term functioning. Coming to an understanding of the reality, seeing it as an advantage, not relying on just medication, but also learning specific coping skills may help bring an end to the suffering.
Bipolar patients may overestimate or underestimate their own situation, feeling that they should be happier than they are. However, researchers are finding downsides to happiness. Too much positive mood leads to declines in creativity and increases risk taking. Negative mood states have a place in the variations in mood that everyone experiences. Fear, guilt, pessimism and other negative moods have healthy purposes and bipolar patients may do well to reevaluate their transient negative mood states as all bad.
Lack of education about bipolar, misperception of mood, and maladaptive coping mechanisms for life events and situations may explain much about bipolar, however, a brain connection is present as well. Deviations in brain morphometry, including shape and volume, are detected with noninvasive neuroimaging data, usually an MRI or Magnetic Resonance Imaging. CT scans, Magnetic Resonance Spectroscopy (MRS), Positron Emission Tomography (PET), and functional imaging (fMRI and fMRS) are employed as well to take 3D images of the brain.
Brain regions involved in mood have been found to have reductions in size in bipolar patients. Brain structure differences between individuals with bipolar disorder and healthy comparisons were studied and subjects with bipolar had cerebral volume reduction in the hippocampal and amygdala regions. Bipolar patients also show dysfunction in the prefrontal cortex, the region of the brain involved in emotion-processing and regulation, higher thought processing and goal planning.
Studies have shown alteration in the biochemical substrates involved in regulation of mood including glutamate, myoinositol and choline. Deficits in these substrates predict difficulties with emotional expression and behavior.
Cause of Bipolar Disorder
The origin or development of bipolar disorder remains unknown, however several studies have linked the illness to several genes or DNA. Genetic factors influence the risk for bipolar disorder, and the expression of the genes may be triggered by environmental stressors. Researchers have mainly implicated the gene for Diacylglycerol Kinase, a key player in the lithium-sensitive phosphatidyl inositol pathway responsible for cell signaling. When one biochemical player malfunctions, downstream reactions can be affected, triggering negative conditions.
An example of an environmental stressor which may have triggered bipolar gene expression, has been found in men coping with their partner’s breast cancer treatment. Some men were found to have developed severe bipolar symptoms, enough to cause hospitalization. Psychosocial problems developed when the men experienced changes in their emotional, social, and economic lifestyle due to their partner’s affliction.
Heredity plays a major influence in this disorder as 75 to 80 percent of all cases are hereditary, passed down in the gene pool. The best way to predict whether an individual will develop the condition is the presence of a close family member with bipolar disorder. Having a parent with bipolar disorder increases the likelihood as much as four times, that a child will develop this mood disorder.
Bipolar Disorder Side Effects
Changes or impairments in functioning can affect one’s social life and career. Relationships may change drastically as loved ones struggle to cope with mood swings and unpredictability. Functioning at work may be fraught with conflict or underperformance. Emotional, physical and financial dysfunction may keep reoccurring as the person cycles from one mood to another and one crisis after the other.
Bipolar patients have increased health care costs, lower annual income, higher unemployment, and more reliance on public assistance. At work, the patient often has more absenteeism, lower productivity and lower overall functioning. Long-term effects include a lower quality of life, suicidal behavior, and decreased life span. Severity of psychosocial effects increases as the severity of the disorder increases.
Elevated levels of the stress hormone cortisol, were found in children during chronic and episodic stress periods with the bipolar parent. Early over secretion of cortisol may set a pathway of metabolic changes that lead to bipolar later in life. Researchers believe that children are not only inheriting bipolar genes and traits, but also that growing up with someone bipolar is stressful and chaotic, increasing the risk for developing a mood disorder.
People with bipolar disorder are at increased risk for diabetes, obesity, hypertension, endocrine disorders, autoimmune disorders and cardiovascular disease. Negative metabolic changes can also result from mood stabilizers, anticonvulsants, and antipsychotic medications used to treat bipolar. Comorbidities or simultaneously occurring conditions affect most patients with bipolar. Substance use is prevalent along with psychiatrically complicating issues like attention deficit hyperactivity disorder (ADHD), anxiety disorders and panic attacks. Comorbidities are explained by genetic factors.
