Bipolar disorder involves periods of elevated or irritable mood (mania), alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.
Causes, incidence, and risk factors
Bipolar disorder affects men and women equally. It usually appears between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.
Types of bipolar disorder:
People with bipolar disorder type I have had at least one fully manic episode with periods of major depression. In the past, bipolar disorder type I was called manic depression.
People with bipolar disorder type II have never experienced full-fledged mania. Instead they experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of depression.
A mild form of bipolar disorder called cyclothymia involves less severe mood swings with alternating periods of hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be misdiagnosed as having depression alone.
In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people who are vulnerable to the illness:
Life changes such as childbirth
Medications such as antidepressants or steroids
Periods of sleeplessness
Recreational drug use
Symptoms
The manic phase may last from days to months and can include the following symptoms:
Agitation or irritation
Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
Little need for sleep
Noticeably elevated mood
Hyperactivity
Increased energy
Lack of self-control
Racing thoughts
Over-involvement in activities
Poor temper control
Reckless behavior
Binge eating, drinking, and/or drug use
Impaired judgment
Sexual promiscuity
Spending sprees
Tendency to be easily distracted
These symptoms of mania are seen with bipolar disorder I. In people with bipolar disorder II, hypomanic episodes involve similar symptoms that are less intense.
The depressed phase of both types of bipolar disorder includes the following symptoms:
Daily low mood
Difficulty concentrating, remembering, or making decisions
Eating disturbances
Loss of appetite and weight loss
Overeating and weight gain
Fatigue or listlessness
Feelings of worthlessness, hopelessness and/or guilt
Loss of self-esteem
Persistent sadness
Persistent thoughts of death
Sleep disturbances
Excessive sleepiness
Inability to sleep
Suicidal thoughts
Withdrawal from activities that were once enjoyed
Withdrawal from friends
There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can make the symptoms worse.
Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.
Signs and tests
A diagnosis of bipolar disorder involves consideration of many factors. The health care provider may do some or all of the following:
Ask about your family medical history, particularly whether anyone has or had bipolar disorder
Ask about your recent mood swings and for how long you've experienced them
Observe your behavior and mood
Perform a thorough examination to identify or rule out physical causes for the symptoms
Request laboratory tests to check for thyroid problems or drug levels
Speak with your family members to discuss their observations about your behavior
Take a medical history, including any medical problems you have and any medications you take
Note: Use of recreational drugs may be responsible for some symptoms, though this does not rule out bipolar affective disorder. Drug abuse may itself be a symptom of bipolar disorder.
Treatment
Spells of depression or mania return in most patients, in spite of treatment. The major goals of treatment are to:
Avoid cycling from one phase to another
Avoid the need for a hospital stay
Help the patient function as best as possible between episodes
Prevent self-destructive behavior, including suicide
Reduce the severity and frequency of episodes
The doctor will first try to determine what may have triggered the mood episode, and identify any medical or emotional problems that might interfere with or complicate treatment.
Drugs called mood stabilizers are considered to be the first-line treatment. The following are commonly used mood stabilizers:
Carbamazepine
Lamotrigine
Lithium
Valproate (valproic acid)
Other antiseizure drugs may also be tried.
Other drugs used to treat bipolar disorder include:
Antipsychotic drugs and anti-anxiety drugs (benzodiazepines), which can be used to stabilize mood
Antidepressant medications can be added to mood-stabilizing drugs to treat depression. People with bipolar disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, an antidepressant is only used in people who are also taking a mood stabilizer.
Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar disorder that does not respond to medication.
ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia.
ECT is the most effective treatment for depression that is not relieved with medications.
Transcranial magnetic stimulation (TMS) uses high frequency magnetic pulses that target affected areas of the brain. It is most often used as a second-line treatment after ECT.
Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stabilized and their behaviors are under control.
Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the potential risks and benefits of treatment for their children.
SUPPORT PROGRAMS AND THERAPIES
Family treatments that combine support and education about bipolar disorder (psychoeducation) appear to help families cope and reduce the odds of symptoms returning. Programs that emphasize outreach and community support services can help people who lack family and social support.
Important skills include:
Coping with symptoms that are present even while taking medications
Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
Learning to take medications correctly and how to manage side effects
Learning to watch for early signs of a relapse, and knowing how to react when they occur
Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients seek out proper support services, and help make sure the patient follows medication therapy.
Getting enough sleep is extremely important in bipolar disorder, because a lack of sleep can trigger a manic episode. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones.
A patient with bipolar disorder cannot always reliably tell the doctor about the state of the illness. Patients often have difficulty recognizing their own manic symptoms.
Mood variations in bipolar disorder are not predictable, so it is sometimes difficult to tell whether a patient is responding to treatment or naturally emerging from a bipolar phase.
Treatment strategies for children and the elderly have not been well-studied, and have not been clearly defined.
Expectations (prognosis)
Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.
Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.
Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with bipolar affective disorder require immediate emergency attention.
Complications
Stopping or improperly taking medication can cause your symptoms to come back, and lead to the following complications:
Alcohol and/or drug abuse as a strategy to "self-medicate"
Personal relationships, work, and finances suffer
Suicidal thoughts and behaviors
This illness is challenging to treat. Patients and their friends and family must be aware of the risks of neglecting to treat bipolar disorder.
Calling your health care provider
Call your health provider or an emergency number right way if:
You are having thoughts of death or suicide
You are experiencing severe symptoms of depression or mania
You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms
References
Moore DP, Jefferson JW. Bipolar disorder. In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier;2004:chap 80.
Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 420.
Benazzi F. Bipolar disorder -- focus on bipolar II disorder and mixed depression. Lancet. 2007;369:935-945. [PubMed]
Morriss RK, Faizal MA, Jones AP, Williamson PR, Bolton C, McCarthy JP. Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database Syst Rev. 2007;24;(1):CD004854. [PubMed]
Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722. [PubMed]
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