Bipolar Disorder

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The biopolar disorder characterized by episodes of mood swings ranging from depressive low to manic highs, was originally named manic depression by Emil Kraepeline, a German psychiatrist who described the disorder in 1899 (Lagasse, 2008).

Bipolar disorder is a cyclical condition, typically involving periods of clinical depression alternating with episodes of mania or hypomania (which can include, among other things, expansive, elevated, or irritable mood; decreased need for sleep; and/or risk-taking behavior).

Kraepelin recognized that manic depression takes different forms. Likewise, in the modern diagnostic system, different types of bipolar disorder are recognized (Preston, O’Neal, & Talaga, 2008).

The bipolar disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000), sometimes termed the bipolar spectrum, consist of bipolar 1, bipolar II, cyclothymic disorder, and bipolar disorder not otherwise specified (NOS).

  • Bipolar I is usually characterized by one or more manic or mixed episodes (when depression and mania occur simultaneously).
  • bipolar II is characterized by one or more major depressive episodes accompanied by at least one hypomanic (lower-grade mania) episode.
  • Cyclothymic disorder is characterized by many periods of hypomanic symptoms (that do not meet the criteria for manic episodes) and depressive symptoms (that do not meet the criteria for major depressive episodes).
  • If there is very rapid cycling, or alternating, of manic and depressive symptoms that do not meet the duration criteria for manic or depressive episodes, a diagnosis of bipolar disorder NOS is assigned (American Psychiatric Association, 2000).

Manic episodes (or mania) are described as distinct periods of time (usually at least one week) marked by abnormally and persistent expansive, elevated, or irritable mood, which may be accompanied by grandiosity (an inflated sense of self involving feelings of superiority or importance), decreased need for sleep, pressured speech, flight of ideas, increased involvement in goal-directed activities, excessive pleasure-seeking, and/or risk-taking behaviors.

Hypomania is a milder form of mania causing less severe functional impairment and not requiring hospitalization.

Hypomania may be marked by increased productivity and creativity and is not accompanied by the psychosis (e.g., delusionsOpens in new window or hallucinationsOpens in new window) that may accompany full-blown mania (American Psychiatric Association, 2000).

A hypomanic episode may be preceded by or follow a major depressive episode or may presage an eventual manic episode. When prominent depressive and manic symptoms occur simultaneously for at least a week, the episode is considered mixed.

In mixed episodes, mood may shift rapidly, and the episode may be prolonged and exacerbated by increase in the use of alcohol or stimulants (American Psychiatric Association, 2000).

Bipolar disorder has a different presentation in adults, adolescents, and children. The marked mood changes recognizable in adults may present as irritability, hostility, aggression, and/or inattention in children.

Bipolar disorder can be misdiagnosed as borderline personality disorderOpens in new window (in adults) and as attention-deficit hyperactivity disorder (ADHD)Opens in new window or a conduct/behavior disorder (e.g., oppostional defiant disorder or conduct disorder) in children.

Bipolar disorder may be comorbid with ADHD and is often comorbid with substance abuse (especially in adolescents and adults). It is important to distinguish between substance-induced mood symptoms and substance abuse disorder associated with bipolar disorder.

It can be difficult to distinguish between bipolar disorder and schizoaffective disorderOpens in new window or other major mood disorders (e.g., major depressive disorder). While psychotic symptoms may be present in both schizophrenia and bipolar disorder, schizophrenia does not have the primary mood symptoms that are associated with psychosis in bipolar disorder.

When diagnosing bipolar disorder, it is important to rule out medical conditions—such as thyroid disease or other metabolic disorders, infectious diseases such as encephalitis, seizure disorders, brain tumor, or stroke—that can cause symptoms that present similarly as bipolar disorder.

Estimates of the lifetime prevalence of bipolar I in community samples range from 0.4 to 1.6 percent (American Psychiatric Association, 2000), while eh incidence of bipolar II ranges from 0.5 to 5 percent (Benazzi, 2007).

The average age of onset for a first manic episode is the mid-twenties, although some cases emerge in childhood or adolescence, while others do not appear until after 50 years of age (American Psychiatric Association, 2000; Preston et al., 2008).

