What Is Bipolar Disorder?

Formerly called manic-depressive illness or manic depression, bipolar disorder is a treatable mental health condition marked by extreme shifts between low and high moods, or energy levels.

These dramatic “mood swings” can vary in duration and severity.

According to the National Institute of Mental Health (NIMH), approximately 10 million U.S. adults, or roughly 4%, will experience bipolar disorder.

Let’s find out more about the three common types of bipolar diagnoses, the signs and symptoms of bipolar, what causes bipolar disorder, and the treatment options available. 

What are the signs and symptoms of bipolar disorder?

According to the American Psychiatric Association (APA), people with bipolar disorder experience intense emotional states—called mood episodes—that typically occur during distinct periods of days to weeks. These mood episodes are categorized as manic/hypomanic (abnormally happy or abnormally irritable mood) or depressive (sad mood).

While the APA points out that people who do not have bipolar disorder experience mood fluctuations, these typically last hours, rather than days or weeks.

Mood episodes can vary greatly, depending on the individual. In general, the National Institute of Mental Health (NIMH) says, bipolar disorder causes atypical shifts in mood, marked by changes in activity, energy, and concentration levels. Ultimately, manic and depressive episodes affect the person’s ability to perform daily tasks. 

The three types of bipolar disorder

According to the APA, there are three types of bipolar disorder—bipolar I, bipolar II, and cyclothymic disorder (also called cyclothymia). 

Here, we’ll break down each type: 

Bipolar I

The two main poles of bipolar I are mania and depression. 

Bipolar I is typically identified by manic episodes that last at least seven days, and/or symptoms severe enough to require hospitalization. Depressive episodes that last at least two weeks are also associated with bipolar I. 

Although bipolar I can include hypomanic episodes, a bipolar I diagnosis is marked by the patient experiencing at least one manic episode.

Bipolar II

In bipolar II, the two polar moods are identified as hypomania and depression—with each episode lasting for at least four consecutive days. 

The differences between mania in bipolar I and hypomania in bipolar II include the severity and duration of the symptoms. 

While both are episodic states characterized by energized moods or feelings of excitement, hypomania is a milder and shorter form of mania. Thus, bipolar II is significantly less likely to affect a person’s day to day life. 

Cyclothymic disorder

A third, and even milder, form of bipolar disorder is called cyclothymic disorder. 

People with cyclothymia experience mood cycles with similar symptoms to those found in bipolar I and II. However, they typically experience more frequent cycles, less symptomatic severity, and shorter episodes. 

According to the Cleveland Clinic, cyclothymic disorder involves many frequent “mood swings,” oscillating between hypomania and depressive symptoms that can sometimes switch over the course of a day. 

The Diagnostic and Statistical Manual of Mental Health Disorders, fifth edition (DSM-5-TR) defines the duration of the disorder as lasting for at least two years, with more days present than not, and a stable mood cannot have lasted longer than two consecutive months. 

At the time of diagnosis, hypomanic and depressive periods have been present for at least half of the total time since the onset of symptoms—two-years for adults, and one-year for children and adolescents.

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5-TR) outlines the criteria for various episodes prevalent in different types of bipolar disorders. 

A manic episode is most often associated with a bipolar I diagnosis. Although those with bipolar I may also experience hypomanic episodes, the marked difference between bipolar I and the other two forms of bipolar, is the prevalence of one or more manic episodes. 

Therefore a hypomanic episode is more characteristically associated with a bipolar II or cyclothymic diagnosis, and depressive episodes are characteristic of all three types of bipolar disorder. 

The main difference between manic and hypomanic episodes is the severity and duration of their symptoms. Although the signs and symptoms for both are similar, manic episodes last at least seven consecutive days and/or require hospitalization, while hypomanic episodes only last a minimum of four days in bipolar II and are even shorter lived. 

