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BIPOLAR DISORDER

Bipolar, or manic-depressive, disorder is a frequent, severe, mostly recurrent mood disorder associated with great morbidity. Bipolar disorders are brain disorders that cause changes in a person’s mood, energy and ability to function. Bipolar disorder is a category that includes three different conditions — bipolar I, bipolar II and cyclothymiacs disorder.
People with bipolar disorders have extreme and intense emotional states that occur at distinct times, called mood episodes. These mood episodes are categorized as manic, hypomanic or depressive. People with bipolar disorders generally have periods of normal mood as well. Bipolar disorders can be treated, and people with these illnesses can lead full and productive lives. 

What is bipolar disorder?

We all have our ups and downs, but with bipolar disorder (once known as manic depression or manic-depressive disorder) these peaks and valleys are more severe. Bipolar disorder causes serious shifts in mood, energy, thinking, and behavior—from the highs of mania on one extreme, to the lows of depression on the other. More than just a fleeting good or bad mood, the cycles of bipolar disorder last for days, weeks, or months. And unlike ordinary mood swings, the mood changes of bipolar disorder are so intense that they can interfere with your job or school performance, damage your relationships, and disrupt your ability to function in daily life.

During a manic episode, you might impulsively quit your job, charge up huge amounts on credit cards, or feel rested after sleeping two hours. During a depressive episode, you might be too tired to get out of bed, and full of self-loathing and hopelessness over being unemployed and in debt.

The causes of bipolar disorder aren’t completely understood, but it often appears to be hereditary. The first manic or depressive episode of bipolar disorder usually occurs in the teenage years or early adulthood. The symptoms can be subtle and confusing; many people with bipolar disorder are overlooked or misdiagnosed—resulting in unnecessary suffering. Since bipolar disorder tends to worsen without treatment, it’s important to learn what the symptoms look like. Recognizing the problem is the first step to feeling better and getting your life back on track.

The lifetime prevalence of bipolar disorder is 1·3 to 1·6%. The mortality rate of the disease is two to three times higher than that of the general population. About 10–20% of individuals with bipolar disorder take their own life and nearly one third of patients admit to at least one suicide attempt. The clinical manifestations of the disease are exceptionally diverse. They range from mild hypomania or mild depression to severe forms of mania or depression accompanied by profound psychosis. Bipolar disorder is equally prevalent across sexes, with the exception of rapid cycling, a severe and difficult to treat variant of the disorder, which arises mostly in women. Because of the high risk of recurrence and suicide, long-term prophylactic pharmacological treatment is indicated. Lithium salts are the first choice long-term preventive treatment for bipolar disorder. They also possess well documented antisuicidal effects. Second choice prophylactic treatments are carbamazepine and valproate, although evidence of their effectiveness is weaker. 

Ancient beginnings

Aretaeus of Cappadocia began the process of detailing symptoms in the medical field as early as the 1st century in Greece. His notes on the link between mania and depression went largely unnoticed for many centuries. The ancient Greeks and Romans were responsible for the terms “mania” and “melancholia,” which are now the modern day “manic” and “depressive.” They even discovered that using lithium salts in baths calmed manic people and lifted the spirits of depressed people. Today, lithium is a common treatment for people with bipolar disorder. The Greek philosopher Aristotle not only acknowledged melancholy as a condition, but cited it as the inspiration for the great artists of his time. It was common during this time for people across the globe to be executed for having bipolar disorder and other mental conditions. As the study of medicine advanced, strict religious dogma stated that these people were possessed by demons and should therefore be put to death. 

Studies of bipolar disorder in the 17th century

In the 17th century, Robert uBurton wrote the book “The Anatomy of Melancholy,” which addressed the issue of treating melancholy (nonspecific depression) using music and dance. It did, however, expand deeply into the symptoms and treatments of what’s now known as clinical depression: major depressive disorder. Later that century, Theophilus Bonnet published a great work titled “Sepuchretum,” a text that drew from his experience performing 3,000 autopsies. In it, he linked mania and melancholy in a condition called “manico-melancholicus.”

