Bipolar Disorders

Different bipolar disorders have subtly different symptoms. They can be extremely serious, requiring hospitalization to recover. A clear treatment plan and support are essential for people with anyanyone with a type of bipolar disorder.

Key takeaways

• Bipolar disorders are mood disorders characterized by episodes of intense elation or irritable mood known as mania or hypomania. These are often interspersed with periods of depression

• Bipolar disorder is a lifelong condition with complex causes, including biological, genetic, and environmental factors

• Bipolar disorder can be effectively managed with medication

Understanding bipolar disorders

Bipolar disorders are a class of mental disorders that are characterized by extreme variations in mood.^[1]These variations, whether feeling elated or depressed, have a significant impact on patients’ work and personal lives.

Bipolar disorders are both common and potentially extremely severe. They represent one of the top 10 leading causes of disability worldwide.^[2]Bipolar disorders are thought to affect around 2.4% of the population and are equally common in men and women^[2][3][4]

Types of bipolar disorder

The different types of bipolar disorder are distinguished by the severity of the symptoms and by the pattern of the episodes.^[5]Bipolar I, bipolar II, and cyclothymia have different levels of severity, while rapid cycling bipolar, bipolar with mixed features, and bipolar with seasonal pattern all refer to how and when the episodes occur.

Bipolar I

Bipolar I disorder is the most severe of the bipolar disorders. People with this condition experience episodes of full mania that last for at least seven days. During a manic period, they typically feel either extremely elated or extremely restless and irritable.^[6]They may struggle to sleep and have poor impulse control.

Around 3 in 4 people with bipolar I disorder may sometimes experience psychosis during their manic episodes, including delusions or hallucinations.^[7]Bipolar I disorder is extremely serious. Manic episodes will significantly disrupt normal functioning, and people with this disorder may need to be hospitalized to aid their recovery.

People with bipolar I disorder do not necessarily experience episodes of depression, but the vast majority do.^[7]

Bipolar II

Bipolar II disorder is a less severe disorder than bipolar I, but it is still a serious mental health condition. People with bipolar II experience episodes of hypomania, which involve feeling elated and/or restless and irritable, with many of the same symptoms as mania without meeting the full criteria. They do not experience psychosis, and their symptoms can generally be managed without hospitalization.

For bipolar II disorder, episodes of hypomania must last for at least 4 days, although they regularly last longer. These periods are uncharacteristic for the person and observable by others but do not cause marked impairment.^[6]Patients might still be able to work, for example.

Unlike bipolar I, people with bipolar II disorder always also experience depressive episodes. These include feeling sad or upset, struggling to enjoy activities, sleeping too much or struggling to sleep, and feeling worthless.

Cyclothymia

Cyclothymia is a slightly less severe bipolar disorder than bipolar II. Similar to bipolar II, people with cyclothymia experience both episodes in which they have either hypomanic or depressive symptoms. In cyclothymia, however, the depressive symptoms are less severe.^[4]

People diagnosed with cyclothymia can feel as though their condition is dismissed because it is the least severe of the bipolar disorders. It’s important to recognize that any bipolar disorder is a serious mental condition requiring treatment.

Rapid cycling bipolar

Bipolar disorder is described as rapid cycling if it includes 4 or more distinct episodes, not including remission, within 1 year. Both bipolar I and bipolar II can be described as rapid cycling.

Bipolar with mixed features

Bipolar with mixed features refers to a version of bipolar I or bipolar II disorder where there is not an entirely clear distinction between manic or hypomanic episodes and depressive ones. Patients experiencing this type of bipolar disorder may have both types of symptoms on the same day or even at the same time.

Bipolar with mixed features can be a particularly destabilizing and disorienting form of bipolar disorder. Patients with this subtype may switch rapidly from feeling full of energy and being invincible to believing themselves to be powerless and worthless over the course of a few minutes or hours. Alternatively, they may have symptoms of mania, such as feeling elated, whilst simultaneously experiencing depressive symptoms, such as feeling lethargic.

Bipolar with mixed features carries a higher risk of self-harm and suicide than bipolar without mixed episodes.^[9]

Bipolar with seasonal pattern

Both bipolar I and bipolar II disorders can have a seasonal pattern, where changes in the seasons can trigger manic, hypomanic, or depressive episodes. Most commonly, this is associated with manic or hypomanic symptoms during the summer months and depressive ones during the winter, but this is not always the case for everyone.