Bipolar I occurs equally in males and females, while twice as many women as men are diagnosed with bipolar III. The first episode is usually mania in men and depression in women (Preston et al., 2008); rapid cycling is more common in women than men (American Psychiatric Association, 2000).

Estimates of suicideOpens in new window rate in individuals with bipolar disorder vary from 10 to 20 percent (American Psychiatric Association, 2000; Preston et al., 2008). There are more individuals with bipolar disorder from higher socioeconomic groups and with higher levels of education (Preston et al., 2008).

Individuals with bipolar disorder have elevated rates of first-degree biological relatives with a history of a major mood disorder (bipolar I, bipolar II, or major depressive disorder).

Theories about the causes of bipolar disorder mainly focus on neurobiology and genetic transmission, although other areas (such as environmental factors) have been explored.

From the 1970s through the 1990s, neurobiological research focused on neurotransmitters (substances that modulate brain function and influence mood, e.g., serotonin and dopamine), synaptic activity (i.e., transmission of messages between neurons), cell membrane function, and second messenger systems.

Research in the late 1990s expanded to include molecular and cellular processes, neuroplasticity (changes in brain organization as a result of experience), and signaling networks (neural connection patterns).

These include theories involving catecholamines (the neurotransmitters dopamine, epinephrine, and norepinphrine), the HPA axis (the hypothalamic-pituitary-adrenal axis of the brain that controls reactions to stress and regulates many bodily processes), and genetic and familial theories (Preston et al., 2008).

Lithium’s antimanic effects were discovered in 1949 but did not gain acceptance as a treatment for bipolar disorder in the United States until 1970 because of concerns about toxicity (Preston et al., 2008). Lithium is currently viewed as a safe and effective treatment for bipolar disorder, along with other anticonvulsant mood stabilizers, especially carbamazepine (Tegretol or Equetro), divalproex (Depakote), and lamotrigine (Lamictal).

Lithium and the anticonvulsant mood stabilizers can have side effects, and therapeutic levels must be monitored periodically through blood tests to prevent toxicity.

Alternative or adjunctive treatments for bipolar disorder include newer anticonvulsants, some antipsychotics, some antidepressants, and antianxiety agents, often used in combinations to target specific constellations of symptoms.

The use of antidepressantsOpens in new window to treat depressionOpens in new window in bipolar disorder is controversial; some studies claim that antidepressants can trigger manic episodes or induce rapid cycling, while other sources claim there is no evidence to support this (American Psychiatric Association, 2000).

Medication treatment of bipolar disorder is generally long term because of the relapsing nature of the disease. Many practitioners consider a combination of psychotherapy and medication to be the optimal treatment for bipolar disorder (Miklowitz & Alloy, 1999; Olson & Pacheco, 2005; Preston et al., 2008). Other treatments for bipolar disorder include education about the disorder, family therapy, group therapy, and individual therapy.

Bipolar disorder can have serious adverse effects on employment, education (especially in children), and relationships and can be associated with increased levels of alcohol or other substance abuse, violent or abusive behavior, or episode antisocial behavior. Onset of bipolar disorder at a young age can increase the severity of the disorder; repeated occurrences of severe episodes (mania and/or depression) can worsen prognosis, so early treatment is essential.

  1. Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness. New York: Random House.
  2. American Psychiatirc Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
  3. Benazzi, F. (2007). Bipolar II disorder: Epidemiology, diagnosis and management. CNS Drugs, 21, 727 – 740.
  4. Lagasse, P. (2008). The Columbia encyclopedia (6th ed.). New York: Columbia University Press.
  5. Miklowitz, D.J., & Alloy, L. B. (1999). Pyschosocial factors in the course and treatment of bipolar disorder: Introduction to the special section. Journal of Abnormal Psychology, 108, 555 – 557.
  6. Olson, P. M., & Pacheco, M.R. (2005). Bipolar disorder in school-age children. Journal of School Nursing. 21 (3), 152 – 157.
  7. Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2008). Handbook of clinical psychopharmacology for therapists (5th ed.). Oakland, CA: New Harbinger.