The 19th century: Falret’s findings

French psychiatrist Jean-Pierre Falret published an article in 1851 describing what he called “la folie circulaire,” which translates to circular insanity. The article details people switching through severe depression and manic excitement, and is considered to be the first documented diagnosis of bipolar disorder. 

The 20th century: Kraepelin’s and Leonhard’s classifications

The history of bipolar disorder changed with Emil Kraepelin, a German psychiatrist who broke away from Sigmund Freud’s theory that society and the suppression of desires played a large role in mental illness.

Kraepelin’s “Manic Depressive Insanity and Paranoia” in 1921 detailed the difference between manic-depressive and praecox, which is now known as schizophrenia. His classification of mental disorders remains the basis used by professional associations today. A professional classification system for mental disorders has its earliest roots in the 1950s from German psychiatrist Karl Leonhard and others. This system was important to better understand and treat these conditions.

Late 20th century: the APA and the DSM

The term “bipolar” means “two poles,” signifying the polar opposites of mania and depression. The term first appeared in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) in its third revision in 1980. It was that revision that did away with the term mania to avoid calling patients “maniacs.” Now in its fifth version (DSM-5), the DSM is considered the leading manual for mental health professionals. It contains diagnostic and treatment guidelines that help doctors manage the care of many people with bipolar disorder today. The concept of spectrum was developed to target specific difficulties with more precise medications. Stahl lists the four major mood disorders as follows: 

Maniac Episode 

Major depressive Episode 

Hypomanic Episode 

Mixed Episode 

Bipolar I Disorder

Symptoms of Bipolar I Disorder
Bipolar I disorder can cause dramatic mood swings. During a manic episode, people with bipolar I disorder may feel high and on top of the world, or uncomfortably irritable and “revved up. “ During a depressive episode they may feel sad and hopeless. There are often periods of normal moods in between these episodes. Bipolar I disorder is diagnosed when a person has a manic episode. 

Bipolar II Disorder

Bipolar II disorder involves a person having at least one major depressive episode and at least one hypomanic episode (see above). People return to their usual function between episodes. People with bipolar II often first seek treatment because of depressive symptoms, which can be severe.

People with bipolar II often have other co-occurring mental illnesses such as an anxiety disorder or substance use disorder. 

Cyclothymiacs Disorder

Cyclothymiacs disorder is a milder form of bipolar disorder involving many mood swings, with hypomania and depressive symptoms that occur often and fairly constantly. People with cyclothymiacs experience emotional ups and downs, but with less severe symptoms than bipolar I or II.

Cyclothymiacs disorder symptoms include the following:

For at least two years, many periods of hypo manic and depressive symptoms (see above), but the symptoms do not meet the criteria for hypo manic or depressive episode.

During the two-year period, the symptoms (mood swings) have lasted for at least half the time and have never stopped for more than two months. 

Manic Episode

A manic episode is a period of at least one week when a person is very high spirited or irritable in an extreme way most of the day for most days, has more energy than usual and experiences at least three of the following, showing a change in behavior:

Exaggerated self-esteem or grandiosity

Less need for sleep

Talking more than usual, talking loudly and quickly

Easily distracted

Doing many activities at once, scheduling more events in a day than can be accomplished

Increased risky behavior (e.g., reckless driving, spending sprees)

Uncontrollable racing thoughts or quickly changing ideas or topics

The changes are significant and clear to friends and family. Symptoms are severe enough to cause dysfunction and problems with work, family or social activities and responsibilities. Symptoms of a manic episode may require a person to get hospital care to stay safe. The average age for a first manic episode is 18, but it can start anytime from early childhood to later adulthood 

Hypomanic Episode

A hypomanic episode is similar to a manic episode (above) but the symptoms are less severe and need only last four days in a row. Hypomanic symptoms do not lead to the major problems that mania often causes and the person is still able to function. 