Crime and Substance Abuse
Bipolar patients have a much higher incidence of substance use than patients with schizophrenia, obsessive-compulsive disorder, and unipolar depression. Bipolar patients have a 61% lifetime prevalence of substance use, including alcohol, stimulants and illegal drugs. The higher crime rate found in bipolar patients is due to substance abuse, researchers say, and not a direct result of the illness.
Half of all individuals with bipolar disorder are estimated to make at least one suicide attempt. Suicide rates increase during the depressed cycle. Untreated bipolar patients complete suicide 10%-15% of the time. Male veterans with bipolar disorder committed suicide more frequently. Researchers have found abnormal levels of a protein in the brains of people who had committed suicide. Lithium, a commonly prescribed drug to treat bipolar disorder shares the same pathway as the protein, and may explain why suicide is prevalent in those with the disorder.
Bipolar Disorder Diagnosis
A physician or psychiatrist will begin with a verbal interview of the patient and possibly the family and friends, and compile a comprehensive history complete with medical records. Family and friends may play an instrumental role in alerting the patient and the physician to warning signs. Having supportive encouragement from loved ones and acceptance by the physician may reduce the stigma and allow patients to speak openly about their experience.
The perceived feelings of stigmas as well as side effects of medications may reduce adherence to psychological treatments and medications. However, the first step is the most important one, to seek treatment and be properly diagnosed and classified. Family, friends and physicians should be aware of common risks for depression and mania.
Causes or Risks for Depression
- Life Events – divorce, job loss, marriage, death or illness of a loved one, retirement, and moving can trigger depression.
- Substance use – alcohol or drug abuse.
- Medical conditions – cancer, chronic pain, obesity, and insomnia.
- Medications – steroids can cause depression.
- Social Issues – loneliness, abuse or neglect in childhood or as an adult.
Causes or Risks for Mania
- Social Gatherings or Crowds – high energy situations may trigger a manic episode as the person goes into hyper drive mirroring the situation.
- Loud Sounds or Music – loud music or locations with high sound volumes like construction sites could induce mania.
- Insomnia – people may become slightly delirious with lack of sleep, edging into mania or hypomania.
- Change – new job demands, a new neighborhood or social environment may stimulate hyperactivity or risk taking.
- Stimulants – coffee, roller coasters, falling in love and other novel situations could excite the molecular pathways that influence mania.
Mis-Diagnosis of Bipolar
The main mistake that physicians make in diagnosing bipolar is to not ask if there are any signs of something opposite to depression. A diagnosis of unipolar depression is very common, however physicians may catch more bipolar disorders by asking if there have been any episodes of mania.
Researchers say that many bipolar patients are misdiagnosed and receiving inappropriate treatment by taking an antidepressant and not a mood stabilizing medication. Lithium, valproate, and carbamazepine are the appropriate mood stabilizers, anticonvulsants or antipsychotic medications proven for bipolar disorder. Emphasis must be placed on properly diagnosing the disorder, in order that treatment will be helpful and not harmful. Patients diagnosed with depression must be cleared of bipolar disorder before the administration of antidepressant drugs.
Multiple screening methods are used to diagnose and differentiate between bipolar subtypes, however they cannot take the place of a proper evaluation by a qualified psychiatrist. Improved diagnostic detection uses screening questionaires as a tool, but not as the primary method for screening for the potential presence of bipolar disorder. Discovery of patterns of mood episodes over the lifetime can alert a physician more than a screening method.
Mood Disorder Questionnaire (MDQ) – a self-assessed test developed by a team of psychiatrists, researchers and consumers. The test is taken by a person by answering 13 questions. A score of 7 or more affirmative responses is a positive result and likely to result in an official diagnosis of bipolar disorder.
