Bipolar I Disorder (BD-I)

This article provides a comprehensive overview of bipolar I disorder, including the signs and symptoms, risk factors, treatment options, and how it compares to bipolar II disorder.

Key Takeaways:

• Bipolar I disorder is characterized by manic episodes, which involve extreme increases in energy and mood

• The severity of this disorder can significantly impact daily functioning, relationships, and well-being. In many cases, manic episodes require hospitalization

• Professional treatment for bipolar I disorder is typically long-term, due to the chronic nature and risk of relapse. Medication is the most common treatment, although psychotherapy and other supportive strategies are often used too

Understanding Bipolar I Disorder

Bipolar I disorder (BD-I) is a mental health disorder that is classified under the “Bipolar and related disorders” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). The main feature of BD-I is the presence of manic episodes, which are characterized by abnormally elevated mood, increased energy, and heightened activity. The majority of people with BD-I also experience depressive episodes, although having one is not required for BD-I diagnosis.^[1]

BD-I These manic episodes last for at least a week, though many and often persist for much longer. They also may require hospitalization due to the extreme nature of the symptoms and potential risks of harm towards oneself or others.^[2]

Prevalence of Bipolar I

Bipolar I disorder is estimated to affect around 0.6% of the population, although some estimates are as high as 1.5%. Prevalence rates are essentially the same between men and women, and there are no notable differences among different races, ethnicities or socioeconomic statuses.^[3]

Symptoms of Bipolar I

Bipolar I includes a range of psychological and behavioral symptoms, particularly those related to mania. Since a diagnosis of BD-I requires the presence of a manic episode, the following symptoms are related to mania:^[1][2][3]

• Extremely elevated or happy mood (euphoria)

• Extreme irritability

• Significantly increased energy and/or activity level

• Heightened self-esteem or grandiosity

• Decreased need for sleep (feeling rested after only a few hours)

• Racing thoughts

• Very easily distracted

• Frequently change thoughts or conversational topics

• Talking significantly more than usual

• Engaging in risky activities (e.g. shopping sprees, sexual promiscuity, reckless driving)

• Restlessness

While the intensity of these symptoms may vary, they all cause significant disruptions to one’s ability to function and often require hospitalization for the person’s safety. In addition, BD-I sometimes leads to severe mania, which may also involve psychotic features, such as delusions or hallucinations.^[1]

Bipolar I vs Bipolar II Disorder

Bipolar I and bipolar II disorder differ in several key ways. Firstly, bipolar I disorder involves mania, whereas bipolar II involves hypomania, which is a milder form of mania that doesn’t interfere with daily functioning or require hospitalization.

Secondly, bipolar II requires the presence of at least one major depressive disorder, which involves intense and persistent sadness, lack of pleasure, and other symptoms that contrast with mania, whereas this is not required for a bipolar I diagnosis. In other words, all people with bipolar II have major depressive episodes, while some people with bipolar I may not.^[1][2

Causes of BD-I

The exact causes of BD-I are not fully understood, although it likely results from a combination of genetic, neurochemical, and environmental factors. Possible causes include:^[2][3]

• Heritability (including the presence of certain genes)

• Imbalance in neurotransmitters, especially serotonin and dopamine

• Changes in brain structure and function

• Nervous system inflammation

• Stressful life events, especially in early life

Is BD-I Genetic?

Genetic factors play a role in the development of BD-I. Research shows that 80 to 90% of individuals with bipolar disorder have a relative with bipolar disorder or depression. Researchers have also identified at least 30 different genes that are associated with an increased risk of developing bipolar disorder.^[1][2]

However, genetics is only one of many factors. Many people with a family history of BD-I never develop this disorder. Twin studies have shown that even if one identical twin develops BD-I, the other might not, highlighting the influence of non-genetic factors.^[4]

Prevention

BD-I can’t be fully prevented, given that genetic and biological factors play a role, and that the exact causes aren’t completely identified. However, certain strategies may help prevent the development of this disorder or help to minimize symptoms.

First, it’s important to seek help as soon as you notice symptoms, even if they’re just mild. This can lead to appropriate treatment (if necessary), which reduces the risk of developing more severe symptoms.

