Bipolar disorder

Bipolar disorder
SynonymsBipolar affective disorder, bipolar illness, manic depression, manic depressive disorder, manic-depressive illness,[1] manic-depressive psychosis, circular insanity,[1] bipolar disease[2]
Comedy and tragedy masks without background.svg
Bipolar disorder is characterized by episodes of depression and mania.
SymptomsPeriods of depression and elevated mood[3][4]
ComplicationsSuicide, self-harm[3]
Usual onset25 years old[3]
TypesBipolar I disorder, bipolar II disorder, others[4]
CausesEnvironmental and genetic[3]
Risk factorsFamily history, childhood abuse, long-term stress[3]
Differential diagnosisAttention deficit hyperactivity disorder, personality disorders, schizophrenia, substance use disorder[3]
TreatmentPsychotherapy, medications[3]
MedicationLithium, antipsychotics, anticonvulsants[3]

Bipolar disorder, previously known as manic depression, is a mental disorder that causes periods of depression and periods of abnormally elevated mood.[6][3][4] The elevated mood is significant and is known as mania or hypomania, depending on its severity, or whether symptoms of psychosis are present.[3] During mania, an individual behaves or feels abnormally energetic, happy, or irritable.[3] Individuals often make poorly thought out decisions with little regard to the consequences.[4] The need for sleep is usually reduced during manic phases.[4] During periods of depression, there may be crying, a negative outlook on life, and poor eye contact with others.[3] 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.[3] Other mental health issues such as anxiety disorders and substance use disorder are commonly associated.[3]

The causes are not clearly understood, but both environmental and genetic factors play a role.[3] Many genes of small effect contribute to risk.[3][7] Environmental factors include a history of childhood abuse, and long-term stress.[3] The condition is divided into bipolar I disorder if there has been at least one manic episode, with or without depressive episodes, and bipolar II disorder if there has been at least one hypomanic episode (but no manic episodes) and one major depressive episode.[4] In those with less severe symptoms of a prolonged duration, the condition cyclothymic disorder may be diagnosed.[4] If due to drugs or medical problems, it is classified separately.[4] Other conditions that may present in a similar manner include attention deficit hyperactivity disorder, personality disorders, schizophrenia and substance use disorder as well as a number of medical conditions.[3] Medical testing is not required for a diagnosis, though blood tests or medical imaging can be done to rule out other problems.[8]

Treatment commonly includes psychotherapy as well as medications such as mood stabilizers and antipsychotics.[3] Examples of mood stabilizers that are commonly used include lithium and various anticonvulsants.[3] Involuntary treatment in a hospital may be needed if a person is a risk to themselves or others but refuses treatment.[3] Severe behavioral problems, such as agitation or combativeness, may be managed with short term antipsychotics or benzodiazepines.[3] In periods of mania, it is recommended that antidepressants be stopped.[3] If antidepressants are used for periods of depression, they should be used with a mood stabilizer.[3] Electroconvulsive therapy (ECT), while not very well studied, may be helpful for those who do not respond to other treatments.[3][9] If treatments are stopped, it is recommended that this be done slowly.[3] Many individuals have financial, social or work-related problems due to the illness.[3] These difficulties occur a quarter to a third of the time, on average.[3] The risk of death from natural causes such as heart disease is twice that of the general population.[3] This is due to poor lifestyle choices and the side effects from medications.[3]

Bipolar disorder affects approximately 1% of the global population.[10] In the United States, about 3% are estimated to be affected at some point in their life.[5] The most common age at which symptoms begin is 25.[3] Rates appear to be similar in females and males.[11] The economic costs of the disorder has been estimated at $45 billion for the United States in 1991.[12] A large proportion of this was related to a higher number of missed work days, estimated at 50 per year.[12] People with bipolar disorder often face problems with social stigma.[3]

Signs and symptoms

An 1858 lithograph captioned 'Melancholy passing into mania'

