Bipolar Disorder

Definition

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

There are four basic types of bipolar disorder; all of them involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely “up,” elated, and energized behavior (known as manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

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  • Bipolar I Disorder—defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible.
  • Bipolar II Disorder—defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes described above.
  • Cyclothymic Disorder (also called cyclothymia)—defined by numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.
  • Other Specified and Unspecified Bipolar and Related Disorders—defined by bipolar disorder symptoms that do not match the three categories listed above.

Warning Signs and Symptoms

bipolar-disorder-general-2Often Mistaken for ‘Just’ Depression

People with bipolar disorder are frequently misdiagnosed as having only depression. In bipolar II disorder, the milder form, manic episodes are mild and can pass by unnoticed. Time spent with depression symptoms, meanwhile, outnumbers time spent with hypomanic symptoms by about 35 to one in people with bipolar II disorder.

Time spent with depression symptoms also usually outweighs time spent with mania symptoms in bipolar I disorder by about three to one, although the more severe mania in bipolar I generally is easier to identify.

Major depressive disorder — often referred to as unipolar depression — is different from bipolar disorder II — also called bipolar depression — in that unipolar depression has no intervals of hypomania while bipolar II does have intervals of hypomania.

Anyone evaluated for depression should also be evaluated for a lifetime history of manic or hypomanic episodes.

Does Your Teenager Have Bipolar Disorder?

Bipolar disorder commonly begins to show itself in the late teens. Bipolar disorder in the teenage years is serious; it’s often more severe than in adults. Adolescents with bipolar disorder are at high risk for suicide.

Unfortunately, bipolar disorder in teens frequently goes undiagnosed and untreated. Partly, this is because while symptoms may begin in adolescence, they often don’t meet the full diagnostic criteria for bipolar disorder. Some experts think that bipolar disorder also can be over diagnosed in children or younger adolescents, especially when symptoms involve just mood swings or disruptive behaviors rather than changes in energy or sleep patterns. Partly for that reason, the diagnosis of “disruptive mood dysregulation disorder” has come into use to describe teens who mainly have persistent irritability and severe temper outbursts or mood swings.

Symptoms of bipolar disorder in teens may be unusual — not a straightforward “manic depression.” ADHD, anxiety disorders, and substance abuse are often also present, confusing the picture.

Some symptoms that suggest a teenager might have bipolar disorder are:

  • Uncharacteristic periods of anger and aggression
  • Grandiosity and overconfidence
  • Easy tearfulness, frequent sadness
  • Needing little sleep to feel rested
  • Uncharacteristic impulsive behavior
  • Moodiness
  • Confusion and inattention

Other potential symptoms that may indicate the presence of a psychiatric disorder requiring evaluation may include feeling trapped, overeating, excessive worry, and anxiety. Other possible diagnoses in addition to bipolar disorder that should be considered in the setting of symptoms such as these include unipolar (major) depression, anxiety disorders, substance use disorders, adjustment disorders, attention deficit hyperactivity disorder, and personality disorders such as borderline personality disorder.

It’s important to remember that sometimes some of these symptoms can occur in many healthy teens and adults. The time for concern is when they form a pattern over time, interfering with daily life. Children with symptoms that suggest bipolar disorder should be seen and evaluated by a psychiatrist or psychologist with expertise in mood disorder.

Bipolar Disorder and Substance Abuse Can Go Hand in Hand

Substance abuse often complicates the diagnosis and treatment of bipolar disorder. Substance abuse is bipolar disorder’s partner in crime. Some studies show that as many as 60% of people with bipolar disorder also abuse drugs or alcohol. Untreated substance abuse can make it virtually impossible to manage the mood symptoms of bipolar disorder if both disorders are present. It can also be hard to make a confident diagnosis of bipolar disorder when someone is actively abusing substances that cause mood swings.

Substances such as alcohol and cocaine can also cloud the picture in bipolar disorder. For example, people high on cocaine can appear manic when they’re not, or have a depression “crash” when the drug wears off. Some people with bipolar disorder use drugs and alcohol as a part of the impulsivity and recklessness of mania. Others may have an independent substance use disorder, which requires its own treatment. Substance abuse may make bipolar episodes (mania and depression) more frequent or severe, and medicines used to treat bipolar disorder are usually less effective when someone is using alcohol or illicit drugs.

bipolar-disorder-general-3Diagnosing Bipolar Disorder

Doctors have come a long way in fully understanding different moods in bipolar disorder and in making an accurate diagnosis. It wasn’t that long ago when bipolar disorder was confused with other disorders such as unipolar depression or with schizophrenia (a serious mental illness with symptoms of incoherent speech, delusions, and hallucinations). With the greater understanding of mental disorders today, doctors can identify the signs and symptoms of bipolar depression, hypomania, and mania, and most cases, treat the disorder effectively and safely with bipolar medications.

