Bipolar disorder, also known as manic-depressive illness, is a disorder characterized by extreme shifts in mood, energy, behavior and functioning. According to 2012 statistics from the Depression and Bipolar Support Alliance Organization, Bipolar I and Bipolar II disorder (described below) affect approximately 5.7 million adult Americans, or 1.8 percent of the population. The number is much higher when taking into account “Bipolar Spectrum” and “Soft Bipolar Disorder” (described below). Bipolar disorder typically emerges in adolescence or early adulthood, although it may appear in childhood or later adulthood. Men and women are equally likely to develop bipolar disorder.
The specific causes of bipolar disorder are not yet known. Research suggests a strong genetic contribution, but the specific genes involved and exactly how these genes influence the development and expression of bipolar disorder are unclear. Environmental factors, such as traumatic experiences, daily life stressors, family conflict, and even positive life events, also play a significant role in the development of the disorder and the triggering of mood episodes.
Categories of Bipolar Disorder: The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) identifies four types of bipolar disorder:
- Bipolar I
- Bipolar II
- Cyclothymic Disorder
- Bipolar Disorder Not Otherwise Specified (NOS)
Each of these four disorders is comprised of a different combination of mood episodes (manic, hypomanic, major depressive episodes and mixed). Following is a brief description of the four types of bipolar disorder. The mood episodes are described below.
Bipolar I: The individual has had one or more manic or mixed episodes. Often the individual has also had major depressive episodes, although this state is not required for this diagnosis.
Bipolar II: The individual has had one or more major depressive episodes and at least one hypomanic episode, but has not had a manic or mixed episode.
Cyclothymic Disorder: For at least two years the individual has cycled between low-grade depression and hypomania, with little time symptom-free. The person has never had a manic or mixed episode, and the depression has not been severe enough to meet the criteria for major depressive episode (if it has, then the diagnosis is Bipolar II).
Bipolar Not Otherwise Specified (NOS): An individual does not meet the full criteria for one of the other bipolar disorders, but clearly suffers from a mood disorder that appears bipolar in nature. An example is a person who experiences major depressive episodes and also experiences hypomanic symptoms, but the hypomanic symptoms do not last as long as is required for a hypomanic episode.
Major Depressive Disorder: Major depressive disorder, also known as unipolar depression, is when an individual has one or more major depressive episodes but has never experienced a manic, hypomanic, or mixed episode.
So, what are manic episodes, hypomanic episodes, major depressive episodes and mixed episodes?
Bipolar Episodes: As noted above, each of the four bipolar disorders is comprised of a different combination of mood episodes (manic, hypomanic, major depressive episodes and mixed).
Manic Episodes: Mania is the high state, the time when people might feel invincible or euphoric, and have a grandiose sense of self. Typically, people in manic states experience what they believe is a heightened sense of clarity, often as their thoughts race. Mania is commonly described as pleasurable, even addictive or seductive. However, some people experience an extremely irritable mood during mania, which may be quite painful. Also, manic episodes are sufficiently severe to cause significant problems with social or work functioning. Therefore, even when mania feels good, it tends to have painful consequences. A manic episode is defined as a period of at least seven days (or less if the person has to be hospitalized) with:
- Abnormally elevated, expansive or irritable mood and at least three other symptoms (four if the mood is irritable rather than elevated)
- Inflated self-esteem or grandiosity
o Decreased need for sleep (e.g., feeling rested after two-three hours of sleep)
o Increased activity (socially, or at work or school) or physical agitation
o Being more talkative than usual
o Racing thoughts
o Distractibility
o Engaging in risky behavior (e.g., reckless driving, shoplifting, excessive spending
Hypomanic Episodes: Hypomania is a mild version of mania where the symptoms are the same but are less intense – they only need to last four days and do not significantly impair a person’s functioning. Many people find they are more productive and have positive social interactions when hypomanic. Others find that although a single hypomanic episode does not cause much impairment, repeated episodes negatively affect finances, social relationships, and/or work performance.
Major Depressive Episodes (MDEs): Depression is the down state when people feel sad or blue, or simply cannot enjoy anything. This state tends to be characterized by changes in sleep, appetite and weight, energy, and cognitive (thinking) abilities. People may feel worthless and guilty, and may consider suicide.
Major depressive episode is defined as a period of at least two weeks with five or more of the following symptoms:
o Depressed mood and/or anhedonia (an inability to take pleasure in things, or greatly diminished interest in activities usually enjoyed) and
o A decrease or increase in appetite; weight loss or gain
o Sleep disturbance (insomnia or hypersomnia)
o Feeling physically slowed down or physically restless
o Fatigue or loss of energy
o Feelings of worthlessness or excessive guilt
o Difficulty concentrating or making decisions
o Recurrent thoughts of death or suicide
Mixed Episodes: Approximately 40% of people with bipolar disorder have mixed episodes, when both mania and depression are experienced at the same time, nearly every day, for at least one week. People describing mixed states often comment that they feel “tired but wired,” or that they go from laughing to crying in a matter of seconds. Similarly, people tend to be over-energized, agitated and irritable. Their thoughts race, but unlike pure mania, the thoughts are nearly all negative. Mixed states are perhaps the most dangerous mood episodes of all, with risk of suicide higher than pure depressive episodes.
Psychotic symptoms: In addition to the symptoms described above, severe depression or mania may be accompanied by psychotic symptoms. These symptoms include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence, and are not explained by a person’s cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time.
Bipolar Spectrum and Soft Bipolar Disorder: Many believe bipolar disorder is not easily grouped into one of the four categories described above but is actually a spectrum disorder (called Bipolar Spectrum). For example, according to DSM-IV, a mixed episode is part of a Bipolar I disorder. However, some experience hypomania and depression at the same time. In this case, clinicians and researchers use the term “Bipolar II, mixed” even though this terminology is not consistent with DSM-IV. Also, some clinicians and researchers believe certain forms of major depressive disorder are better classified as a “Soft Bipolar Disorder” (e.g., when a person has many depressive episodes, starting at a young age, with a poor response to antidepressant medications).
Such distinctions are helpful in treating mood disorders, so psychologists and psychiatrists continue to develop diagnostic systems that will best guide patients and doctors.
Course: The course of bipolar disorders can be quite variable. Bipolar disorders tend to be recurrent, where people experience multiple mood episodes over time. Left untreated, bipolar episodes typically become more frequent and more severe over time.
For some, episodes are separated by periods of wellness during which the person suffers few to no symptoms. These periods can last for months or even years. Others have a more chronic course with little respite between episodes. When four or more mood episodes occur within a 12-month period, the person is said to have bipolar disorder with rapid cycling.
Other Mental Illnesses: It is easy to confuse bipolar disorders with other mental illnesses. The most common disorders confused with bipolar disorder are:
o Attention-deficit/hyperactivity disorder
o Borderline personality disorder
o Schizophrenia or schizoaeffective disorder
o Recurrent major depressive disorder
o Substance-induced mood disorder, or mood disorder due to a medical condition
Alcohol and substance abuse complicate bipolar disorder.
Treating Bipolar Disorders: People with bipolar disorder are treated with a combination of medications – mood stabilizers, antidepressants, antipsychotics, and/or antianxiety agents. Side effects are common and many say they miss the high or clarity associated with mania. Medication is often combined with psychotherapy, which can be individual, family, couples or group therapy.
For more information about treatment, click here.