Below is a list of symptoms for both manic and hypomanic of episodes, as well as depressive episodes, according to the DSM-5-TR:

Symptoms of manic and hypomanic episodes

1. Inflated self-esteem or grandiosity
   
2. Decreased need for sleep (e.g., feels rested after three hours of sleep)
   
3. More talkative than usual or feels pressure to keep talking
   
4. Flight of ideas or subjective experience/racing thoughts 
   
5. Reported or observed distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) 
6. Increase in goal-directed activity (e.g., socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless activity)
7. Excessive involvement in risky activities (e.g., engaging in impulsive buying sprees, sexual indiscretions, or foolish business investments)

Major depressive episode

1. 1. 1. 1. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful)
               Note: Children and adolescents may exhibit irritable behavior
2. Reported or observed, significantly diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective account or observation)
3. Unintentional fluctuations in weight (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation (observable by others, not merely subjective feelings of sluggishness or restlessness)
6. Fatigue or loss of energy
7. Feelings of worthlessness, or excessive/ inappropriate guilt
8. Reported or observed diminished concentration or indecisiveness
9. Recurrent thoughts of death (not just fear of dying), or suicidality—marked by reports of recurrent suicidal ideation, a specific suicide plan, or a suicide attempt

What is it like when a person is experiencing a manic, hypomanic, or depressive episode? 

Examples of manic and hypomanic episodes

A person who is in the midst of a manic, or even hypomanic episode, may not sleep for multiple days and nights. 

In some cases, they’re heavily focused on a particular project that has little or no relevance to their daily functioning. In other cases, they could engage in impulsive and risky behaviors.

For example, a woman in the middle of an episode might think she is writing the next great American novel, but what she actually produces may read as pages and pages of gibberish. She could experience delusions of grandeur, claiming she is sure to be chosen as the next winner of the Pulitzer Prize for fiction.

During a manic or hypomanic episode, a client may go on an online shopping spree—spending excessively and maxing out their credit cards. 

Since distractibility and loss of concentration is a common symptom, a client may also have numerous tabs open on her computer as a result of her disjointed and erratic thought processes—jumping from one search query to the next, and so on—i.e., tops (clothing), to tops (spinning), to toys, to Christmas decorations, and so forth.

Examples of depressive episodes

A person who is living with depressive symptoms associated with bipolar disorder may lose all interest in the activities she used to find enjoyable (e.g., going out with friends, going to the movies, reading, etc.). 

She may find it difficult to concentrate or to function at her job. She may have insomnia or be sleeping too much, lose her appetite or overeat. 

In severe depression, she may be unable to get out of bed, to shower, or to brush her teeth. She may feel worthless or as if she is a burden to her family or friends. She may even be experiencing suicidal thoughts, with or without a plan.

Why are bipolar disorder and borderline personality disorder (BPD) often confused? 

Bipolar disorder is often confused with borderline personality disorder (BPD).

One of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria for borderline personality disorder is “affective instability due to a marked reactivity of mood”—which means rapidly shifting between different emotional states. These mood swings usually last a few hours and rarely last more than a few days. 

When the term “mood swings” is heard, it’s not unusual to think of bipolar disorder first. Although cyclothymic disorder is marked by rapidly shifting moods as well, in general, the mood episodes in bipolar disorder tend to last longer than those in BPD.

The DSM-5-TR lists eight other criteria for BPD, and five out of the nine total criteria need to be met for a person to qualify for the diagnosis. These criteria are markedly different from those of bipolar disorders. 

So, when a clinician digs deeper—past the mood swings—they’re likely to make the correct diagnosis, be it bipolar disorder or BPD.

Causes of bipolar disorder 

Chemical imbalance

People who have been diagnosed with bipolar disorder have an imbalance of specific chemicals in the brain known as neurotransmitters. 

Neurotransmitters assist in sending messages between areas of the brain. An imbalance of neurotransmitters in the brain has been identified as a contributing factor of bipolar disorder and symptom severity. 

This chemical imbalance looks different in each person with bipolar disorder, however, there are considerable trends in their neurochemistry. Studies show that increased or decreased levels of certain neurotransmitters correspond to manic or depressive episodes in people with bipolar diagnoses.

