Bipolar disorder, sometimes referred to as manic-depression, is a genetically-based psychiatric disorder, which involves poorly regulated changes in brain chemistry resulting in extreme mood swings. With a proper diagnosis and treatment plan (usually a combination of mood-stabilizing medication and therapy), a person with bipolar can have a long, happy and successful life.
Bipolar Episodes
Signs of Bipolar Disorder include episodes of mania or hypomania, which can involve euphoric and expansive mood; or dysphoric mood, which is marked by high levels of irritability and agitation. These episodes also typically include grandiose self-image, decreased need of sleep, rapid thoughts, pressured speech, distractibility, increased energy and creative desires, and severe impulsivity that lead to high-risk behaviors.
Mania lasts at least seven days in a row, and can lead to severe consequences to health, finances and relationships. Hypomania has the same symptoms, but usually of shorter duration—at least four days—and often with fewer consequences per episode.
In bipolar depressive episodes, the mood can become severely reduced, dark, and demoralizing. Often in this mood zone, a person becomes very sad, restless, low on energy, hopeless, and even suicidal. While manic or hypomanic, a person can feel terrific, charged with energy and a sense of great creativity, and a strong desire to get several things done at once. However, bipolar depression will make the same person lose energy and interest in anything important or pleasurable, potentially causing a severe crash in his or her emotional or physical well-being.
Cycles of manic, hypomanic, and depressive episodes can last from several days to several weeks, and often come with periods of feeling “in-between,” known as the baseline mood zone. In the most severe instances of bipolar, psychotic features including hallucinations or delusions may be present during extreme mood episodes.
Types of Bipolar Disorder
There are three basic types of bipolar disorder, known as bipolar I disorder, bipolar II disorder, and cyclothymic disorder, which some people casually refer to as bipolar III. The distinction among these three types is important when it comes to understanding the overall course of the disorder and the various treatments that can be used.
Bipolar I Disorder
All that is needed to be diagnosed with bipolar I disorder is a history of at least one manic episode in the person’s lifetime. While depression is common in bipolar I disorder, it is not necessary for the diagnosis. A person with bipolar I may have had hypomanic episodes, but a single manic episode forever defines this type of the disorder.
When psychotic features of hallucinations, such as hearing voices that are not actually present, or delusional thinking are evident in bipolar disorder, only the bipolar I diagnosis applies. The seven-day minimum of a manic episode helps define the diagnosis, unless treatment interrupts the episode, as we would see in a psychiatric hospitalization.
People in a manic episode can become very excited, flush with energy and extravagance. They can exhibit rapid thoughts and become accelerated in their speech making it difficult to interrupt them. They also purposely avoid sleep due to the increased energy and need to get many things completed. They often engage in high-risk behaviors, such as spending sprees, sexual indiscretions, alcohol or drug binges, driving too fast, etc.
Not only can these behaviors lead to financial and relationship problems, but legal troubles may also eventually result. In any case, people with bipolar I disorder will often deny the consequences of mania, or justify the need to protect their manic behavior as a means to maintain creative output in their lives, despite the extensive threat bipolar I can have on their overall health and functioning.
When manic, a person with bipolar I can be mistaken as having another disorder, such as ADHD, OCD, panic disorder, or narcissistic personality disorder. If they have psychotic symptoms, they can be thought of as having schizophrenia. But the intense change in mood drives all the symptoms of this particular psychiatric disorder. When mania subsides, they often return to a more typical, or baseline, mood zone. The confusion now is about whether or not they have any psychiatric disorder at all.
Bipolar II Disorder
Bipolar II disorder has traditionally been thought of as a lesser form of the condition compared to bipolar I. The reason for this difference is how a manic episode, which defines bipolar I, can be longer in duration and have more severe consequences within a particular episode. A hypomanic episode, which is characteristic of bipolar II, has the same symptoms but tends to be shorter in duration and generally less consequential in its effects. However, the impression that bipolar II is a lesser form of the overall condition of bipolar disorder is misleading.
First of all, simply looking at a manic episode and a hypomanic episode in a side-by-side comparison does not tell the full story of how devastating an overall bipolar II disorder can be. Unlike bipolar I, a bipolar II diagnosis fits if there is a history of one hypomanic episode and one episode of major depression. And the effects of the bipolar II condition should essentially change how that person is perceived by others around him or her.
