What is Bipolar Disorder?
Bipolar disorder is defined as a chronic mental condition with the ability to cause mood swings and the inability to make decisions clearly. Individuals diagnosed with bipolar disorder present both high and low moods which are clinically known as mania and depression. Mania and depression vary from typical ups and downs, and if left untreated, they can get worse over time.1 Despite worsening symptoms, most affected individuals can lead a better life with a good treatment program. Bipolar disorder is an adverse condition which has the ability to cause risky behaviors characterized by suicidal tendencies. It can also be managed through therapy and medication.
Bipolar disorder is a chronic condition, typically experienced in early adulthood with an onset age of 25 years.2 However, in some cases, bipolar disorder can be diagnosed in childhood or in older years. In the USA, it is estimated that about 2.9% of bipolar cases are diagnosed on an annual basis with approximately 83% categorized as severe.3 Research shows that the condition affects both men and women equally. Since its conception, physicians have made great strides to have a full comprehension of the various moods involved in the classification of bipolar disorder to make an accurate diagnosis. Prior to this groundbreaking discovery, doctors had challenges in differentiating bipolar disorder from other conditions such as depression and schizophrenia. However, having a greater understanding of the symptoms associated with bipolar disorder, doctors have been able to better diagnose bipolar disorder, improving the management and treatment of the condition.
Doctors use a two-way conversation with the patient to understand mood swings, behaviors, and how bipolar disorder affects life. Although physical assessment is essential in understanding general health, talking with the patient is crucial in paving the way to comprehend mood swings and other symptoms. This helps doctors understand, diagnose and treat bipolar disorder. It is recommended that the physician take accurate notes of the patient’s symptoms, which include the severity, length, and frequency to make a proper diagnosis. Diagnosis is made using the criteria stipulated by the DSM-5. Therefore, when a physician is making a diagnosis, they are likely to ask questions regarding one’s personal and family history, with a focus on the presence of mental conditions within the family. Bipolar disorder can be a result of genetic factors. Having information about family history is essential in the diagnosis of bipolar disorder. Other questions will be about bipolar symptoms, reasoning, and the ability to make decisions while maintaining social relationships.
Bipolar disorder is an elusive condition that poses challenges in its diagnosis. Additionally, there is a recognized spectrum of bipolar disorders that present symptoms ranging from severe, moderate and milder mood swings, making it difficult to differentiate with typical mood fluctuation. Some of the subtypes of bipolar disorder include:
Characterized by full-blown manic episodes and symptoms is the first subtype. Furthermore, the symptoms associated with bipolar I disorder can have impairing effects. Individuals suffering from this subtype present characteristics of depressive symptoms.
Bipolar II disorder is recognized by raised moods that are not severe enough to present full-blown mania. Diagnosis of these symptoms is clinically referred to as hypomanic episodes and are characterized by less intense, elevated moods. Also, the condition is understood through the individual presentation of depressive signs and less severe manic episodes.
Cyclothymic disorder is a chronically unstable mood disorder in which the individual presents hypomania and mild cases of depression for two years. Other characteristics include brief, normal periods that last for approximately 8 weeks. Also, this subtype is used to describe recurring hypomanic episodes and clinical symptoms of depression, although the depressive symptoms don’t get to the level of diagnosis as a major bipolar disorder.
These subtypes are diagnosed in individuals that fail to meet the requirements of being classified as either of the subtypes discussed above or any other known subtype. However, individuals in this subtype present episodes of clinically essential, abnormal characteristics of mood swings. These subtypes are yet to be classified officially as a subtype of bipolar disorder and whether treatment is required.
Despite the common presentation of manic episodes or hypomania as defining features of bipolar disorder, depressive episodes are observed throughout the course of the condition. Depression is a major cause that results in the inability to function normally in daily activities for a period of two weeks. Many individuals diagnosed with bipolar disorder present symptoms of depression. In a longitudinal study involving 146 bipolar I disorder patients, subjects showed subsequent depressive symptoms which were three times more than manic symptoms. In another study that involved 86 bipolar II disorder patients, subjects spent approximately 50% of the time during the study presenting depression symptoms. Depression ranges from severe to moderate to low, and when presenting in a chronic form it is called dysthymia.
Individuals presenting symptoms of depression show other major signs that challenge their daily functioning. For instance, depressed persons present a significant loss of interest in things that they previously had passion engaging in. Other symptoms include weight loss, fatigue, inadequate sleep, feelings of worthlessness, excessive guilt, and suicidal thoughts. Suicidal thoughts are elevated during depressive episodes, with approximately 17% of individuals diagnosed with bipolar I disorder and 24% of individuals with bipolar II disorder attempting suicide during the course of the condition. In the worst case scenario, approximately 8% of men and 5% of women with bipolar disorder die from suicide. Moreover, research shows that about 0.4% of individuals with bipolar disorder succumb to suicide annually. Notably, significant cases of suicidal thoughts and actual suicides are reported during depressive episodes over the course of the disease.
