Bipolar Disorder: Types, Causes, & Treatments

What Is Bipolar Disorder?

Bipolar disorder is a mental health disorder whose core feature is a disturbance in mood.² The hallmark feature of a bipolar diagnosis is mania.³ Mania is a dysregulated form of mood instability where an individual can feel extreme elation with accompanying disturbances in thinking and behavior.² While depression may be present, it is not necessary for a diagnosis. What is needed for a diagnosis is at least one lifetime manic episode. The peak age at onset of bipolar I disorder across studies is between 20 and 30 years, but onset occurs throughout the life cycle.⁴

Types Of Bipolar Disorder

Bipolar disorder is an umbrella term and is not diagnosable in and of itself. There are a few types of bipolar disorders that are diagnosable. The symptoms are broadly the same but differ in intensity and frequency.

Bipolar I

For a bipolar I diagnosis, an individual will have had to experience at least one manic episode in their lifetime. Major depressive episodes are typical but not needed for diagnosis.⁵ The mania also must last one week for it to be considered a manic episode. The mood in a manic episode is often described as euphoric, excessively cheerful, high, or “feeling on top of the world.”⁴

Moreover, a clinical diagnosis requires a specifier related to the condition. These specifiers describe the course and impact of the illness. Specifiers include; mild, moderate, severe, with psychotic features, partial remission, in full remission, and unspecified. Bipolar I sexual symptoms affects men and women equally.⁵

Bipolar II

There are some differences between bipolar I vs. bipolar II. For a bipolar II diagnosis, an individual will have had to experience at least one hypomanic episode and one major depressive episode in their lifetime.⁵ A hypomanic episode is less intense than a full manic episode. As opposed to a week for bipolar I, it must persist for at least four consecutive days.⁴

Bipolar II should not be conceptualized as a less severe or substantial type of illness. Bipolar II has a high episode frequency, high rates of psychiatric comorbidities, and recurrent suicidal behaviors that impair quality of life.⁵ The diagnostic criteria for a major depressive disorder must also be met, which includes criteria such as depressed mood most of the day, markedly diminished interest in activities, significant weight loss/gain, insomnia/hypersomnia, psychomotor agitation, loss of energy, feelings of worthlessness, issues with thinking and decision making, and recurrent thoughts of death.⁴ Bipolar II disorder is most common in women.⁵

Cyclothymic Disorder

Cyclothymic Disorder (aka Cyclothymia) is a distinct diagnosable mental health issue. It is characterized as hypomanic and depressive periods that do not fulfill the criteria for hypomania or major depression for at least two years.⁵ The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms.⁴ The risk fluctuates and it can evolve into bipolar I or II. There is a 15% – 50% risk that an individual with cyclothymic disorder will subsequently develop bipolar I disorder or bipolar II disorder.⁴

Late-Onset Bipolar Disorder

Late-onset bipolar disorder is the onset of bipolar disorder in individuals 50 or older.

Other Specified & Unspecified Bipolar & Related Disorders

In this category fall those individuals with bipolar-like disorders that do not meet criteria for bipolar I disorder, bipolar II disorder, or cyclothymia because of insufficient duration or severity or characteristic symptoms of bipolar and related disorders that do not meet full criteria for other categories.⁵

Individuals present with subclinical signs and symptoms that are not severe enough to present definite or readily observable. Included are short-duration hypomanic episodes with major depressive disorder, hypomanic episodes with insufficient symptoms with major depressive disorder, hypomanic episodes without prior major depressive disorder, short-duration cyclothymia, substance or drug-induced bipolar and related disorder, and bipolar and related disorders due to another medical condition.⁵

Bipolar Symptoms

Bipolar symptoms vary based on intensity and frequency for bipolar disorders. However, the foundational signs and symptoms remain the same for each disorder under the bipolar umbrella. Consistent criteria across all disorders include some combination of mania, hypomania, and major depressive disorder.

Mania & Hypomania Symptoms

Mania is a feeling of euphoria that lasts about a week. Hypomania is a less intense mania presentation and must last for at least four days. An individual can feel invincible and present as frenzied. Mania/hypomania is usually liked by the individual and enjoys its presence.¹⁶

Symptoms of a manic or hypomanic episode may include:

• Elevated mood
• Increased motor activity-energy
• Increased sexual interest
• Decreased need for sleep
• Irritability
• Language or thought disorder
• Lack of insight

Symptoms of a Major Depressive Episode

A major depressive disorder is less tolerated than a manic episode. Depression is more than just feeling sad. It can be a debilitating experience that affects the person’s ability to have a fulfilling life. It can include disruptions in cognitive and physical abilities.⁷

Symptoms of a major depressive episode may include:

• Depressed mood
• Hopelessness
• Anhedonia
• Fatigue
• Physical pain
• Decreased motor activity
• Lack of motivation
• Poor concentration
• Thought blocking
• Disrupted sleep
• Disrupted appetite

Symptoms of a Mixed Episode

A mixed episode is when a person experiences the symptoms and effects of major depression and mania/hypomania at the same time. Rather than being distinct and separate states, the individual will experience both conflicting states together.