Major Depressive Episode

A major depressive episode is a period of two weeks in which a person has at least five of the following (including one of the first two):

Intense sadness or despair; feeling helpless, hopeless or worthless

Loss of interest in activities once enjoyed

Feeling worthless or guilty

Sleep problems — sleeping too little or too much

Feeling restless or agitated (e.g., pacing or hand-wringing), or slowed speech or movements

Changes in appetite (increase or decrease)

Loss of energy, fatigue

Difficulty concentrating, remembering making decisions

Frequent thoughts of death or suicide

Bipolar disorder can disrupt a person’s life and relationships with others, particularly with spouses and family members, and cause difficulty in working or going to school. People with bipolar I often have other mental disorders such as attention-deficit/hyperactivity disorder (ADHD), an anxiety disorder or substance use disorder. The risk of suicide is significantly higher among people with bipolar disorder than among the general population. 

Myth: People with bipolar disorder can’t get better or lead a normal life.
Fact: Many people with bipolar disorder have successful careers, happy family lives, and satisfying relationships. Living with bipolar disorder is challenging, but with treatment, healthy coping skills, and a solid support system, you can live fully while managing your symptoms.

Myth: People with bipolar disorder swing back and forth between mania and depression.
Fact: Some people alternate between extreme episodes of mania and depression, but most are depressed more often than they are manic. Mania may also be so mild that it goes unrecognized. People with bipolar disorder can also go for long stretches without symptoms.

Myth: Bipolar disorder only affects mood.
Fact: Bipolar disorder also affects your energy level, judgment, memory, concentration, appetite, sleep patterns, sex drive, and self-esteem. Additionally, bipolar disorder has been linked to anxiety, substance abuse, and health problems such as diabetes, heart disease, migraines, and high blood pressure.

Myth: Aside from taking medication, there is nothing you can do to control bipolar disorder.
Fact: While medication is the foundation of bipolar disorder treatment, therapy and self-help strategies also play important roles. You can help control your symptoms by exercising regularly, getting enough sleep, eating right, monitoring your moods, keeping stress to a minimum, and surrounding yourself with supportive people.

Risk Factors

Bipolar disorder can run in families. In fact, 80-90 percent of individuals with bipolar disorder have a relative with either depression or bipolar disorder. However, environmental factors can also contribute to bipolar disorder — extreme stress, sleep disruption and drugs and alcohol may trigger episodes in vulnerable patients. 

Treatment and Management

Bipolar disorder is very treatable. Medication alone or a combination of talk therapy (psychotherapy) and medication are often used to manage the disorder over time. Each person is different and each treatment is individualized. Different people respond to treatment in different ways. People with bipolar disorder may need to try different medications and therapy before finding what works for them.

Medications known as “mood stabilizers” are the most commonly prescribed type of medication for bipolar disorder. Anticonvulsant medications are also sometimes used. In psychotherapy, the individual can work with a psychiatrist or other mental health professional to work out problems, better understand the illness and rebuild relationships. A psychiatrist is also able to prescribe medications as part of a treatment plan. Because bipolar disorder is a recurrent illness, meaning that it can come back, ongoing preventive treatment is recommended. In most cases, bipolar disorder is much better controlled if treatment is continuous.

In some cases, when medication and psychotherapy have not helped, a treatment known as electroconvulsive therapy (ECT) may be used. ECT uses a brief electrical current applied to the scalp while the patient is under anesthesia. The procedure takes about 10-15 minutes and patients typically receive ECT two to three times a week for a total of six to 12 treatments.
Since bipolar disorder can cause serious disruptions and create an intensely stressful family situation, family members may also benefit from professional resources, particularly mental health advocacy and support groups. From these sources, families can learn strategies to help them cope, to be an active part of the treatment and to gain support for themselves. 

Treatment

Treatments for bipolar II are similar to those for bipolar I — medication and psychotherapy. Medications most commonly used are mood stabilizers and antidepressants, depending on the specific symptoms. If depression symptoms are severe and medication is not working, ECT (see above) may be used. Each person is different and each treatment is individualized. 

Symptoms

There are several types of bipolar and related disorders. They may include mania or hypomania and depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life.

Bipolar I disorder. You've had at least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break from reality (psychosis).

Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode.

Cyclothymic disorder. You've had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression).

Other types. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or early 20s. Symptoms can vary from person to person, and symptoms may vary over time.