In other words, at least one person close to that individual would agree that there is a noticeable change in their typical characteristics during hypomania. Often, because of the more objective input from family or associates around that person, the full effects of hypomania are uncovered. And in those instances, a clearer picture of hypomanic consequences can reveal impairments to occupational and social functioning.
Without a history of major depression, a person cannot be considered as having bipolar II. Someone having occasional hypomania by itself is not a bipolar disorder. But because the depressive episodes in bipolar II can be very severe—even suicidal—it’s mistaken to think of bipolar II as the lighter form of the overall condition.
To be clear, there are no comparisons in the duration or severity of depressive episodes between bipolar I and II, so it’s not unusual for bipolar II depression to be quite devastating. And the collective effects of hypomanic episodes can result in many dire consequences in the long-term.
If there is any advantage of having bipolar II over bipolar I, it can be somewhat easier to treat when it’s correctly identified. But because it’s generally more difficult to assess, people with bipolar II can, on average, go many more years undiagnosed than their bipolar I counterparts.
As a result, they may suffer consequences over a longer period of time, again making the side-by-side comparisons of bipolar I and II confusing. Like mania, hypomania is frequently misidentified as other conditions, including anxiety disorders, ADHD, personality disorders, etc., inevitably delaying effective treatment interventions.
Cyclothymia
Cyclothymia is marked by occasional episodes of hypomania and occasional periods of minor depression, known as dysthymia, that occur over a two-year period in adults and one year in children and adolescents. Sometimes, cyclothymia can be a precursor to bipolar I or II later on, especially when it starts in young people.
Causes of Bipolar Disorder
The genetic factor is the strongest and most consistent one in the development of bipolar disorder.1 In other words, bipolar runs in families and is passed through family genes. What is coded in the person’s DNA essentially sets the foundation for the brain’s inability to regulate moods consistently. A person generally must have this genetic predisposition for the true bipolar symptom pattern to eventually emerge during the lifespan.
Catalytic factors can bring out those symptoms. Some common catalysts involve hormonal changes, such as in puberty, or in women during or after childbirth, known as peripartum bipolar onset. Drug and alcohol abuse or certain medical disorders can also trigger underlying bipolar symptoms.
Traumatic experiences can trigger bipolar symptoms as well, but it’s important to know that trauma alone does not completely cause bipolar disorder. The average age of onset is late adolescence to early adulthood, though accurate recognition and diagnosis may not occur until several years into adult life.
It’s good to know of any family history of mental illness—especially bipolar disorder—if family historical information is available. And it’s even more important to share the family history with an appropriate mental health professional. This can improve the assessment and diagnosis, along with what the proper treatment can be for anyone who may have bipolar disorder.
Is It Bipolar Disorder or Depression?
An important study showed about two-thirds of bipolar patients are misdiagnosed and treated as having other psychiatric disorders, while those patients had consulted a mean average of nearly 4 clinicians before receiving appropriate care.2 Among people with bipolar who are misidentified, a significant majority are given a diagnosis of major depression.
Most people with a major depressive disorder unrelated to bipolar disorder (typically known as non-bipolar depression or unipolar depression) can be treated safely and effectively with psychotherapy along with antidepressant medication, if needed. But when people with undetected bipolar are treated this way, a host of mental health problems can occur, making the underlying bipolar condition much worse.
It’s understandable that someone may not immediately be given the bipolar diagnosis if their first mood swing begins in a depression mood zone. This seems particularly true of people who have bipolar II disorder. And sometimes, there may be more than one depressive episode before a manic or hypomanic episode happens in a person with bipolar.
Bipolar vs. Other Disorders
While sometimes a history of manic symptoms is not presented right away, it’s also common for those symptoms to be confused with other mental health conditions, such as ADHD, OCD, borderline or narcissistic personality disorders, or schizophrenia. One typical variable that helps clinicians distinguish bipolar mania from anything else is the intermittent nature of bipolar mood swings.
That is to say, bipolar mania and depression usually come and go in episodes; therefore, they are described as “episodic.” Other conditions can have symptoms that wane a bit from time to time, but they are not as drastic and variable as in bipolar disorder. Thus, these other disorders are thought of as more “pervasive,” since they pervade the person’s daily life, especially if untreated.
For example, a person with schizophrenia may neither be depressed or energetic to experience hallucinations or delusional thinking. Another example is ADHD. While distractibility is common in both bipolar mania and ADHD, the ability to focus tends to improve in bipolar when the mania subsides.
