Bipolar Disorder

Bipolar disorder (BD) is a type of mood disorder. Bipolar disorder was called manic depression in the past, and that term is still used by some people. It is a psychiatric illness that causes major disruptions in lifestyle and health.

Everyone has occasional highs and lows in their moods. But people with bipolar disorder have extreme mood swings. They can go from feeling very sad, despairing, helpless, worthless, and hopeless (depression) to feeling as if they are on top of the world, hyperactive, creative, and grandiose (mania).

• This disease is called bipolar disorder because the mood of a person with bipolar disorder can alternate between 2 completely opposite poles, euphoric happiness and extreme sadness.

• Symptoms of both mania and depression sometimes occur together, in what is called "mixed state."

• The extremes of mood usually occur in cycles. In between these mood swings, people with bipolar disorder are able to function normally, hold a job, and have a normal family life. The episodes of mood swings tend to become closer together with age.

• When a person is in the grip of this disease, chaos can occur. Bipolar disorder can cause major disruption of family and finances, loss of job, and marital problems.

• Severe depression carries with it thoughts of suicide and actual acts of suicide and in some cases acts of homicide.

• Extreme mania can lead to aggressive behavior and homicidal acts.

• A number of persons with bipolar disorder may turn to drugs and alcohol to "self-treat" their emotional disorder, resulting in substance dependence.

Most people start showing signs of bipolar disorder in their late teens (the average age of onset is 20 years). These signs may be dismissed as "growing pains" or normal teenage behavior. Bipolar disorder may not be properly diagnosed until the sufferer is 25-40 years old, at which time the symptoms may become clearer.

Bipolar disorder occurs in both men and women. About 2.3 million people in the United States have the disorder.

Because of the extreme and risky behavior that goes with bipolar disorder, it is very important that the disorder be identified. With proper and early diagnosis, this mental condition can be treated.

The exact cause of bipolar disorder has not been discovered, but there are significant genetic components. 

• Bipolar disorder may result from a chemical imbalance within the brain. The brain's functions are controlled by chemicals called neurotransmitters. An imbalance of one of these neurotransmitters, such as norepinephrine, may cause bipolar disorder. When levels of this chemical are too high, mania occurs. When levels of norepinephrine drop below normal levels, a person may experience depression.

• Other scientists believe that bipolar disorder may also be a result of premature death of brain cells that deal with mood and emotion. This causes the brain to lose control of mood.

• Risk factors for bipolar disorder include the following:

• If a family member has bipolar disorder, other family members may be at risk. However, stress of some kind often is needed to trigger the disease.

• Certain drugs, such as cocaine or methamphetamine (speed), can trigger bipolar disorder.

• Some people are affected by the seasons and may be more depressed during the winter (see Seasonal Depression).

• Bipolar disorder may be caused by severe emotional stress at some time in life.

• A viral infection may bring on the disease.

• Most people never know why they develop bipolar disorder.

• Not everyone with severe mood swings or a change in personality has bipolar disorder. Mood swings can be caused by other medical conditions that need to be diagnosed and treated properly. Medical diseases and medications that may have symptoms similar to bipolar disorder include the following:

• Head trauma (blood clot or bleeding in the brain)

• Thyroid problem (both underactive and overactive)

• Systemic lupus erythematosus (a condition that may affect various body organs, including the brain)

• Brain tumor

• Epilepsy (seizures)

• Neurosyphilis (a form of the sexually transmitted disease, syphilis, that has gone to the brain because it went untreated too long)

• AIDS (acquired immunodeficiency syndrome the ultimate result of infection with the human immunodeficiency virus or HIV)

• Sodium imbalance (sodium, one of several elements found in body cells that is necessary for their proper function)

• Diabetes mellitus (a disorder of, among other things, sugar processing in the body)

• Certain medications that decrease the amount of serotonin or norepinephrine, such as some antihypertensive drugs and some preparations of steroids and birth control pills

• Other psychiatric conditions and drug abuse may also mimic bipolar disorder.

