Definition

Bipolar disorder is a disorder characterized by extreme swings in mood, energy, and ability to function. The mood changes of bipolar disorder are more dramatic than normal ups and downs. They can hurt relationships and cause poor job or school performance. Bipolar disorder can be treated; contact your doctor if you think you may have this condition.

The two extremes of the illness are mania (when energy peaks, mood may be overly euphoric or irritable) and depression (when lethargy takes over, mood may be very blue). Severe episodes of mania or depression may sometimes be associated with psychotic symptoms such as hallucinations, delusions, or disorders of thought.

There are three forms of this condition: bipolar I disorder, bipolar II disorder, and cyclothymic disorder. Bipolar I disorder involves recurrent episodes of mania and depression. Bipolar II disorder involves milder episodes of mania (called hypomania) that alternate with episodes of depression. Cyclothymic disorder may be diagnosed in patients who experience frequent depressive symptoms and hypomania for at least two years and who have been without symptoms for no more than two months.

Causes

The cause of bipolar disorder is not known. This condition tends to run in families. Specific genes may play a role, but bipolar disorder is not caused by one single gene. Rather, many different genes likely act together.

Medications such as corticosteroids and medical conditions, such as thyroid disease and multiple sclerosis , may be accompanied with features of bipolar disorder. The diagnosis of bipolar disorder is made only when none of these causes are present.

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Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. Having family members with bipolar disorder increases your chance of developing this condition. If you have a family member with bipolar disorder, tell your doctor.

Symptoms

Symptoms include:

• Dramatic mood swings, ranging from elated excitability to hopeless despondency
• Periods of normal mood in between ups and downs
• Extreme changes in energy and behavior

Periods of highs are called mania. Signs and symptoms of mania include:

• Persistent and inexplicable elevation in mood
• Increased energy and effort toward goal-directed activities
• Restlessness and agitation
• Racing thoughts, jumping from one idea to another
• Rapid speech or pressure to keep talking
• Trouble concentrating
• Decreased need for sleep
• Overconfidence or inflated self-esteem
• Poor judgment, often involving spending sprees and sexual indiscretions

Periods of lows are called depression. Signs and symptoms of depression include:

• Prolonged sad, hopeless, or empty mood
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in activities once enjoyed, including sex
• Decreased energy or fatigue
• Trouble concentrating, remembering, and/or making decisions
• Restlessness or diminished movements
• Agitation
• Sleeping too much or too little
• Unintended weight loss or gain
• Thoughts of death or suicide with or without suicide attempts

Diagnosis

Your doctor will ask about your symptoms and medical history and will usually perform a physical exam. In some cases, laboratory tests are ordered to rule out other causes of mood and behavior symptoms. You may be referred to a mental health specialist. Diagnosis of bipolar disorder is based on:

• Presence of symptoms over time
• Absence of other causes, such as some medications, thyroid disease, or Parkinson's disease
• Family history of bipolar disorder

An episode of mania is diagnosed if elevated mood is accompanied by three or more of the mania symptoms listed above during most of the day, nearly every day, for one week or longer. If the mood is irritable, not elevated, four symptoms must be present for a diagnosis of mania.

A depressive episode diagnosis requires that five or more of the depressive symptoms listed above last for most of the day, nearly every day, for a period of two weeks or longer.

Treatment

Talk with your doctor about the best treatment plan for you. Treatment options include:

Medications

The following medications may be used to treat bipolar disorder (many patients are treated with a combination of two or more of these medications):

• Lithium—a mood stabilizer, often used as initial treatment (helps prevent manic and depressive episodes from returning)
• Valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), topiramate (Topamax)—antiseizure medications, also used as mood stabilizers instead or in combination with lithium
• Benzodiazepines (clonazepam [Klonopin] or lorazepam [Ativan]) can be used to treat agitation or insomnia
• Zolpidem (Ambien)—used to treat insomnia
• Antidepressants (serotonin reuptake inhibitors or bupropion [Wellbutrin])—used to treat depression
• Antipsychotic medications—used for acute manic or mixed episodes and maintenance treatment
  • Classic antipsychotic medications (eg, haloperidol [Haldol]) are not often used because of risks of tardive dyskinesia (uncontrollable movements).
  • Atypical antipsychotic medications (eg, risperidone, olanzapine, aripiprazole, ziprasidone, and quetiapine) are more effective with less risk of tardive dyskinesia

Treatment may need to be continued for prolonged periods or indefinitely, depending on the pattern of the illness, to prevent significant mood swings.

Psychotherapy

Psychotherapy may include:

• Cognitive-behavioral therapy
• Counseling
• Family therapy
• Interpersonal and social rhythm therapy, a form of therapy designed to treat bipolar disorder

Electroconvulsive Therapy

Electroconvulsive therapy may be effective for both mania and depression when medications fail.

Prevention

There are no guidelines for preventing bipolar disorder.

RESOURCES:

Child and Adolescent Bipolar Foundation
http://www.bpkids.org

Depression and Bipolar Support Alliance
http://www.dbsalliance.org

National Institute of Mental Health
http://www.nimh.nih.gov/index.shtml

CANADIAN RESOURCES:

Canadian Psychiatric Association
http://www.cpa-apc.org

Mood Disorder Association of Canada
http://www.mooddisorderscanada.ca/index.htm

References:

Belmaker R. Medical progress: bipolar disorder. N Eng J Med . 2004;351:476-486.

Bipolar disorder. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/publicat/bipolar.cfm . Accessed November 10, 2005.

Hirschfeld RMA. Guideline Watch: Practice Guideline for the Treatment of Patients with Bipolar Disorder . 2nd ed. Arlington, VA: American Psychiatric Association; 2005. Available at: http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm . Accessed January 20, 2007.

Hirschfeld RMA, Bowden CL, Gitlin MJ, et al. Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revision). American Psychiatric Association; 2002. Available at: http://www.psych.org/psych_pract/treatg/pg/Practice%20Guidelines8904/BipolarDisorder_2e.pdf . Accessed on January 20, 2007.

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