Bipolar disorder
Bipolar disorder is a serious mental illness marked by extreme mood fluctuations, including manic, hypomanic, and depressive episodes. These mood swings can significantly impact daily functioning and relationships, creating challenges for both individuals with the disorder and their loved ones. This condition is thought to have biochemical and genetic origins, with research suggesting that stress may trigger the recurrence of mood episodes. It affects approximately 1.6% of the American population and is diagnosed in both men and women, with variations in symptom expression. Treatment often involves a combination of medication, such as lithium and mood stabilizers, alongside psychotherapy to help manage symptoms and improve quality of life. The disorder can be accompanied by other psychiatric conditions, which complicates treatment and increases the risk of suicide. Support from family and friends, as well as participation in support groups, plays a crucial role in helping those affected navigate the complexities of bipolar disorder.
Bipolar disorder
Bipolar disorder is a category of serious mental illnesses characterized by manic, hypomanic, and/or depressive symptoms. Advanced neurobiological research and assessment techniques have shown bipolar disorder to have biochemical origins and a genetic element. Research indicates that stress may play a role in the precipitating recurrence of episodes. The main treatment interventions include lithium, mood-stabilizing anticonvulsants, antipsychotics, and psychotherapy.
TYPE OF PSYCHOLOGY: Biological bases of behavior; psychopathology; psychotherapy
Introduction
Although mood fluctuations are a normal part of life, individuals with bipolar disorder, or bipolar affective disorder (also called manic-depressive disorder), experience extreme mood changes. Bipolar disorder has been identified as a major psychiatric disorder category characterized by dramatic mood and behavior changes. These changes, ranging from episodes of high euphoric moods to deep s, with accompanying behavioral and changes, are devastating to those with the disorder and perplexing to the loved ones of those affected. Prevalence rates have been estimated at 1.6 (0.8 to 2.6) percent of the American population. Bipolar disorder is divided fairly equally between men and women.
Clinical psychiatry has been effective in providing biochemical intervention in the form of lithium carbonate to stabilize or modulate the ups and downs of this illness. However, lithium treatment has only been effective for approximately 70 percent of those administered the compound. Mood-stabilizing anticonvulsant medications, such as divalproex sodium (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal), are showing promise in helping some people with the disorder who were formerly referred to as lithium nonresponders. Antipsychotic medications are increasingly being prescribed to individuals with bipolar disorder. is seen by most practitioners as a necessary adjunct to medication.
Types and Symptoms
According to the Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR (2022), the diagnostic manual of the American Psychiatric Association, there are three diagnostic types of bipolar disorder. Bipolar disorder diagnoses are categorized according to the extent of severity, the types of the symptoms, and the duration of the symptoms.
Individuals with bipolar I disorder experience at least one manic episode, a period when they are in inappropriately good moods, or “highs,” or are extremely irritable. During a manic episode, they may overcommit to work projects and meetings, social activities, and family responsibilities in the belief that they can accomplish anything; this is known as manic grandiosity.
Some with bipolar I disorder may also experience major depressive episodes or hypomanic episodes. At times, psychotic symptoms such as delusions, severe paranoia, and hallucinations may accompany a manic episode. For this reason, bipolar I disorder is also considered a psychotic disorder. These symptoms may lead to a misdiagnosis of another psychotic disorder, such as schizophrenia. Although it may be difficult to arrive at a differential diagnosis between schizophrenia and bipolar disorder when a person is acutely psychotic, a long-term view of the individual’s symptoms and functioning can distinguish between the two disorders.
The prevalence of bipolar I disorder is divided fairly equally between men and women. However, women report more episodes of depression than men and are more likely to be diagnosed with bipolar II disorder.