• Attention deficit/hyperactivity disorder (ADHD)

• Anorexia nervosa

• Drug abuse (cocaine, methamphetamine use)

• Bulimia nervosa

• Panic disorder

• Posttraumatic stress disorder

• Social phobia

• Schizoaffective disorder

• Schizophrenia

• Delusional disorder

Mania and depression are the opposing phases in bipolar disorder.

• Mania: A person in the manic phase may feel indestructible, full of energy, and ready for anything. Other times that person may be irritable and ready to argue with anyone who tries to get in the way.
  • Unrealistic plans, spending sprees, an increase in sexual affairs, or other reckless behavior, such as wild driving, also may occur.

  • Less sleep and food than usual are needed.

  • The person with mania can stay up all night but may find that not much was accomplished because he or she was easily distracted.

  • The person with bipolar disorder may talk very quickly and jump from subject to subject. They often exhibit pressured speech during mania.

  • Self-esteem may be inflated.

  • Any decisions that are made with regard to business and finances are often not good ones.

  • Clothing choices may also change, and the person with bipolar disorder may start wearing brighter, more flamboyant clothes.

  • These behaviors, which can be quite upsetting, usually prompt a family member to take notice and try to get the person help.

  • Most people who are going through the manic phase of bipolar disorder deny that anything is wrong with them and refuse to see a medical professional.

  • They are grandiose and may have delusions (false ideas) of grandeur (greatness).

• Depression: Although mania is said to alternate with depression, most people have more depressive episodes than manic ones.
  • Sadness and crying spells are common.

  • People who are depressed may not care enough to wash or comb their hair, change clothes, or even get out of bed in the morning.

  • These people may sleep too much (hypersomnolence) or have difficulty getting to sleep (insomnia).

  • Many of these people have no interest in food or have no appetite and lose weight. However, some eat excessively.

  • People with depression have trouble thinking; they may forget to do important things such as paying bills because they feel so down.

  • They withdraw from friends.

  • Hobbies that used to bring pleasure suddenly hold no interest for people who are depressed.

  • Depression brings feelings of hopelessness and helplessness.

  • People who are depressed may not see a point in living anymore and may actually think about ways to kill themselves.

• Some people with bipolar disorder cycle between the 2 extremes every few months or weeks. Other people with bipolar disorder may cycle several times within the same day.

• Signs of mania
  • Increased activity and gestures (pacing, tapping feet)

  • Inflated self-esteem

  • Poor judgment

  • Racing thoughts

  • Decreased need for sleep

  • Poor temper control

  • Irritability

  • Pressured speech: The person speaks very fast, as if his or her mouth can't keep up with the rapid thoughts. The person may be unable to respond to social cues to stop talking.

  • Increased activities with high risk of painful consequences (sexual affairs, gambling, risky investments)

  • Psychotic symptoms
    • Delusions (false beliefs)

    • Hallucinations (seeing or hearing things that aren't real)

• Signs of depression
  • Excessive worry

  • Excessive guilt

  • Sadness, crying spells

  • Loss of energy

  • Change in sleep pattern (insomnia at night, daytime sleepiness)

  • Major changes in appetite or weight

  • Feelings of worthlessness

  • Trouble concentrating

  • Social withdrawal

  • Lack of interest in previously enjoyable activities

  • Thoughts of death or suicide

Generally, people with severe bipolar disorder symptoms will not seek medical care on their own. A family member or close friend is usually the one seeking help for the person. The person needs to be seen by a medical professional in these situations:

• When changes in personality, including extreme moodiness, start to affect a person's life, ruin relationships with others, or threaten basic health. Medical conditions such as diabetes and thyroid disorders can cause mood swings. These are relatively easy to detect and treat. They are the starting point of an evaluation of mood swings.

• When changes in sleep and appetite begin to affect health, the person needs to be evaluated. Some people may not want any help. If they fear the stigma of having a mental illness, they need to know that many other things could be responsible for the changes in their behavior. This is especially true for anyone older than 40 years who develops signs of bipolar disorder.