Symptoms of a mixed episode of bipolar may include:

• Sadness
• Hopelessness
• Increased energy
• Racing thoughts
• Disrupted motor activity

Bipolar Disorder Symptoms in Women vs. Men

Bipolar symptoms among men and women are relatively stable among the genders. The course of the illness varies depending on factors such as age at onset. The number of affective episodes of each polarity do not seem to differ across genders.⁸

Treatment considerations and risk factors likely differ as follows:

• Women are more likely to be hospitalized for manic episodes
• Women have a higher lifetime risk of alcohol use disorder⁴
• Women diagnosed with bipolar disorder are at an increased risk for comorbidity with alcohol and drugs⁸
• The course, in women, may be influenced by the menstrual cycle, pregnancy, the postpartum period, and menopause⁹
• Women are more likely to experience rapid cycling and mixed mania⁹

Bipolar Symptoms in Children & Teens

Early onset of illness is associated with an unremitting course of illness, frequent switches of polarity, mixed episodes, psychosis, a high risk of suicide, and poor functioning or quality of life.¹⁰ Symptoms between the two groups are similar to that of adults. The increased activity criterion can be difficult to distinguish in children as they can easily take on many tasks simultaneously, create elaborate and unrealistic project plans, and develop previously absent and developmentally inappropriate sexual preoccupations.¹⁴

Bipolar symptoms in children and teens may include:

• Irritability
• Isolation
• Poor communication

Borderline Personality Disorder vs. Bipolar Disorder

The biggest similarity between borderline personality disorder vs. bipolar disorder is the disruption in the mood. Some individuals may be wrongly diagnosed with bipolar disorder due to mood dysregulation. Other BPD criteria such as unstable social relationships and a lack of self-image may be present in an individual person with bipolar disorder, but this is certainly not a defining feature of the condition.

When a person with BPD is emotionally dysregulated, it can look like someone is experiencing a manic episode. The acting out and inability to properly control one’s emotions that is present in BPD may be viewed as bipolar disorder by the unsophisticated clinician. A thorough clinical assessment should easily weed out bipolar disorder from BPD.

What Causes Bipolar Disorder?

Bipolar disorder is a heritable genetic condition whose presentation and course are heavily influenced by the environment. While an individual may have a predisposition to bipolar disorder, the setting and circumstances in which the person lives have a tremendous effect. Like most mental health issues, there is no single cause to attribute to a burgeoning bipolar diagnosis.

The following may contribute to a bipolar diagnosis:

• Brain structure: Studies have demonstrated that different brain areas may be responsible for the formation of bipolar disorder. However, no one area of the brain or study is conclusive in its findings.³
• Genetics: There is a strong link between the disorder being “passed down” in families. The recurrence risk for BPD in first-degree relatives of BPD patients is approximately 9%, nearly ten times that of the general population.¹
  Twin studies have also demonstrated a strong genetic link for bipolar disorder.³
• Environmental factors like severe stress: Evidence suggests that the first episode of bipolar disorder often is associated with stress.³

Co-Occurring Conditions

Several mental health concerns can overlap with bipolar disorder, including psychosis, substance use, suicide, anxiety, and eating disorders. Some of these comorbid conditions may make diagnosis challenging and can result in a bipolar misdiagnosis. Additionally, the secondary mental health concerns may not be given their appropriate concern as the bipolar diagnosis may overshadow any other issues. Common conditions that co-occur with bipolar disorder include:

• Psychosis: Reality-altering states must be present, including hallucinations, delusions, and disorganized behavior/thoughts.
• Anxiety disorders: Anxious rumination may be mistaken for racing thoughts (and vice versa), and efforts to minimize anxious feelings may be taken as impulsive behavior.⁴
• Attention-deficit/hyperactivity disorder (ADHD): Persistent symptoms of inattention, hyperactivity, and impulsivity need to have been present before the age 12.⁴
• Drug / alcohol use disorder: Alcohol or drugs would have to be the primary reason and explainer as to the dysregulation in the mood.
• Eating disorders: An individual will likely exhibit restrictive eating or binging and purging behavior. Food will take up an inordinate amount of time in their life, and losing weight will be a key factor.
• Post-traumatic stress disorder (PTSD): A traumatic event is likely to have occurred or the recurrence of many traumatic events within a chaotic environment. Symptoms such as re-experiencing, dissociation, and nightmares are needed for diagnosis.

How Is Bipolar Disorder Diagnosed?

Bipolar is diagnosed through a comprehensive clinical interview. Many different areas will be assessed including family history and the origin and nature of symptoms. There are several diagnostic criteria that need to be present for a bipolar disorder diagnosis. Some individuals may fall into the other specified and unspecified bipolar and related disorders if the full diagnostic parameters are not met. Differential diagnoses will also be considered as bipolar disorder may mask other mental health conditions, and other mental health conditions may take the appearance of bipolar disorder.

In the future, it’s possible a bipolar brain scan will assist in diagnosis and treatment.