Bipolarity Index – a system for diagnosing the dimensions of bipolar disorder, rather than using strict categories. The five dimensions of bipolarity: age at onset, the course of the illness, episode characteristics (mania or hypomania), medication response and family history.
Composite International Diagnostic Interview (CIDI) – Developed by the World Health Organization for use by trained laypeople. Several variations exist with some short-form versions for both interview use and patient self-assessment.
Bipolar Spectrum Diagnostic Scale (BSDS) – this story driven diagnostic tool asks the patient to place a check mark at the end of each sentence that agrees with their own experience.
Primary Care Evaluation of Mental Disorders (PRIME-MD) – a tool used in primary care practice and research to identify mental disorders.
Patient Health Questionnaire (PHQ-9) – a diagnostic and management tool for use in primary care settings to screen for depression.
Patient Health Questionaire (PHQ-2) – a short version with the only the following 2 questions,
“Over the past 2 weeks have you felt down, depressed, hopeless?”
“Over the past 2 weeks have you felt little interest or pleasure in doing things?”
Physicians may find screening mnemonics to be useful tools. A mnemonic is a learning aid that helps inform or jog the memory.
Screening for symptoms of mania/hypomania: “DIGFAST”
- D: distractibility – poorly focused, multi-tasking
- I: insomnia – decreased need for sleep
- G: grandiosity – inflated self-esteem
- F: flight of ideas – racing thoughts subjectively/tangential thought process
- A: activities – increase in goal-directed activities
- S: speech – pressured or hyper-talkative
- T: thoughtlessness – high risk-taking behaviors
Screening for hypomanias: “HIGH-4″
- H: hyperactivity, or distractibility, flight of ideas, pressured speech, racing thoughts
- I: insomnia and irritability
- G: grandiosity
- H: hyperhedonia (feeling great pleasure), or high-risk sexual activity, shopping sprees
- 4: 4 days’ minimum duration.
Screening for major depressive episode: “SIG E CAPS”:
- S: sleep
- I: interest
- G: guilt
- E: energy
- C: concentration
- A: appetite
- P: psychomotor retardation
- S: suicidal ideation.
Differentiating bipolar depression from unipolar major depression: “WHIPLASHED”
- W: worse or wired when taking antidepressants
- H: hypomania, hyperthymic temperament, or mood swings
- I: irritable, hostile, or mixed features
- P: psychomotor retardation (more common in bipolar depression)
- L: loaded family history of mood disorders
- A: abrupt onset and/or termination of depressions or relatively brief episodes (<3 months)
- S: seasonal or postpartum depression
- H: hyperphagia and hypersomnia
- E: early age at onset (<25 years old)
- D: delusions, hallucinations, other psychotic features.
- B: brevity of episodes
- I: impulsivity
- P: premorbid hyperthymic personality or polarity switch on antidepressant
- O: overeating and oversleeping
- L: lability of mood
- A: anxiety disorders and substance abuse disorders comorbid
- R: relatively resistant to treatment
- F: family history of schizophrenia or bipolar disorder
- A: abrupt onset, agitation, and behavioural abnormalities
- M: mixed episodes
- I: instability of job and marriage
- L: lithium or lamotrigine as potential treatments
- Y: young age.
Tests Commonly Ordered
- FBC – full blood count or complete blood count.
- TFTs – thyroid function blood test.
- Serum vitamin D – Vitamin D levels used to help diagnose problems.
- Toxicology screen – identifies substances intentionally or accidentally swallowed, inhaled, injected, or absorbed.
- Fasting lipid profile – measures cholesterol and triglyceride counts.
- Fasting glucose – checks for high or low blood sugar level.
- MRI brain – non-invasive imaging test of the brain.
Diagnosis and Differentiation of Subtypes
The DSM-IV-TR criteria for bipolar disorder include these key factors:
- Depression – major depressive episode(s) lasting more than a week with functional impairment.
- Mania – episode(s) of manic or mixed episodes, grandiosity, distractibility, talkativeness, involvement in risky pleasure pursuits, physical agitation or hyperactivity, racing thoughts, decreased need for sleep.