Mania is also a major symptom of bipolar disorder. For an individual to be diagnosed with bipolar disorder they must present signs of mania or hypomania. Hypomania is categorized as a milder form of mania, with symptoms of psychosis such as hallucinations and delusions. Individuals who have been diagnosed with hypomania have the ability to function typically in a social or professional situation. The experience of mania and hypomania differs from one individual to another where some people experience the symptom regularly while for others it is a rare experience.
Some people may enjoy the experience of mania. Especially when experienced shortly after an episode of depression, the experience may go beyond the control of an individual. Thus, elevated moods get to an uncontrollable level when they become irritable, adversely affecting behavior and individual judgment. Also, individuals in mania episodes tend to make reckless decisions and behave impulsively. During these occasions, they are frequently unaware of the adverse consequences of their actions.
Additionally, in a manic state, it’s common to exhibit features that pose challenges to daily functioning. For instance, individuals may present signs of inflated self-esteem, outspokenness, and elevated levels of over-familiarity. An observer may report unkemptness and inappropriate dress code from the affected individual. Additionally, individuals in a manic state may talk excessively, and their speech may be faster and louder than usual. In its severe form, a manic state renders speech incoherent and difficult to understand. Also, an individual may find it difficult to be calm and concentrate, and may find it necessary to use gestures in their expression.
There is no single factor that can be considered a causative agent of bipolar disorder. However, bipolar disorder is an interplay of many factors that trigger its onset. Current research has kept the focus on the biological causes of bipolar disorder, which include genetic causes, neurohormonal causes, and difference observed in the brain structure of affected individuals.4 Other causes include psychosocial foundations and the environment of the individual.
Bipolar disorders are linked to genetic risk factors, and research has been useful in providing evidence of genetic transmission in bipolar cases. Twin studies and familial research have shown a close link between inheritance and bipolar disorder. Approximately 60% of individuals inherit mood disorders from family members and relatives. Despite this association, demonstrating genetics and genetic phenotypes have been a difficult concept to explain. Notably, the issue of inheritance is complex and is not consistent with the specific gene model for bipolar disorder, with the exception of a few family cases.
Studies have been essential in demonstrating that bipolar disorder is a familial disease. Individuals with parents or siblings diagnosed with bipolar disorder have an increased risk of developing the disease or another related psychiatric disorder. Additionally, these people have a high susceptibility to developing unipolar major depression, which provides major insight on the close link between the two conditions. Research involving the study of both monozygotic and dizygotic twins (in which none the twins are affected with bipolar disorder) consent with the genetic transmission of bipolar disorder. For instance, monozygotic twins with bipolar probands have an approximate risk of 40 to 70% in developing bipolar disorder with a concordance rate of 60%, which is higher than in dizygotic twins. Research has been using the variation of concordance rates between dizygotic and monozygotic twins to approximate the effect of genes causing bipolar disorder.
Although most studies are focused on the biological contribution causing bipolar disorder, environmental factors also play a significant role in influencing these factors. Studies indicate that environmental influences contribute approximately 15% of the development of bipolar disorders. Notably, research has found that negative events often precede the development of manic and depressive symptoms that characterize bipolar disorder. Additionally, studies have been useful in demonstrating that bipolar patients experience at least a single stressful factor prior to presenting mood changes.
Bipolar I has a lifetime prevalence of about 1% of the general population. Notably, the overall prevalence of bipolar spectrum disorders is around 2.4%. The prevalence of bipolar I in the USA is at 1%, which is slightly higher than most countries. In England, research found that the lifetime prevalence for bipolar disorder is 2%. However, some reports showed that these results were an underestimate. Following the fact that the study did not distinguish among the different subtypes of bipolar disorder, this would account for the percentage. In a meta-analysis involving 25 studies, the lifetime prevalence for both bipolar I and II disorders was 1.06% and 1.57% respectively in the USA. This percentage mirrors similar studies in the UK, Germany, and Italy, while review from African countries demonstrates a prevalence of 0.1 to 1.83%. The difference observed globally can be attributed to the differences in ethnicity, diagnostic criteria, and research design.
Research has shown the equal prevalence of bipolar disorder in both men and women. Studies have reported that women are three times more likely to present rapid cycling. Rapid cycling is described as the event when an individual presents four or more episodes of mood swings within a period of twelve months. Other studies have found that women may present more depressive symptoms along with mixed episodes compared to men with the same disorder.
Individuals have major misconceptions that misinform their decisions in the search for treatment:
The first misconception that most individuals hold is that bipolar disorder is a rare disease, but in reality, it is common and has the ability to affect about 2% of individuals in the American population alone.
Bipolar disorder is understood by many as characteristic of mood swings which are observed in the general population. However, the symptoms of bipolar disorder are different in their ability to hinder normal individual functioning.
Another major misconception is that there is only one category of bipolar disorder; however, the fact is that there is a spectrum of bipolar disorders.
Another misconception is that bipolar disease is not serious and can be treated through exercise and diet; however, the truth is that the condition requires the intervention of a professional.