Unspecified bipolar

The criteria for the different types of bipolar disorder are relatively rigid, and some patients may not fit exactly into one of the categories. However, this doesn’t necessarily mean someone doesn’t have a type of bipolar disorder. These patients are typically described as having unspecified bipolar disorder.

Bipolar vs borderline personality disorder

There are strong similarities between bipolar disorders and borderline personality disorder, and they can easily be misdiagnosed. They both involve dramatic shifts in mood and impulsive behavior.^[10]

It is easiest to tell the difference between a bipolar disorder and borderline personality disorder between episodes. Someone with a bipolar disorder who is in remission will usually not show significant signs of their condition. Borderline personality disorder does not usually have these periods of stability.^[11]

Symptoms of bipolar disorders

Given the nature of the condition, the symptoms of bipolar disorders differ dramatically depending on which kind of episode a patient is experiencing (if any). Here are some of the main symptoms people with bipolar disorders may experience at different points in time.^[8]

Manic episodes

During a manic episode, people are generally either extremely elated or highly restless and irritable. They may also experience other symptoms such as

• Inflated self-esteem

• Reduced need for sleep

• Having large, often unrealistic plans

• Talking more than usual

• Racing thoughts

• Being very easily distracted

• Being more active. This might mean doing more tasks or simply fidgeting and struggling to sit still

• Increased risk-taking or harmful behaviors, for example gambling or risky sexual behavior

• Psychosis

Manic episodes are characterized by a lack of impulse control, meaning that people will rarely think through the consequences of their actions and may make decisions that are rewarding in the short term but cause difficulties in the longer term, such as skipping work to do something more fun. People experiencing a manic episode may not recognize that their mood is a problem.^[12]

Hypomanic episodes

People with bipolar II disorder or cyclothymia won’t experience full manic episodes. Instead, they experience hypomania. Hypomania is a less extreme form of mania.

Someone who is experiencing hypomania will have similar symptoms to someone experiencing mania. They might be excitable and elated or irritable. They might need less sleep than usual, talk more, be easily distracted, and take more risks. The biggest difference is that they won’t experience psychosis, and their symptoms won’t prevent them from carrying out many of their normal daily tasks. Many people struggle to recognize when they are experiencing hypomania.

Depressive episodes

Most people with a bipolar disorder will have some depressive episodes. During these periods, they have a very low mood and may take less pleasure in their normal activities.

Other symptoms of a depressive episode include

• Feeling sad or getting upset easily upset

• Lower self-confidence

• Reduced appetite

• Loss of interest in hobbies and activities

• Changes into sleep patterns, including insomnia and hypersomnia

• Suicidal thoughts and self-harm

Mixed episodes

During a mixed episode, patients experience symptoms associated with manic or hypomanic episodes and those associated with depressive episodes at the same time or in very close proximity.^[12]They might feel elated and full of energy one minute, only to become despondent and lethargic shortly after. This might be swiftly followed by them regaining their manic or hypomanic symptoms.

Mixed episodes can also include symptoms of both types of episodes at the same time. They might have an inflated self-esteem and even psychosis at the same time as feeling extremely sad and fatigued.

Remission

Bipolar disorder is a lifelong diagnosis. People who have the disorder still have it even when they’re not actively in a manic, hypomanic, or depressive episode. The times between these episodes are known as remission.

During remission, a patient’s symptoms wouldn’t be enough to diagnose them with bipolar disorder, but this doesn’t mean that the symptoms are entirely gone. They may feel some residual sadness following a depressive episode or increased energy following a manic or hypomanic episode.^[13]

Causes and risk factors of bipolar disorders

The exact causes of bipolar disorder are unknown, and there are likely to be many factors working together when someone develops the condition. These factors are include genetic, biological, and environmental in naturefactors.

There is a genetic component to bipolar disorders, meaning that there is a higher risk of developing one of these conditions for people with a close family member who has one.^[14]This genetic predisposition interacts with other risk factors, such as traumatic childhood events.^[15]

Environmental triggers, such as the seasons, can affect when episodes occur, but they are unlikely to be an underlying cause of the disorder.

Diagnosing bipolar disorders

There are no physical tests to diagnose bipolar disorders.^[16]Instead, a clinician (usually a psychiatrist or clinical psychologist) will look for symptoms to help them make a diagnosis. Most of their information will come from talking to the person themselves about their experiences, but they may also talk to friends, family members, and caregivers to form a complete picture.^[8]

Before a diagnosis of bipolar disorder can be given, clinicians also need to be sure that the symptoms are not caused by any other conditions or substances, such as medications or recreational drugs.^[17]

Diagnosing bipolar I disorder

For a diagnosis of bipolar I disorder, someone must have experienced at least one episode of mania that lasted for more than a week.