Bipolar II disorder is diagnosed when a person has at least one episode of major depression and one episode of a milder form of mania known as hypomania. In bipolar II disorder, although there is an observable change in mood and functioning, the hypomanic episode causes less severe impairment than that seen in manic episodes. Frequently, those with bipolar II disorder also have other mental illnesses that exacerbate hypomanic or depressive symptoms. It is very rare for an individual’s to change from bipolar II disorder to bipolar I disorder.
is a form of bipolar disorder in which a person experiences alternating periods of subclinical hypomanic and depressive symptoms for two years or more; periods of such mood swings occur at least half of the time and do not pause for longer than two months. Seasonal affective disorder (SAD) is characterized by alternating mood episodes that vary according to seasonal patterns; the mood changes are thought to be related to changes in the amount of sunlight and accompanying effects on the levels of melatonin. In the Northern Hemisphere, the typical pattern is associated with manic symptoms in the spring and summer and depression in the fall and winter. Manic episodes often have a shorter duration than the depressive episodes. Bipolar disorders must be differentiated from depressive disorders, which include major depression () and dysthymia, a milder but chronic form of depression. Children are diagnosed with bipolar disorders using the same criteria as adults.
Comorbidity
Many studies have reported that up to 65 percent of bipolar disorder patients have comorbid diagnoses, that is, they have at least one additional psychiatric diagnosis. The most frequent comorbid diagnoses among individuals with bipolar disorder are attention-deficit hyperactivity disorder (ADHD), substance use disorder, anxiety disorders (especially generalized anxiety disorder and panic disorder), and drug abuse. Comorbidity is important to note because bipolar disorders with comorbid diagnoses are associated with higher rates of suicidality, less favorable response to lithium, exacerbated symptoms, and poorer outcomes.
Causes
The causes of bipolar disorders are not fully understood. However, family, twin, and adoption studies indicate that genetic factors play a major role. Approximately 80 percent of individuals with bipolar disorder have a biological relative with some form of mood disorder, whether bipolar disorder or depression. It is not uncommon to see families in which several generations are affected by bipolar disorder. Serotonin, norepinephrine, and , brain chemicals known as that regulate mood, arousal, and energy, respectively, are thought to be altered in bipolar disorders.
One theory is that bipolar disorder is associated with dysregulation in brain regions that are implicated in emotion, such as the amygdala and basal ganglia. This theory is supported by functional brain imaging studies that indicate that during cognitive or emotional tasks, people with bipolar I disorder show different patterns of activity in the amygdala. In terms of structural brain imaging, people with bipolar disorder also display differences in the volume of activity in certain regions such as the amygdala and basal ganglia.
A diathesis-stress model has been proposed for some such as hypertension. This model has also been applied to bipolar disorder. In a diathesis-stress model, there is a susceptibility (the diathesis) for the disorder. An individual who has a diathesis is at risk for the disorder but may not show signs of the disorder unless there is sufficient stress. In this model, a genetic, structural, or biochemical predisposition toward the disorder (the bipolar diathesis) may lie dormant until stress triggers the emergence of the illness. The stress may be psychosocial, biological, neurochemical, or a combination of these factors.
A diathesis-stress model can also account for some of the recurrent episodes of mania in bipolar I disorder. Investigators suggest that positive life events, such as the birth of a baby or a job promotion, as well as negative life events, such as divorce or the loss of a job, may trigger the onset of episodes in individuals with bipolar disorder. Stressful life events and the social rhythm disruptions that they cause can have adverse effects on a person’s circadian rhythms. Circadian rhythms are normal biologic rhythms that govern such functions as sleeping and waking, body temperature, and oxygen consumption. Circadian rhythms affect hormonal levels and have significant effects on both emotional and physical well-being. For those reasons, many clinicians encourage individuals with bipolar disorder to work toward maintaining consistency in their social rhythms.
Investigators have compared the course of bipolar disorder to kindling, a process in which epileptic seizures increase the likelihood of further seizures. According to the kindling , triggered mood episodes may leave the individual’s brain in a sustained sensitized state that makes the person more vulnerable to further episodes. After a while, external factors are less necessary for a mood episode to be triggered. Episode sensitization may also account for rapid-cycling states, in which the individual shifts from depression to mania over the course of a few hours or days. Some individuals are diagnosed with a subtype of bipolar disorder known as rapid cycling bipolar disorder, which is defined as four or more episodes per year. Rapid cycling is characterized by poorer outcome.