Mania is the defining feature of bipolar disorder[13] and can occur with different levels of severity. With milder levels of mania, known as hypomania, individuals are energetic, excitable, and may be highly productive.[14] As hypomania worsens, individuals begin to exhibit erratic and impulsive behavior, often making poor decisions due to unrealistic ideas about the future, and sleep less.[14] At the extreme, manic individuals can experience distorted or delusional beliefs about the universe, hallucinate, hear voices, to the point of psychosis.[14] A depressive episode commonly follows an episode of mania.[14] The biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood.[15]

Manic episodes

An 1892 color lithograph depicting a woman diagnosed with "Hilarious Mania"

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 hypo- or mania may exhibit three or more of the following behaviors: speak in a rapid, uninterruptible manner, short attention span, racing thoughts, increased goal-oriented activities, agitation, or they may exhibit behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending.[13] To meet the definition for a manic episode, these behaviors must impair the individual's ability to socialize or work.[13][14] If untreated, a manic episode usually lasts three to six months.[16]

People with hypomania or mania may experience a decreased need of sleep, impaired judgment, and speak excessively and very rapidly.[14][17] Manic individuals often have a history of substance abuse developed over years as a form of "self-medication".[18] At the more 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.[14] They may feel unstoppable, or as if they have been "chosen" and are on a "special mission", or have other grandiose or delusional ideas.[19] This may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital.[14][17] 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.[20]

The onset of a manic or depressive episode is often foreshadowed by sleep disturbances.[21] Mood changes, psychomotor and appetite changes, and an increase in anxiety can also occur up to three weeks before a manic episode develops.[22]

Hypomanic episodes

Hypomania is the milder form of mania, defined as at least four days of the same criteria as mania,[14] but 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.[13] Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some.[23] Hypomanic episodes rarely progress to full blown manic episodes.[23] Some people who experience hypomania show increased creativity[14] 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.[14] 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.[24] What might be called a "hypomanic event", if not accompanied by depressive episodes, is often not deemed problematic, unless the mood changes are uncontrollable, volatile, or mercurial.[23] Most commonly, symptoms continue for a few weeks to a few months.[25]

Depressive episodes

'Melancholy' by W. Bagg after a photograph by Hugh Welch Diamond

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.[26] 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.[27]

The earlier the age of onset, the more likely the first few episodes are to be depressive.[28] 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.[29]

Mixed affective episodes

In bipolar disorder, mixed state is a condition during which symptoms of both mania and depression occur simultaneously.[30] 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.[30] 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.[30] Anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania.[30] Substance abuse (including alcohol) also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance abuse.[30]

Associated features

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.[31] These include reduced attentional and executive capabilities and impaired memory.[32] How the individual processes the universe also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states.[22] Some studies have found a significant association between bipolar disorder and creativity.[33] Those with bipolar disorder may have difficulty in maintaining relationships.[34] There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder: mood abnormalities (including major depressive episodes) and attention deficit hyperactivity disorder (ADHD).[35]

Comorbid conditions

The diagnosis of bipolar disorder can be complicated by coexisting (comorbid) psychiatric conditions including the following: obsessive-compulsive disorder, substance abuse, eating disorders, attention deficit hyperactivity disorder, social phobia, premenstrual syndrome (including premenstrual dysphoric disorder), or panic disorder.[18][26][36][37] 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.[38]

Other Languages
azərbaycanca: Bipolyar pozuntu
한국어: 양극성 장애
Bahasa Indonesia: Gangguan bipolar
íslenska: Geðhvörf
Basa Jawa: Bipolar
Bahasa Melayu: Gangguan bipolar
Nederlands: Bipolaire stoornis
日本語: 双極性障害
norsk nynorsk: Bipolar liding
oʻzbekcha/ўзбекча: Maniakal-depressiv psixoz
português: Transtorno bipolar
Simple English: Bipolar disorder
slovenščina: Bipolarna motnja
srpskohrvatski / српскохрватски: Bipolarni afektivni poremećaj
Basa Sunda: Gangguan bipolar
中文: 躁鬱症