Lastly, some believe that mania is a positive and productive experience, but in actuality, mania can be irritable in its severe forms.
Bipolar disorder is commonly associated with the misuse of substances such as cocaine, cannabis, opioids, and alcohol. Although significant levels of comorbidity are undeniable, it’s challenging to determine which condition lead to the other.5 Increased research on the impact of cannabis use in the development of bipolar disorder and other mental conditions has been gaining ground. The motivation for substance use is dependent on prior experience using the substance and its effect in altering mood. Therefore, substance use in bipolar disorder follows thematic stages that involve drug experimentation during the initial stages of the disorder: coping with the condition, enjoying the consequences of drug use, feeling normal, and stress management.
Bipolar disorders can be observed in individuals diagnosed with eating disorders. Research has shown that bipolar disorders have the ability to alter the normal functioning of neurotransmitters such as serotonin. Serotonin is a chemical compound whose responsibility in emotion regulation is also vital in regulating eating conditions and bipolar symptoms. Also, the impact of disordered eating can best be observed in mood changes. Some people eat more when under certain moods or depression as a way of dealing with stress levels.
Bipolar disorder is categorized as a chronic medical condition which requires ongoing treatment. If the disorder is left untreated, the condition may worsen over time, which makes early diagnosis and treatment a significant step in managing the condition successfully. There are various categories of treatment used in the management of bipolar disorder.
Pharmacological treatments have been found to be highly effective in the management of manic and depressive symptoms. Research shows that as the disorder progresses, depressive symptoms tend to get worse. As such, repetitive episodes of depression are responsible for significant impairment of individual daily functioning. Hence, strict compliance with treatment options is essential in the management of the disorder. Mood stabilization medications like antipsychotic drugs are often supplemented with benzodiazepine for the management of manic episodes.6 Although lithium has a slow onset action, it is preferred in the management of mania symptoms. Bipolar depression is treated with antidepressants, antipsychotic drugs like quetiapine, and anticonvulsants such as lamotrigine and lithium.
Despite the increased preference of pharmacotherapy for the management of bipolar disorder, research shows that medication is only one part of successful treatment. Therefore, there is a need for other interventions that will address remission, rates of recurrence, and residual signs exhibited by the patient.
Cognitive behavioral therapy (CBT) for the management of bipolar disorder extends its use from Beck’s CT model for depression, which refers to a skills-focused model that assists individuals to recognize and change the relationship between maladaptive thoughts and moods. Patients learn to cope with the condition through the use of thought records, having mood diaries, and activity scheduling where patients are taught to change adverse thoughts and negative thinking which will disrupt mania and depression symptoms. Research has found that the use of CBT in bipolar patients is essential in contributing to low relapse rates. Notably, CBT can be applied to group therapy and has a high effective rate with an approximate relapse rate of 66 weeks.
Family therapy has also been successfully applied to the treatment of bipolar disorder where the therapy is administered to the patient along with the family. Therapy focuses on psycho-education, enhanced communication skills, and problem-solving skills. In studies with family therapy, the model has been effective in reducing the relapse rate with a high rate of survival without a major presentation of mood episodes.
Interpersonal and social rhythm therapy has also been advocated as a way of disrupting underlying biological rhythms that offset the risk of bipolar disorder. Therapies include the implementation of having a sleep-and-wake timetable, mealtime, and physical activities which assist in the management of bipolar symptoms.
Beyond Bipolar: Finding Happiness After Diagnosis
Bipolar disorder is a common disease that affects about 2% of the population. Although there is no specific cause, the condition is a result of biological and environmental factors that increase the risk of its development. There is a broad spectrum of bipolar disorders, which is characterized by symptoms of depression and mania. Substance use and misuse have been known to exacerbate the risks associated with bipolar disorder and should therefore be avoided. Bipolar disorder is a chronic condition and should be treated as such with pharmacological and therapeutic interventions to help manage the condition. Complete treatment can help manage symptoms and build a support network for long-term success.
- Fink, C., & Kraynak, J. (2012). Bipolar Disorder For Dummies. Hoboken, NJ: John Wiley & Sons.
- Culpepper, L. (2014). The Diagnosis and Treatment of Bipolar Disorder. The Primary Care Companion For CNS Disorders. doi:10.4088/pcc.13r01609
- Ayano, G. (2016). Bipolar Disorder: A Concise Overview of Etiology, Epidemiology Diagnosis and Management: Review of Literatures. SOJ Psychology, 1-8.
- Purse, M. (2016, February 7). Understanding Your Bipolar Treatment Plan. Retrieved from https://www.verywellmind.com/treating-bipolar-disorder-3576129
- Healey, C., Peters, S., Kinderman, P., McCracken, C., & Morriss, R. (2009). Reasons for substance use in dual diagnosis bipolar disorder and substance use disorders: A qualitative study. Journal of Affective Disorders, 113(1-2), 118-126.
- Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251-269.
- McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530-542.
- Swartz, H. A., & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence. FOCUS, 12(3), 251-266.