Symptoms Not Present
- Not due to substance abuse.
- No medical or medication cause.
- No psychiatric comorbidity or other psychiatric problems.
Bipolar I disorder is defined by the DSM-IV-TR, the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association as a disorder including mania and major depression with at least one manic or mixed episode.
Bipolar II disorder involves episodes of major depression and hypomania, but never a full blown manic episode.
Bipolar Spectrum Subtypes
- Bipolar disorder, not otherwise specified (NOS). Patients have atypical presentations that do not meet the criteria for Bipolar I or II and differentiates from a substance-induced mood disorder.
- Cyclothymia is chronic and numerous cycling between moods, but does not rise to the level of severity or duration to be classified as Bipolar I or II.
In addition to the standard classification, physicians may make additional findings based on the individual situation.
- rapid-cycling or not rapid cycling.
- acute depression, mania, hypomania, or not acute but ongoing.
- with agitation or without agitation.
- mild, moderate or severe co-disease present or not present.
- pregnant or non-pregnant.
Bipolar Disorder Treatment
Treatment for bipolar disorder involves restoring molecular actions, neuroprotective and neurotrophic factors for restoring cerebral volume in the hippocampal, amygdala and prefrontal cortex regions of the brain. Drug therapy treatments for bipolar disorder would increase the volumes of these brain regions.
The National Institute of Mental Health conducted the largest ever study of bipolar treatment options. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) began in 1998 and ended in 2006, with about 5000 people studied. Data continues to be studied and results published and can be viewed online and in published journals.
Traditional antidepressants are not indicated. Rather, bipolar disorder requires a customized long-term management plan that includes medication(s), psychosocial therapy, and monitoring for side effects and complications. Only a physician can diagnose bipolar disorder, prescribe medication and describe side effects.
Treatments for bipolar disorder include:
- Anti-Seizure/Mood-stabilizers – Depakote, Tegretol, and Lamotrigine to stop the cycling through the highs and lows. Lithium is a time-tested and proven mood stabilizer that significantly increases brain volume in affected regions. However, some side effects of Lithium include a high risk for overdosing, weight gain, and kidney damage.
- Tranquilizers – Seroquel, Zyprexa and Abilify are used to create a roof, stalling the feeling of getting too high.
Treatment must be customized to the individual and adjusted as necessary. Some additional pharmacologic treatments are indicated in some situations depending on complicating factors of agitation, pregnancy, rapid-cycling, co-factor diseases either psychiatric or medical:
- Intramuscular neuroleptic – direct injection of anti-psychotic with a needle.
- Benzodiazepine – a class of tranquilizers.
- Atypical antipsychotics – anti-psychotic medication which do not trigger motor or movement difficulties.
- Clonazepam – commonly named Klonopin or Paxim, high-potency and fasting acting drug, not indicated for long-term use.
- Clozapine – an anti-psychotic drug mainly used for schizophrenia.
- Electroconvulsive Therapy (ECT) – electrical currents given in a medical setting may cause positive brain changes, without the problems associated with the treatment administered in the past.
- Quetiapine plus Lithium – an atypical antipsychotic prescribed with Lithium to increase effectiveness.
- Valproate Semisodium – for long-term treatment of bipolar rapid-cycling subtype.
Behaviors to Avoid
Alcohol and drug use is common in bipolar disorders of all subtypes. Elimination of substance use may decrease symptoms and increase long-term health outcomes.
Proper ingestion of biologically valuable foods may help brain function and decrease alcohol cravings. Fish oil and similar anti-inflammatory foods may have a neuro-therapeutic effect. DHA, the fatty acid and the main ingredient in fish oil, restored normal behavior in bipolar patients. Researchers believe that omega-3 fatty acids work on the molecular pathways in the brain similar to the action of psychiatric drugs.
Exercise and Sleep
Restoring circadian rhythms and replenishing naturally occurring hormones is a low cost, extremely effective strategy to control mood. Exercise and sleep are vital health behaviors for almost any issue, especially for regulating mood. Researchers have found that bipolar patients have problems with motor movement, balance, and judging their bodies’ relationship to the environment. Exercise and balance therapy may improve brain regions associated with bipolar.