Bipolar Disorder Treatment

Acute stabilization is the conventional approach to bipolar disorder treatment, where the goal is to stop a manic episode or move a person from a depressive state into a stable state.¹¹ The most efficacious treatment approach to bipolar disorder is a combination of therapies. Medication, therapy, and socialization are all important in treating the symptoms.

Medication

The first line of treatment defense for bipolar disorder is mood stabilizers. These bipolar medications provide the brain a much needed chemical stability allowing the person to not cycle between mood episodes. Antipsychotic drugs are also effective in the acute treatment of mania.¹¹ Most individuals will start to see results from these medications within the first couple of days.

Common bipolar medications include:

• Lithium
• Lamictal
• Depakote
• Tegretol
• Abilify

Psychotherapy

Talk therapy is a wonderful adjunctive treatment. It can help the individual build coping skills to deal with the effects of mania and depression. Psychotherapy is powerful at addressing how the individual feels about being diagnosed with bipolar disorder and managing symptoms.

Psychotherapy options for bipolar disorder may include:

• Cognitive behavioral therapy (CBT): CBT can be helpful, as it helps clients reframe their thoughts and attitudes
• Motivational interviewing: Motivational interviewing is beneficial when addressing ambivalence toward treatment and increase engagement

Other Bipolar Treatment Options

Very little evidence exists of effective strategies for patients who do not respond to first-line treatments.¹¹ The below treatments may be effective on an individual basis but are not considered evidence based. Best practices remain medication and some type of therapy.

Other treatment methods of bipolar disorder may include:

• Electroconvulsive therapy: Electroconvulsive therapy (ECT) treatment involves sending an electrical signal into an individual’s brain in order to rewire the neural passages.
• Transcranial magnetic stimulation: This treatment involves magnets to stimulate nerve cells in the brain.
• Hospitalization: Hospitalization is necessary when a person has decompensated to a point where they cannot function. Their ability to take care of themselves is diminished and they are at risk to harm themselves or others. A trip to the hospital may only result in a few day stay in the psychiatric ER until the person is stable, rather than hospitalization in a psychiatric inpatient unit.

Finding Treatment

A primary care provider (PCP) is a good place to start looking for care if you are concerned. While a PCP may diagnose and treat you, this is not their specialty. It is best to receive care from a mental health care specialist on the matter, including a psychologist and psychiatrist. Sometimes an individual or their family may not recognize signs and symptoms until it is too late and the individual will require hospitalization after an acute episode.

A psychiatrist will help diagnose and prescribe medication. A psychologist can also diagnose but cannot prescribe medication. The psychologist can help with providing various forms of therapy and care coordination of resources. A psychiatrist may even refer you to a psychologist and vice versa. To find the right therapist, you can try searching an online therapist directory.

Preparing for Your Appointment

The provider will ask for a detailed history so it is best to have a list of symptoms you have experienced and corresponding dates. Compiling such a list can be challenging as a manic or depressive episode can cause bipolar memory loss. Symptoms may seem less severe while the duration felt shorter due to the nature of the illness. It is best to speak with family and friends so they can provide a comprehensive timeline of one’s behavior.

What to Ask Your Doctor

It is natural to have a lot of questions as this can be a scary and confusing ordeal. A psychiatrist will be able to answer more medical and medication related questions while the psychologist is best at answering psychological and socially relevant matters.

Here are several questions you may want to ask your doctor:

• What medications will work best?
• What are some of the side effects?
• Do I need to take these medications forever?
• How do we decide on increasing the dosage or changing the medications altogether?
• What type of therapy will work best for my condition?
• How long will I need to be in therapy?
• Is this something I or others should be afraid of?
• Will I pass it onto my children?

What to Expect From Your Doctor

Your doctor will likely want to do bloodwork as some of the medications can have side effects. The doctor may even try you on a couple medications before landing on the right one. Dosage may also need tweaking while finding the right fit. It is important to know that prescribing psychiatric medication is not all science as there are several options and not everyone will respond to it in the same way. It can feel disheartening and frustrating going through that part of the process.

How to Cope With Bipolar Disorder

A bipolar diagnosis can feel overwhelming and scary. There can be a lot of stigma surrounding the disorder and it can certainly feel as if your life is over. However, with some small changes, there is no reason not to live as you were prior to the diagnosis. It is important to be mindful of triggers that might bring about an episode. Taking medication routinely and getting enough sleep will also be crucial to managing symptoms.

Below are some tips for coping with bipolar disorder:

• Adhere to medication
• Speak with a psychologist about building coping skills
• Develop a support system of family and friends
• Exercise
• Limit stress
• Develop a sleep schedule
• Avoid alcohol or drugs
• Monitor moods and changes in symptoms

Final Thoughts

Seeking out treatment is a sign of strength. It is best not to blame yourself or others upon getting diagnosed. Bipolar disorder can be a highly treatable condition through adherence and commitment to treatment. It does not have to slow you down or change your trajectory in life. The more you invest in yourself through these times, the better the outcome in the long run.