Bipolar disorder, previously known as manic depression, is a mental disorder that causes periods of depression and periods of abnormally elevated mood. The elevated mood is significant and is known as mania or hypomania, depending on its severity, or whether symptoms of psychosis are present. During mania, an individual behaves or feels abnormally energetic, happy, or irritable. Individuals often make poorly thought out decisions with little regard to the consequences. The need for sleep is usually reduced during manic phases. During periods of depression, there may be crying, a negative outlook on life, and poor eye contact with others. The risk of suicide among those with the illness is high at greater than 6 percent over 20 years, while self-harm occurs in 30–40 percent. Other mental health issues such as anxiety disorders and substance use disorder are commonly associated with bipolar disorder.
The causes are not clearly understood, but both environmental and genetic factors play a role. Many genes of small effect contribute to risk. Environmental risk factors include a history of childhood abuse and long-term stress. About 85% of the risk is attributed to genetics. The condition is classified as bipolar I disorder if there has been at least one manic episode, with or without depressive episodes, and as bipolar II disorder if there has been at least one hypomanic episode (but no manic episodes) and one major depressive episode. In those with less severe symptoms of a prolonged duration, the condition cyclothymic disorder may be diagnosed. If the symptoms are due to drugs or medical problems, it is classified separately. Other conditions that may present similarly include attention deficit hyperactivity disorder, personality disorders, schizophrenia and substance use disorder as well as a number of medical conditions. Medical testing is not required for a diagnosis, though blood tests or medical imaging can be done to rule out other problems.
Treatment commonly includes psychotherapy as well as medications such as mood stabilizers and antipsychotics. Examples of mood stabilizers that are commonly used include lithium and various anticonvulsants. Involuntary treatment in a hospital may be needed if a person is a risk to themselves or others but refuses treatment. Severe behavioral problems, such as agitation or combativeness, may be managed with short term antipsychotics or benzodiazepines. In periods of mania, it is recommended that antidepressants be stopped. If antidepressants are used for periods of depression, they should be used with a mood stabilizer. Electroconvulsive therapy (ECT), while not very well studied, may be tried for those who do not respond to other treatments. If treatments are stopped, it is recommended that this be done slowly. Many individuals have financial, social or work-related problems due to the illness. These difficulties occur a quarter to a third of the time, on average. Due to poor lifestyle choices and side effects from medications, the risk of death from natural causes such as heart disease is twice that of the general population.
Bipolar disorder affects approximately 1% of the global population. In the United States, about 3% are estimated to be affected at some point in their life; rates appear to be similar in females and males. The most common age at which symptoms begin is 25. A large proportion of this was related to a higher number of missed work days, estimated at 50 per year. People with bipolar disorder often face problems with social stigma.
SIGNS AND SYMPTOMS
Both mania and depression are characterized by disruptions in normal mood, psychomotor activity, circadian rhythm, and cognition. Mania can present with varying levels of mood disturbance, ranging from euphoria that is associated with "classic mania" to dysphoria and irritability. The core symptom of mania involves an increase in energy of psychomotor activity. Mania can also present with increased self-esteem or grandiosity, rapid speech, the subjective feeling of rapid thoughts, disinhibited social behavior, or impulsivity. Mania is distinguished from hypomania by length, as hypomania requires four consecutive days, and mania requires more than a week. Unlike mania, hypomania is not always associated with impaired functioning. The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood.
MANIC EPISODES
Mania is a distinct period of at least one week of elevated or irritable mood, which can range from euphoria to delirium, and those experiencing hypomania or mania generally exhibit several following behaviors: speaking in a rapid, uninterruptible manner, decreased need for sleep, short attention span, racing thoughts, increased goal-oriented activities, agitation, or exhibition of behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending. To meet the definition for a manic episode, these behaviors must impair the individual's ability to socialize or work. If untreated, a manic episode usually lasts three to six months.
Manic individuals often have a history of substance abuse developed over years as a form of "self-medication". At the most extreme, a person in a full-blown manic state can experience psychosis: a break with reality, a state in which thinking is affected along with mood. They may feel unstoppable, or as if they have been "chosen" and are on a "special mission", or have other grandiose or delusional ideas. This may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital. The severity of manic symptoms can be measured by rating scales such as the Young Mania Rating Scale, though questions remain about the reliability of these scales.
The onset of a manic or depressive episode is often foreshadowed by sleep disturbances. Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.
HYPOMANIC EPISODES
Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania, but which does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features such as delusions or hallucinations, and does not require psychiatric hospitalization. Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some. Hypomanic episodes rarely progress to full-blown manic episodes. Some people who experience hypomania show increased creativity while others are irritable or demonstrate poor judgment.
Hypomania may feel good to some persons who experience it, though most people who experience hypomania state that the stress of the experience is very painful. Bipolar people who experience hypomania, however, tend to forget the effects of their actions on those around them. Even when family and friends recognize mood swings, the individual will often deny that anything is wrong. What might be called a "hypomanic event", if not accompanied by depressive episodes, is often not deemed problematic, unless the mood changes are uncontrollable, or volatile. Most commonly, symptoms continue for a few weeks to a few months.
DEPRESSIVE EPISODES
Main article: Major depressive disorder
Symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, irritability or anger, loss of interest in previously enjoyed activities, excessive or inappropriate guilt, hopelessness, sleeping too much or not enough, changes in appetite and/or weight, fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicide. In severe cases, the individual may develop symptoms of psychosis, a condition also known as severe bipolar disorder with psychotic features. These symptoms include delusions and hallucinations. A major depressive episode persists for at least two weeks, and may result in suicide if left untreated.