Impact
The burden of bipolar disorder is considerable. In addition to experiencing functional impairment during illness episodes, many people with bipolar disorder experience ongoing functional impairment between episodes. In 2019, the World Health Organization (WHO) estimated that bipolar disorder affected about 40 million people worldwide among adults between the ages of fifteen and forty-four. Bipolar disorder is associated with the highest rate of suicide out of all of the psychiatric disorders. According to Kay Redfield Jamison, one of the foremost experts on bipolar disorder, approximately 50 percent of people with bipolar disorder attempt suicide at least once during their lives. In one large-scale study, when asked to rate their of their well-being in terms of their culture, values, and how they live in relation to their goals, standards, and expectations (that is, their quality of life), individuals with bipolar disorder rated their quality of life lower than members of the general population did. Indeed, study findings suggest that quality-of-life ratings are poorer for people with bipolar disorder than they are for people with anxiety disorders and depression, but better than they are compared with quality-of-life ratings for people with schizophrenia.
Organizations such as the National Alliance on Mental Illness (NAMI) and support groups such as the Depressive and Bipolar Support Alliance (DBSA) have provided a way for people with bipolar disorder to share their pain as well as to triumph over the illness. Many people have found comfort in knowing that others have suffered from the mood shifts, and they can draw strength from one another. Family members and friends can be the strongest supporters and advocates for those who have bipolar disorder or other psychiatric illnesses. Many patients have credited their families’ constant, uncritical support, in addition to competent effective treatment including medications and psychotherapy, with helping them cope with the devastating effects of the illness. As many as 15 percent of those with bipolar disorder commit suicide; this reality makes early intervention, relapse prevention, and treatment of the disorder necessary to prevent such a tragic outcome.
Treatment Approaches
Medications have been developed to aid in correcting the biochemical imbalances thought to be part of bipolar disorder. Lithium carbonate is effective for approximately 70 percent of those who take it. Many brilliant and successful people have reportedly suffered from bipolar disorder and have been able to function successfully with competent and responsible treatment. Some people who have taken lithium for bipolar disorder, however, have complained that it robs them of their energy and . They say that they actually miss the energy associated with manic phases of the illness. This perceived loss, some of it realistic, can be a factor in relapse associated with lithium noncompliance.
Other medications have been developed to help those individuals who are considered lithium nonresponders or who find the side effects of lithium intolerable. Anticonvulsant medications, such as divalproex sodium (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal), which have been found to have mood-stabilizing effects, are often prescribed to individuals with bipolar disorder. During the depressive phase of the disorder, (ECT) and lamotrigine (Lamictal) have also been administered to help restore the individual’s mood to a normal level. Phototherapy is particularly useful for individuals who have SAD. Atypical antipsychotic medications such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) have also been prescribed to individuals with bipolar I disorder for the treatment of mania.
Cognitive behavior therapy is a form of therapy that addresses an individual’s beliefs, assumptions, and behaviors to improve that person’s emotional responses and health. Interpersonal social rhythm therapy encourages individuals to achieve and maintain stable routines, emphasizing the link between daily routines and moods, whereas the interpersonal component of the therapy focuses on the interpersonal issues that arise in individuals’ lives. Psychotherapy, especially cognitive behavior therapy or interpersonal social rhythm therapy, is viewed by most practitioners as a necessary adjunct to medication. Indeed, psychotherapy has been found to assist individuals with bipolar disorder in maintaining medication compliance.
Local mental health associations can recommend psychiatric treatment by board-certified psychiatrists and licensed psychologists who specialize in the treatment of mood disorders. Often, temporary hospitalization is necessary for complete diagnostic assessment, initial mood stabilization and intensive treatment, medication adjustment, or monitoring of an individual who feels suicidal.
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