To be considered a manic episode, they must have had at least three of the symptoms of mania listed above at the same time as an elated mood, or four if their mood was irritable. These symptoms must have been severe, out of character, and caused problems for their everyday functioning.

Diagnosing bipolar II disorder

For a diagnosis of bipolar II disorder, someone must have experienced a hypomanic episode lasting for at least 4 days and at least one major depressive episode. The criteria for a hypomanic episode are similar to those for a manic episode, but it must not include psychosis and the symptoms must not have been as severe.

Diagnosing cyclothymia

A diagnosis of cyclothymia requires that the person has experienced hypomanic and depressive episodes for at least 50% of the time over the previous 2 years. During depressive episodes, the symptoms do not meet the threshold for a major depressive episode. If they do, a diagnosis of bipolar II disorder is given.

When to seek a diagnosis

Bipolar disorder can have a devastating impact on your life and can be effectively treated with medication. This means that it’s important to seek a diagnosis as soon as you experience a manic or hypomanic episode

Therapeutic treatment for bipolar disorders

Psychotherapy is used to help deal with the harm it does to relationships, improve self-awareness to help identify future episodes, and create safety plans and criteria.

Psychotherapy isn’t recommended as the sole treatment for bipolar disorder. The first step should always be medication. Doing both together gives the best results.

Medication treatment for bipolar disorders

Antipsychotics

These reduce symptoms of psychosis, which can be a debilitating symptom of mania. They are regularly prescribed to bipolar patients who don’t have psychosis to help even out their mood. They can also be prescribed during remission, though other medications are more common.^[18]

Antipsychotic medications prescribed for bipolar disorder include:

• Haloperidol

• Olanzapine

• Risperidone

Mood stabilizers

These are some of the most common medications offered to patients with bipolar disorder. They are used during manic or hypomanic episodes to help reduce the intensity of symptoms. They can be prescribed during depressive episodes alongside antidepressants to prevent other medications from inducing a manic episode. They are also used during remission to reduce the likelihood of a relapse.

Mood stabilizers prescribed for bipolar disorder include:

• Lithium

• Valproate

Antidepressants

Antidepressants can be prescribed for people with bipolar disorder during a depressive episode, but they are often less effective for these patients than for those with major depressive disorder (MDD). They can also sometimes trigger a manic or hypomanic episode.^[19][20]

Antidepressants commonly used for people with bipolar disorder include:

• Amitriptyline

• Fluoxetine

• Venlafaxine

Self-management for bipolar disorders

Bipolar disorder is generally well-managed with medication, although it may take some time to find the best medications for you. There are also some helpful steps you can take to look after yourself and reduce the impact of bipolar disorder on your life.

Knowing when you are having a manic or depressive episode can help you to put safety measures into effect and talk to your doctor to tailor your medication to your current state. Using a mood diary or journal can help you spot episodes earlier, making them easier to manage.

Diaries can also assist you in spotting, and then avoiding, things that trigger bipolar episodes. Common advice includes avoiding stress, increasing exercise, incorporating a good diet, improving sleep quality, and building a strong social network.

Where possible, make plans for future episodes, both depressive and manic or hypomanic. Look for ways to reduce the impact of a loss of inhibition, for example by reducing limits on your credit cards, and identifying sources of support for when you are feeling low.

Stay in contact with medical professionals and work with them, especially if your medications are causing unacceptable side effects. If your medication is making you unhappy, talk to your doctor about an alternative rather than stopping your medication abruptly.

Helping others with bipolar disorders

Those same principles can guide you if you want to help others who are coping with bipolar disorder. Help them identify when they are having an episode. This is usually easier if you’ve talked about the subject while they are in remission.

Explore options for a safety plan to minimize the longer-term harm their episodes can cause. Importantly, encourage them to be open about their medication and avoid being judgmental if they stop taking it.

Finally, ensure that you also take care of your own mental and physical health. Caring for someone with bipolar can be challenging at times, so ensure you don’t put yourself in harm’s way.

Takeaway

Bipolar disorder is a lifelong mental health condition that can be effectively managed through a combination of medication and lifestyle adjustments. Although periods of depression can feel the most distressing in the moment, manic and hypomanic episodes can do significant harm to a patient’s life, relationships, and overall well-being.

This information is not intended as a substitute for qualified medical advice. If you are concerned about bipolar disorder, you should seek advice from your doctor or other healthcare professional.