• When the mood swings have become so severe that a person cannot function at home or work

• When a person has thoughts of suicide, especially with a specific plan as to how to take his or her own life
  • If the person might be a danger to self or others, he or she should be seen in a hospital emergency department.

  • Suicidal patients are hospitalized until their mood can be stabilized.

  • If the person refuses to go to the hospital, you may need assistance in getting him or her there. Call 911 if the situation is dangerous.

  • Above all, be sure of your own safety first. A person with bipolar disorder is probably not thinking clearly when in severe mania or depression. He or she may feel that the person calling for help is a traitor.

• With a suicide attempt, call 911 so that the person can be treated in the emergency department. Don't try to take a person who has attempted suicide to the hospital by yourself.

• Homicidal thoughts, threats, or behaviors require immediate intervention.

No specific blood tests or x-rays will tell the health care provider that a person definitely has bipolar disorder. The diagnosis is made on the basis of all the signs and symptoms.

If a person experiences at least 4 of the symptoms of mania and depression for a period of at least 2 weeks, that person may have bipolar disorder or another form of mood disorder.

• The person may have a long history of feeling depressed and then finally have a first manic episode. This clinches the diagnosis. However, any potentially treatable medical condition that could account for severe mood swings should be ruled out first.

• A complete physical examination is performed to check for enlarged glands, poor nerve function, or any other signs of a medical condition.

• A detailed interview will focus on the signs of bipolar disorder such as periods of racing thoughts, risky behavior, and inflated self-esteem followed by periods of depression.

Certain tests may be ordered to rule out medical conditions that could cause mood swings.

• Tests will probably be ordered to check the balance of salts and sugar in the blood, hormone function, blood cell counts, and drug and alcohol levels. These tests all are blood or urine tests.

• CT scan or MRI of the head may be ordered to check for blood clots, bleeding, or tumors.

• Rarely, an EEG (electroencephalogram), a brain wave study, may be ordered if the person is thought to have a seizure disorder. Electrodes are placed all over the scalp and secured by an adhesive. The electrodes are hooked up to a machine that traces brain waves. This is seldom performed in the emergency department.

• A spinal tap (lumbar puncture) may be ordered to get a sample of spinal fluid. This will be done if signs suggest a brain infection, such as meningitis or encephalitis. Such an infection is generally only considered a possibility if the behavior change happened relatively recently or if a fever or other signs of infection are present. The laboratory will study the fluid and be able to tell if an infection is present.

Treatment is based on the results of these tests. If test results are all normal, the diagnosis is most likely a psychiatric disorder, such as bipolar disorder.

Bipolar disorder will not get better without medical treatment.

|Self-Care at Home|

Self-care without medical treatment is not recommended. Self-care measures are not effective in relieving symptoms or preventing harmful behavior.

|Medical Treatment|

Treatment of bipolar disorder centers on (1) medications to stabilize mood swings and (2) counseling with a therapist. However, therapy is more successful with strong support from family and loved ones.

Medications don't always work the first time and may need to be changed many times until the right medication or combination of medicines is found.

• While this change is happening, people with bipolar disorder need to feel that they can count on their friends and family not to give up on them and to bear with them even though their mood swings are causing grief and pain.

• Periods of stress may throw people with bipolar disorder into one of the extremes, and they need strong support systems to help them deal with the disease.

Those people who are a danger to themselves or others will have their medications started in the hospital and will remain there until they are able to control their emotions enough to function at home.

• Psychiatric hospitalization protects the safety of the person with bipolar disorder and loved ones.

• Medical staff can monitor the effects of medications when a person is in the hospital.

• Medications can be adjusted more quickly in the hospital than over a series of outpatient visits.

• Group therapy or 1-on-1 sessions with a psychiatrist also start while in the hospital.

Not all episodes are serious enough to require hospitalization. Many people can be treated as outpatients.

|Medications|

• A variety of medications are available by prescription. These medications are usually referred to as mood stabilizers.
  • Many people start by taking lithium, which has been used for many years to treat bipolar disorder. Yet as many as half of all people with bipolar disorder do not respond to this medication.