It’s generally true that symptoms of disorders other than bipolar will be present no matter the mood state. Knowing these important differences between bipolar disorder and other mental health conditions helps reduce the time it takes for people with bipolar to get to the right treatment plan.
Diagnosing Bipolar Disorder
If you’re wondering about whether you may have depression or the beginning of bipolar, there are some keys to keep in mind when seeking treatment.
First of all, when assessing if your depression is a part of bipolar, know that bipolar disorder has distinct genetic foundations. So if you suspect that any family members may have had bipolar disorder, it’s important to inform your doctor or therapist when entering treatment. If the information is available, a thorough family mental health history can really support a proper bipolar diagnosis.
Next, your personal history of mood swings should be explored. If you’ve had severe ups and downs during childhood or adolescence, these may be more than the common tumult of growing up. They may instead be early expressions of bipolar disorder. It’s especially important to review periods of hyperactivity, bouts of unexplained rage, self-harm, or suicidal thoughts or actions that could have occurred at any time in life.
There certainly may be other explanations for these, such as early life trauma or severe loss and grief experienced during these formative years. But if explosive behaviors or deep depression occurred at different times, especially with little or no provocation, it can point to underlying bipolar disorder.
Usually, most people with bipolar who seek treatment on their own are currently or recently depressed, or are experiencing consequences of untreated bipolar disorder. Any history of mania or hypomania is less obvious, however. And often, bipolar patients will either not understand manic symptoms or will avoid discussion about them.
If you have had at least one occurrence in your life of intense euphoria, excitability, unexplained energy and creativity, avoidance of sleep, or impulsive behaviors, inform your treatment professional. But also bear in mind that mania and hypomania may be marked by intense periods of irritability and agitation, known as dysphoria.
This is in contrast to the euphoria that most people think about with bipolar mania. Often a dysphoric type of manic or hypomanic episode can be mistaken for the kind of agitation seen in major depression. This can mislead the course of treatment to focus only on depression, while missing the full bipolar condition.
Sometimes the actual treatment for non-bipolar depression can reveal bipolar disorder. Typically, if a patient is given an antidepressant medication, and it produces manic symptoms, the person is then diagnosed with bipolar disorder. While this is a very clear indication of bipolar, how the mania surfaces in the individual may take different forms. For example, a person in depression can improve early in the treatment, and as a result, may not show manic symptoms right away.
Any slight improvement may provide a hopeful sign that treatment is working, but when the person starts to get worse because of emerging mania—especially if it’s dysphoric—the unwitting response may be to apply more antidepressant medication. Now we have some real problems.
So, if at some point in your treatment, an antidepressant medication makes you feel more agitated, more irritable, more aggressive, or you start to experience hyperactivity or greater impulsivity, tell your treatment professional right away. This could be the start of a manic episode that is revealing a previously undiagnosed bipolar disorder.
Even more importantly, any increase in suicidal thoughts or possible psychotic symptoms, such as hallucinations, should be reported immediately, as these can be life-threatening. Any antidepressants will either likely be eliminated at this point, or possibly paired with a mood stabilizer or antipsychotic drug to keep a lid on mania.
One important factor is the need to delve deeply into an individual’s mental health history. Often, people present with depression, substance abuse and other presentations that don’t include evidence of mania up front. Certainly, a bipolar-related depressive episode is often profound and requiring of immediate attention, since the risk for suicide would be particularly elevated. However, further inquiry into possible manic involvement could suggest that there’s more diagnostically than meets the eye.
Treatments for Bipolar Disorder
Once bipolar disorder is properly diagnosed, a treatment plan can be accurately developed. This is best achieved in collaboration with the patient, any available and trusted family member, prescribing physician (such as a psychiatrist or psychiatric nurse practitioner), and psychotherapist (unless the physician is also providing psychotherapy).
The standard bipolar treatment plan involves both mood stabilizing medication and psychotherapy, whether it is provided to the individual, a couple, the family as a whole, or any appropriate combination.
Medication
Medications for bipolar disorder typically involve mood stabilizers, such as lithium or certain anti-seizure drugs, or antipsychotic medications, or some combination of those drugs. Other medications such as antidepressants and anti-anxiety drugs may also be used along with mood stabilizers. It’s not unusual for the prescribing doctor to add or subtract medications, or increase or decrease dosages to get the right levels of any particular individual.