One contributing factor to bipolar disorder is an imbalance of certain chemicals in the brain called neurotransmitters. 

The three main neurotransmitters that bipolar disorder may have an effect on are:

• Dopamine
• Serotonin
• Norepinephrine

In people with bipolar disorder, high levels of norepinephrine are correlated with mania and vise-versa (low levels tend to correlate with depressive episodes). The same is true for low levels of serotonin, as it’s an indicator of low or depressed mood.  An excess of dopamine can also indicate  mania.

Genetics

Bipolar disorder has a strong genetic component. Research from the Journal of Medical Genetics suggests that relatives of people with bipolar have a 5 to 10% chance of developing bipolar disorder within their lifetime. For a twin, the lifetime risk is between 40% to 70%.

A study led by the Psychiatric Genomics Consortium found 64 genomic locations associated with bipolar disorder—indicating a strong genetic component in bipolar diagnoses. 

Treatment for bipolar disorder

The treatment for bipolar disorder consists of a multi-pronged approach. Treating bipolar disorder may include medication management, psychotherapy, psychoeducation, self-care techniques, and building a support network—which may include family and friends.

Therapy and mental health support

There are many therapeutic interventions to choose from, however, these specific types of therapies are proven to help people diagnosed with bipolar disorder:

• Cognitive-behavioral therapy: CBT works to help the person diagnosed with bipolar disorder to identify negative beliefs and behaviors and replace them with positive ones. CBT can also help identify triggers for bipolar episodes.
  
• Family-focused therapy: Family support and communicating with family members can help an individual stick with their treatment plan. It can also help a person and their loved ones recognize and manage the warning signs of mood swings.
  
• Interpersonal and social rhythm therapy (IPSRT): IPSRT focuses on stabilizing daily patterns, since following a consistent routine in eating, sleeping and exercising may help more effectively manage moods.
  
• Group psychoeducation: Learning about bipolar disorder can help a person better understand their condition. Being part of a group helps an individual feel as though they are not alone and they can get additional support when needed.
  
• Systematic care management: This type of care consists of a combination of an outpatient specialty team and group therapy. The care for the individual diagnosed with bipolar disorder is provided by a nurse care coordinator and a psychiatrist. Group psychoeducation teaches clients about their symptoms, the need for medications, and provides support in achieving occupational and social goals.        

Medications

The medications typically used to treat bipolar disorder are mood stabilizers. 

Examples of mood stabilizers include:

• Lithium (Lithobid) 
• Valproic acid (Depakene) 
• Divalproex sodium (Depakote) 
• Carbamazepine (Tegretol, Equetro, others)
• Lamotrigine (Lamictal)

Additionally, second generation antipsychotic medications are commonly used in the treatment of bipolar disorder to help with the symptoms of mania. They can be taken alone or with mood stabilizers. 

These include:

• Aripiprazole (Abilify) 
• Asenapine (Saphris) 
• Cariprazine (Vraylar) 
• Lurasidone (Latuda)
• Olanzapine (Zyprexa) 
• Quetiapine (Seroquel) 
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

Key points to remember and resources you can use  

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), symptoms of bipolar disorder, such racing thoughts during a manic episode, aren’t experienced or exhibited the same in everyone, or even in every incident. 

Remember, everyone is different. 

A client might not experience a ‘flight of ideas,’ but may express a sense of grandiosity and report a decreased need for sleep.

What’s more, all of these terms are general, so you’ll have to evaluate based on each specific client before making a diagnosis or treatment plan. 

If you treat bipolar disorder, you can use the SimplePractice professional website to indicate so and reach prospective bipolar clients on our Monarch directory too.

Resources for bipolar disorder psychoeducation 

• Depression and Bipolar Support Alliance
• NAMI: National Alliance on Mental Illness| Bipolar Disorder
• American Academy of Child & Adolescent Psychiatry Bipolar Resource Center
• Brain and Behavior Research Foundation

If you or someone you know is in immediate distress, or is thinking about hurting themselves, call or text the National Suicide Prevention Lifeline at 988.

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