  • Other possibilities are carbamazepine (Tegretol), valproic acid (Depakote), and lamotrigine (Lamictal). These are medicines that were originally developed to treat seizures, and so other antiseizure medicines are sometimes used to treat bipolar disorder as well.

  • Certain medications, such as olanzapine (Zyprexa) and risperidone (Risperdal), used to treat psychosis are sometimes used to treat bipolar disorder; both of these medications have been shown to be effective for such symptoms.  

  • All have side effects, and each person with bipolar disorder needs close monitoring for the side effects while taking the medication.

  • Antidepressant medication usually is taken with the mood stabilizer during depressive episodes. There is now a ready-made combination medicine approved for use in bipolar depression, Symbyax, which has the antipsychotic, olanzapine, along with the antidepressant, fluoxetine (Prozac), both in one capsule.
  
  
• The choice of medications is customized for each person.
  • Be sure to tell your health care provider of any other medical conditions you have.

  • Tell your health care provider about all medications you take, including over-the-counter drugs and herbal preparations. These may interact with the medications used for bipolar disorder.

  • Women also should discuss any plans for pregnancy and breastfeeding with their health care provider, because a change in medication may be necessary.
  
  
• Lithium: The exact way lithium works in controlling the mood swings of bipolar disorder is unknown.
  • Lithium may take as long as 2 weeks to take full effect.

  • It may have an "antisuicide effect."

  • Levels of the drug must be closely monitored with blood tests.

  • Drink plenty of fluids and do not restrict intake of salt while taking lithium because dehydration can cause the level of the drug in the blood to be dangerously high.

  • If you have kidney or heart problems, you may be started on another medication instead.

  • Most common side effects are thirst, increased urination, diarrhea, nausea, tremors, and dizziness.
  
  
• Carbamazepine (Tegretol): This medication reduces the excitability of brain cells and helps to control the symptoms of bipolar disorder.
  • It is especially good for those who cycle between mania and depression very quickly.

  • This drug may be used alone or in combination with another medication.

  • Levels of medication and blood cell counts are monitored.

  • Do not use this drug if you have a liver or blood disease.

  • Do not drink alcohol if you are taking this drug.

  • Side effects include dry mouth, constipation, drowsiness, nausea, trouble urinating, and low blood count (rare).
  
  
• Valproic acid (Depakote): This drug works for bipolar disorder by controlling abnormal electrical activity in the brain that may cause mood swings.
  • This medication can be used alone or in combination with another medication.

  • Blood levels should be monitored.

  • Liver function is tested occasionally.

  • Do not drink alcohol with this drug; the combination may cause excessive sleepiness.

  • Its most common side effects are drowsiness, nausea, diarrhea, tremor, and weakness.
  
  
• Lamotrigine (Lamictal): This medication appears to be most useful for the depressed phase of bipolar disorder.
  • This drug usually is used in combination with another medication.

  • Do not take this drug if you have kidney, lung, or heart problems.

  • Possible side effects, though rare, include severe rash, lip and tongue swelling, balance problems, and vision changes.
  
  
• Olanzapine (Zyprexa): This medication is approved for treatment of both acute mania and maintenance once the symptoms are under control.

  • This medication may be used in combination with an antidepressant for treatment of depression in bipolar disorder.

  • One must be cautious of hyperglycemia in patients on any of the "atypical antipsychotics," of which Zyprexa is one. Patients who are already diabetic need to watch for poorer control of their blood sugar. Weight gain is possible, with or without problems with blood sugar.

  • There is a possibility of so-called extrapyramidal side effects (EPS) at higher doses of this medicine. Oversedation or at least decreased alertness may occur.

  • This medicine may be safer in pregnant women who have bipolar disorder than some of the other medications mentioned above. 

• Risperidone (Risperdal): This is another of the atypical antipsychotic medications, and it has been approved for use in acute mania.

  • At higher doses, this medicine may cause restlessness, tremor, or other EPS symptoms.

  • Other side effects are similar to those of olanzapine. 

|Other Therapy|

For most persons with bipolar disorder, medications do not relieve symptoms completely. Psychological counseling (psychotherapy) complements drug therapy.