Other factors that may help prevent or lessen the severity of BD-I include:

• Initial treatments, such as mood stabilizers

• Stress management

• Tight-knit social relationships

• General healthy lifestyle habits

• Limiting or eliminating alcohol and drug use

• Support groups

BD-I Risk Factors

There are several factors that increase the risk of developing BD-I, including:^[2][3][5]

• Having a blood relative with bipolar disorder

• Childhood trauma, such as abuse or neglect

• Stressful and/or life-altering events (e.g., loss of a loved one, violence, divorce or relationship changes, job loss, childbirth)

• Presence of major depressive disorder

Diagnosing Bipolar I

Bipolar I is often misdiagnosed, often as unipolar forms of depression, such as major depressive disorder. Accurate diagnosis depends on a comprehensive assessment, including clinical interviews with the patient and, ideally, additional input from relatives and information about the overall course of symptoms.^[2]

A full physical exam is necessary to rule out other causes for symptoms, such as medical conditions or substance use, and to screen for co-occurring health issues commonly associated with bipolar disorder. Possible tests include:^[2]

• Metabolic panel

• Urinalysis

• Neurologic evaluation

• Complete blood count

• Electrocardiography

Tests and Assessments for Bipolar I

Initial screening tools are also often used in primary care settings to indicate if bipolar I may be present, and to aid in confirming diagnosis later on. Commonly used screening tools include:^[2]

• Mood Disorders Questionnaire: This questionnaire assesses many of the primary symptoms of mania within bipolar disorder, along with other relevant information, such as family history.

• Hypomania Checklist 32: This checklist assesses 32 manic-related symptoms and behaviors, as well as their frequency, overall severity, and impact on daily functioning.

Positive results on these tests will lead to a thorough clinical assessment, including detailed information about past manic, hypomanic, and depressive episodes. Information is compared to the criteria for BD-I in theDSM-5, which are:

• A distinct period of persistently elevated or irritable mood along with elevated energy or activity, which lasts at least one week and is present most of the day, nearly every day (or any duration requiring hospitalization)

• During this period, three or more of the following symptoms occur (or at least four if the mood is only irritable), which are significantly different from normal behavior:

• Inflated self-esteem or grandiosity

• Decreased need for sleep

• Talking more than usual

• Racing thoughts or “flight” of ideas

• Increased distractibility

• Increased goal-directed activity (e.g. at school or work) or non goal-directed activity (e.g. general restlessness)

• Excessive involvement in risky activities (e.g. spending sprees, sexual promiscuity)

• Mood disturbances are severe enough to impair social or occupational functioning, or to require hospitalization, or result in psychotic features

• Symptoms are not caused by a medical condition or the effects of a substance

The diagnostic process also tests for hypomanic and major depressive episodes. Even though these symptoms are not required for a diagnosis, their presence will affect the overall treatment plan.

Treatment Options for Bipolar I

Treatment for bipolar I typically includes medication, often combined with psychotherapy, electroconvulsive therapy, and other interventions. Severe manic episodes will also require initial hospitalization. Due to the risk of relapse and general severity, treatment plans are typically long-term and may even be lifelong.^[2]

Medication

The most common medications for BD-I are:

• Mood stabilizers (e.g., lithium, valproate)

• Antipsychotics (e.g., asenapine, quetiapine, risperidone)

Sometimes, antidepressants are used alongside these medications, but only on a short-term basis. They aren’t used by themselves because they aren’t effective for BD-I on their own. Benzodiazepines may also be used during hospitalization to help with sleep and overexcitability, but they aren’t advised long-term for this condition due to their side effects and risk of dependence.^[2]

Once a medication protocol is established, long-term use is typically recommended. As relapse rates are relatively high, long-term use helps to minimize severe symptoms and episodes as much as possible.^[3]

Psychotherapy

Psychotherapy may also be used in combination with medication. While not effective as a standalone treatment for BD-I, it may lead to significant benefits when integrated into a wider treatment plan.

Common therapeutic approaches for BD-I include:^[4][5]

• Cognitive behavioral therapy (CBT): Helps to address negative and dysfunctional thoughts and behavioral patterns, which is particularly helpful during depressive episodes.

• Interpersonal therapy (IPT): Focuses specifically on improving relationships and resolving any social/relational issues that may be worsening symptoms

• Family-focused therapy: Focuses on promoting communication, strengthening relationships, and resolving conflicts within families. It also involves education about BD-I, to promote greater understanding.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) may also be used to treat BD-I, especially during severe mania with psychosis, or if medication and psychotherapy have not been effective. ECT involves brief electrical brain stimulation while a patient is under anesthesia, and may lead to beneficial changes in brain function.^[1][2]

Living with Bipolar I

A variety of lifestyle changes and self-management strategies can support professional treatments and improve overall quality of life for people with bipolar I. However, it’s important to note that these strategies are meant to support, but not replace, professional help. Examples include:^[4][5][6]

• Join a support group, especially one designed for those involving others with bipolar disorder

• Reach out to family and friends

• Practice open, honest communication

• Educate yourself on BD-I, especially regarding warning signs and symptoms

• Become aware of your own personal triggers

• Practice stress management techniques, such as meditation, exposure to nature therapy, and deep breathing techniques

• Adopt healthy lifestyle practices, including regular exercise, adequate sleep, and healthy, consistent meals

• Reach out for professional support if you need help in these areas too

• Engage in fun and meaningful activities regularly, especially when feeling stressed