Multicomponent Intervention Program
A customized approach to treating bipolar disorder must include psychotherapy and possibly family counseling as bipolar is handed down in close relatives. Maladaptive coping strategies may be handed down as well. Psychosocial therapy for the individual and the family seeks to increase knowledge, disprove myths and focus on practical coping strategies.
Depression – a persistent negative mood with learned helplessness attitudes. Cases may be transient, mild, severe or chronic.
Generalized Anxiety Disorder – characterized by a lack of control in managing worry and tension. Physical problems may develop including muscle tension, dizziness and panic attacks.
Social Anxiety Disorder – the presence of other people causes persons with this disorder to become overvigilant to their own performance or presentation to others. They worry that other people are looking at them and judging them. This constant fear leads them to avoid social situations.
Attention Deficit Hyperactivity Disorder – found in children and adults with the primary symptoms of impulsivity, inattentiveness and hyperactivity.
Personality Disorders – multiple types of personality disorders can be diagnosed, however all feature a narrow range of feelings, thoughts, and behaviors that do not show adaptability in most situations. A personality becomes fixed in a particular maladaptive psychiatric condition.
The body’s timing system, called the circadian clock, is driven by the day and night cycle. Light and several enzymes complete the resetting of the clock. RORB is a gene affected by the circadian clock. Alterations or abnormalities in this gene are correlated with bipolar disorder and bipolar disorder is often characterized by circadian rhythm abnormalities. Identifying genes or molecular pathways affected by circadian rhythms helps to develop potential drug-based solutions. Treating bipolar disorder may be as simple as resetting the body’s natural clock.
Treatment Resistant Bipolar Disorder
Some people are nonresponsive to treatment, having tried adequate doses of established mood stabilizers. Lamotrigine, a drug used for epilepsy and seizures showed a superior result in treatment resistant bipolar disorder. Lamotrigine users experienced a 23.8% recovery rate. Treatment with inositol gave a 17.4% recovery rate and risperidone gave a 4.6% recovery rate.
Predicting Mood Swings
Researchers have found that they can predict who will have severe mood swings by listening to the patients’ thought patterns. Patients who believed that their moods were out of their control or they had to do certain things to keep their emotions in control, were more likely to have severe episodes. Patients who fostered a new approach to accept and manage their range of emotions, fared better by actually being in control and managing current problems.
Transcranial magnetic stimulation (TMS) has been found to stimulate the prefrontal cortex, a region of the brain implicated in bipolar disorder. Electrical pulses stimulate neurons to increase norepinephrine, serotonin, dopamine and other mood elevating biochemicals. This treatment uses an electrical field, not electricity like shock therapy used to. Patients feel a mild, painless sensation, and report feeling much better after treatment.
Online Peer Group
Bipolar patients can participate in online support groups for support, information and a sharing of experiences. Experts cannot yet provide statistical support for the benefits of online support, however believe the groups are beneficial and relevant.
Bipolar disorder is part of a spectrum of mood disorders. Heredity plays a major role as genes are inherited from parents. Events, stimuli and stress can trigger presentation of symptoms. Maladaptive coping mechanisms are handed down as well, from bipolar parents living in a chaotic environment to children who adopt those coping strategies and develop mood disorders of their own.
Long-term management of any subtype of bipolar disorder is recommended. Outcomes cannot be guaranteed however, as no definitive cure has been found. A high degree of substance abuse and suicidal ideation complicates and worsens treatment outcomes, as well as concurrent psychiatric illnesses which are often difficult to diagnose.
Also, many people never seek treatment or do not have access to adequate medical care. When people do seek medical care, their symptoms are often misdiagnosed and they are given medication for depression only, which may worsen their symptoms. Primary care physicians are advised to ask simple questions about possible manic episodes, when patients present with depressive symptoms, and to refer to a psychiatrist for full diagnosis.