• Counseling usually begins in the hospital or when medical treatment begins.

• Different types of therapy are used. Therapy may be individual or in a group—both can be effective if approached with a positive attitude.

• The goal is to help the person accept and cope with the disease.

• It is often very important for the spouse or other family members to be involved during visits to the therapist.
  • It is important to treat the whole family, not just the person with bipolar disorder, not because they are all "sick," but because this disorder affects them all.

  • Family members can learn valuable ways to deal with their loved one's mood swings.

|Follow-up|

Take your medication as directed. You will very likely be tempted to stop your medication. Many people with bipolar disorder do so. Don’t do so. Instead, talk it over with your health care provider. Stopping your medication will probably cause your symptoms to come back. It may also cause uncomfortable or alarming withdrawal symptoms.

Depending on which medication is used, you may need regular blood tests to monitor levels and to check for side effects of the drug.

You should have regular appointments with your health care provider to see how well the treatment is working and detect any instability of your mood.

Regular sessions with a psychotherapist or counselor are also important.

Ongoing education for you and your family is crucial to help everyone deal with the disease.

You and your family should be taught to watch for early warning signs of crisis and ways to deal with stress to prevent recurrences.

|Prevention|

Nothing is known to prevent bipolar disorder. It is best to avoid drugs that may trigger the disease (such as cocaine or methamphetamine).

Relapses can be prevented or made less severe by following the treatment recommendations of your health care providers. This includes taking medication as directed and attending counseling sessions.

|Outlook|

Bipolar disorder is a long-term condition with no actual cure, only ways to control the symptoms.

With treatment, many people are able to lead normal lives. Some (about 1 in 10) may never have another manic episode.

People with bipolar disorder and their families and friends can learn to pay attention to signs and symptoms of the depression or mania emerging and have their medications adjusted to prevent a relapse of the low or high. Through education and support, they can be able to monitor themselves.

Others battle mood swings for the rest of their lives. With proper medication and regular psychotherapy, however, the disease can be well controlled with few flare-ups.

If untreated, bipolar disorder may lead to risky activities, dysfunction in family and work, and even suicide or homicide.

|Support Groups and Counseling|

Befrienders International – To find a local suicide prevention hotline, log on to the Web site of this suicide prevention group.

Child & Adolescent Bipolar Foundation - 847-256-8525

National Foundation for Depressive Illness, Inc. (NAFDI) - 800-239-1265

Depression and Related Affective Disorders Association (DRADA) – 410-955-4647

Mood Challenge Support Group – 309-671-8000

Mood Disorders Support Group, Inc – 212-533-MDSG

National Alliance for Research on Schizophrenia and Depression – 800-829-8289

Depression and Bipolar Support Alliance – 800-826-3632

National Foundation for Depressive Illness – 800-239-1265

The movie, Mr. Jones, is one depiction of BD.

The book, The Depression Workbook: A Guide for Living With Depression and Manic Depression, 2nd edition, by ME Copeland may be helpful. It is published in Oakland, California by New Harbinger Publishers, 2002.

|Web Links|

American Psychiatric Association

American Psychological Association

1999 Surgeon General's Report on Mental Illness

National Alliance for the Mentally Ill (NAMI)

National Institute of Mental Health, Bipolar Disorder

National Mental Health Association (NMHA)

BD, BPD, depression, mania, euphoria, manic depression, mood disorder, mood swings, suicide, rapid mood cycling, homicide, emotional stress, extreme moodiness, psychotherapy, manic-depressive illness, bipolar disorder

Author: Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA.

Coauthor(s): Mara Aloi, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Allegheny General Hospital, MCP Hahnemann University.

Editors: Ronald C Albucher, MD, Assistant Chief, Psychiatry Service, VA Ann Arbor Healthcare System; Clinical Assistant Professor, Department of Psychiatry, University of Michigan School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Alan D Schmetzer, MD, Professor and Assistant Chair for Education, Department of Psychiatry, Indiana University School of Medicine.