The earlier the age of onset, the more likely the first few episodes are to be depressive. Since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initially misdiagnosed as having major depression and then incorrectly treated with prescribed antidepressants.
MIXED AFFECTIVE EPISODES
Main article: Mixed affective state
In bipolar disorder, mixed state is a condition during which symptoms of both mania and depression occur simultaneously. Individuals experiencing a mixed state may have manic symptoms such as grandiose thoughts while simultaneously experiencing depressive symptoms such as excessive guilt or feeling suicidal. Mixed states are considered to be high-risk for suicidal behavior since depressive emotions such as hopelessness are often paired with mood swings or difficulties with impulse control. Anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania. Substance abuse (including alcohol) also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance abuse.
ASSOCIATED FEATURES
Main article: Associated features of bipolar disorder
Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria. In adults with the condition, bipolar disorder is often accompanied by changes in cognitive processes and abilities. These include reduced attentional and executive capabilities and impaired memory. How the individual processes the universe also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states. Those with bipolar disorder may have difficulty in maintaining relationships. There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder, such as mood abnormalities (including major depressive episodes) and attention deficit hyperactivity disorder (ADHD).
COMORBID CONDITIONS
The diagnosis of bipolar disorder can be complicated by coexisting (comorbid) psychiatric conditions including the following: obsessive-compulsive disorder, substance-use disorder, eating disorders, attention deficit hyperactivity disorder, social phobia, premenstrual syndrome (including premenstrual dysphoric disorder), or panic disorder. A careful longitudinal analysis of symptoms and episodes, enriched if possible by discussions with friends and family members, is crucial to establishing a treatment plan where these comorbidities exist.
CAUSES
The causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear. Genetic influences are believed to account for 60–80 percent of the risk of developing the disorder indicating a strong hereditary component. The overall heritability of the bipolar spectrum has been estimated at 0.71. Studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. For bipolar disorder type I, the rate at which identical twins (same genes) will both have bipolar disorder type I (concordance) is estimated at around 40 percent, compared to about 5 percent in fraternal twins. A combination of bipolar I, II, and cyclothymia similarly produced rates of 42 percent and 11 percent (identical and fraternal twins, respectively), with a relatively lower ratio for bipolar II that likely reflects heterogeneity. There is overlap with major (unipolar) depression and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67 percent in identical twins and 19 percent in fraternal twins. The relatively low concordance between fraternal twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.
GENETIC
Behavioral genetic studies have suggested that many chromosomal regions and candidate genes are related to bipolar disorder susceptibility with each gene exerting a mild to moderate effect. The risk of bipolar disorder is nearly ten-fold higher in first degree-relatives of those affected with bipolar disorder when compared to the general population; similarly, the risk of major depressive disorder is three times higher in relatives of those with bipolar disorder when compared to the general population.
Although the first genetic linkage finding for mania , the linkage studies have been inconsistent. The largest and most recent genome-wide association study (GWAS) failed to find any particular locus that exerts a large effect, reinforcing the idea that no single gene is responsible for bipolar disorder in most cases. Polymorphisms in BDNF, DRD4 , DAO, and TPH1 have been frequently associated with bipolar disorder and were initially successful in a meta-analysis, but failed after correction for multiple testing. On the other hand, two polymorphisms in TPH1 were identified as being associated with bipolar disorder.
Due to the inconsistent findings in a genome-wide association study, multiple studies have undertaken the approach of analyzing single-nucleotide polymorphisms (SNPs) in biological pathways. Signaling pathways traditionally associated with bipolar disorder that have been supported by these studies include corticotropin-releasing hormone (CRH) signaling, cardiac β-adrenergic signaling, Phospholipase C signaling, glutamate receptor signaling, cardiac hypertrophy signaling, Wnt signaling, Notch signaling, and endothelin 1 signaling. Of the 16 genes identified in these pathways, three were found to be dysregulated in the dorsolateral prefrontal cortex portion of the brain in post-mortem studies.
Advanced paternal age has been linked to a somewhat increased chance of bipolar disorder in offspring, consistent with a hypothesis of increased new genetic mutations.
ENVIRONMENTAL
Psychosocial factors play a significant role in the development and course of bipolar disorder, and individual psychosocial variables may interact with genetic dispositions. It is probable that recent life events and interpersonal relationships contribute to the onset and recurrence of bipolar mood episodes, just as they do for unipolar depression. In surveys, 30–50 percent of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated with earlier onset, a higher rate of suicide attempts, and more co-occurring disorders such as post-traumatic stress disorder (PTSD). The number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior.
NEUROLOGICAL
Less commonly, bipolar disorder or a bipolar-like disorder may occur as a result of or in association with a neurological condition or injury. Conditions like these and injuries include stroke, traumatic brain injury, HIV infection, multiple sclerosis, porphyria, and rarely temporal lobe epilepsy.
PREVENTION
Attempts at prevention of bipolar disorder have focused on stress (such as childhood adversity or highly conflictual families) which, although not a diagnostically specific causal agent for bipolar, does place genetically and biologically vulnerable individuals at risk for a more severe course of illness. There has been debate regarding the causal relationship between usage of cannabis and bipolar disorder
MANAGEMENT
Main article: Treatment of bipolar disorde
There are a number of pharmacological and psychotherapeutic techniques used to treat bipolar disorder. Individuals may use self-help and pursue recovery
Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (local legislation permitting) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although these can still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or an Assertive Community Treatment team, supported employment and patient-led support groups, intensive outpatient programs. These are sometimes referred to as partial-inpatient programs..r
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