Achieving mood stabilization with medication can take time and some trials of different combinations to meet an individual’s particular need. Therefore, patience is itself an important bipolar treatment issue. People often have several concerns around medications, including side effects and possible consequences of long-term use. Knowing that bipolar disorder can severely damage a person’s life, including their physical and mental health, a thorough discussion of these concerns should be explored with the treatment team.
Therapy
As for therapy, it’s important to find a professional who is familiar with bipolar and the various factors unique to the disorder. It’s necessary to be involved in therapy through all phases of bipolar treatment, from assessment in pre-stabilization, through stabilization with medication, to post-stabilization as the person with bipolar becomes more familiar with life away from the former consequences of the disorder.
Some typical therapy issues include working through denial and accepting the reality of bipolar in a person’s life. There are often fears of losing the perceived benefits of mania and hypomania, and that treatment will change a person into a boring and listless character. Therapy can help the person with bipolar through any difficulties in achieving mood stabilization, and begin a process of developing living creativity and productively without depending on mania for energy and inspiration.
Avoiding Problems and Getting the Right Care
Here’s the good news about bipolar disorder: Whether it’s bipolar I, bipolar II or cyclothymia, a proper diagnosis and treatment plan can offer a person with bipolar a long, happy and successful life. Treatment typically involves a combination of mood stabilizing medication and psychotherapy, which can involve individual and/or family therapy activities, all of which can be very effective. But the reality is that for many people, bipolar disorder can go unidentified, undiagnosed, improperly treated, or not treated at all.
Drancourt et. al3 showed that patients will have waited nearly 10 years from their first bipolar mood episode, to the time they receive a mood stabilizing medication specifically for bipolar disorder. Because of this 10-year gap in treatment, we have a whole population of underlying bipolar disorder presenting as relational dysfunction, substance abuse, unipolar depression, attention deficits, self-harm, personality disorders, domestic violence, workplace conflicts and many other common presentations to outpatient therapy.
But the biggest problem with unidentified and untreated bipolar disorder is suicide, which is at least 20 times higher in bipolar patients compared to the general population.4 Perhaps even more striking is that bipolar disorder may account for one-quarter of all completed suicides.1
While many people with undetected bipolar enroll in—then languish through— an often cumbersome mental health system, their condition worsens, threatening their own life along with the well-being of every concerned person around them.
To avoid problems in identifying and ultimately getting the best treatment possible, here are some important things to consider when confronting the possibility of bipolar disorder in your life.
Bipolar patients and their families often struggle to accept the disorder out of shame, which itself is born out of stigma. Knowing that bipolar is genetic in its foundations, with natural internal and external catalysts driving symptoms to emerge, people can appreciate that having bipolar is nobody’s fault. There really is no one to blame, and no reason to feel ashamed when bipolar becomes a part of a family’s life story.
It’s vital to discuss the possibility of bipolar with your treatment professional if you have any suspicion of mania, mood swings, recurrent depression, or psychotic experiences if your life or the life of your loved-one, or if bipolar disorder exists within your family history. Since professionals often address immediate symptoms and issues, they may not sense a history of bipolar disorder without first bringing it to their attention.
Yet, many different fears can hold people back from seeking proper treatment for bipolar disorder specifically. These include concerns about medications and difficulty accepting a lifelong mental illness. Many people with bipolar often fear giving up the great feelings that accompany a manic or hypomanic episode.
Nobody wants to be told that what makes them feel terrific and supercharged is actually part of a disorder that should be taken away. As a result, the defense of denial is an expected aspect of bipolar disorder. It’s especially important for people with bipolar to feel in control of the energetic and hyper-creative parts of mania as an offset to the desperate, hopeless feelings of their depressive episodes.
Family members can possess fears, and at times, denial of bipolar in their lives. For example, parents can worry more about their children being “labeled for life” instead of how the disorder can destroy their life goals. Or spouses of people with bipolar may initially view it as simply an excuse for the “bad behavior” that has fractured their marriages.
There are many roadblocks along the path to success with bipolar treatment. But a combination of thorough assessment, education, and treatment centered around the medical stabilization of bipolar swings is useful in addressing all pertinent fears for patients and families, while engaging these important members into a collaborative, lifelong care plan. Reducing fear in all participants is key to remaining connected to treatment, while building hope that stabilization will ultimately improve the quality of life for bipolar patients and their families.