Most of us have become used to specialized blood tests or other laboratory measures to help our doctors make an accurate diagnosis. However, most lab tests or imaging tests are not useful in diagnosing bipolar disorder. In fact, the most important diagnostic tool may be talking openly with the doctor about your mood swings, behaviors, and lifestyle habits.

While a physical examination can reveal a patient’s overall state of health, the doctor must hear about the bipolar signs and symptoms from the patient in order to effectively diagnose and treat bipolar disorder.

What does a doctor need to know to diagnose?

A bipolar disorder diagnosis is made only by taking careful note of symptoms, including their severity, length, and frequency. “Mood swings” from day to day or moment to moment do not necessarily indicate a diagnosis of bipolar disorder. Rather, the diagnosis hinges on having periods of unusual elevation or irritability in mood that are coupled with increases in energy, sleeplessness, and fast thinking or speech. The patient’s symptoms are fully assessed using specific criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders or DSM-V.

In making the diagnosis of bipolar disorder, the psychiatrist or other mental health expert will ask you questions about your personal and family history of mental illness and bipolar disorder or other mood disorders. Because bipolar disorder sometimes has a genetic component, family history can be helpful in making a diagnosis. (Most people with bipolar disorder, however, do not have a family history of bipolar disorder.)

Also, the doctor will ask detailed questions about your bipolar symptoms. Other questions may focus on reasoning, memory, ability to express yourself, and ability to maintain relationships.

Do other illnesses mimic symptoms?

Mood swings and impulsive behavior can sometimes reflect psychiatric problems other than bipolar disorder, including:

  • Substance use disorders
  • Borderline personality disorder
  • Conduct disorders
  • Impulse control disorders
  • Developmental disorders
  • Attention deficit hyperactivity disorder
  • Certain anxiety disorders such as post-traumatic stress disorder

Psychosis (delusions and hallucinations) can occur not only in bipolar disorder but other conditions such as schizophrenia or schizoaffective disorder. In addition, people with bipolar disorder often have additional psychiatric problems such as anxiety disorders (including panic disorder, generalized anxiety disorder (GAD), and social anxiety disorder), substance use disorders, or personality disorders that may complicate an illness presentation and require independent treatment.

Some non-psychiatric illnesses, such as thyroid disease, lupus, HIV and other infections, and syphilis, may have signs and symptoms that mimic those of bipolar disorder. This can pose further challenges in making a diagnosis and determining the treatment.

Other problems often resemble mania but reflect causes other than bipolar disorder. An example is mood or behavior changes caused by steroid medications like prednisone (used to treat inflammatory diseases such as rheumatoid arthritis and asthma, musculoskeletal injuries, or other medical problems).

What should I do before I see the doctor about bipolar disorder?

Before meeting with your doctor to clarify a diagnosis, it’s helpful to write down the symptoms you notice that may reflect depression, hypomania, or mania. Particular attention should focus not just on mood but also changes in sleep, energy, thinking, speech, and behavior. It is also useful to get an in-depth family history from relatives before meeting with your doctor. A family history can be very helpful in supporting a suspected diagnosis and prescribing appropriate treatments.

In addition, consider bringing your spouse (or other family member) or a close friend with you to the doctor’s visit. Oftentimes, a family member or friend may be more aware of a person’s unusual behaviors and be able to describe these in detail to the doctor. Before your visit, think about and record the following:

  • Your mental and physical health concerns
  • Symptoms you’ve noticed
  • Unusual behaviors you’ve had
  • Past illnesses
  • Your family history of mental illness (bipolar disorder,depression, mania, seasonal affective disorder or SAD, or others)
  • Medications you are taking now and in the past (bring all medications to your doctor’s appointment)
  • Naturaldietary supplements you are taking (bring your supplements to your doctor’s appointment)
  • Your lifestyle habits (exercise, diet,smoking, alcohol consumption, recreational drug use)
  • Yoursleep habits
  • Causes of stressin your life (marriage, work, relationships)
  • Questions you may have about bipolar disorder

What tests will the doctor use to make a bipolar diagnosis?

Your doctor may have you fill out a mood questionnaire or checklist to help guide the clinical interview when he or she assesses mood symptoms. In addition, your doctor may order blood and urine tests to rule out other causes of your symptoms. In a toxicology screening, blood, urine, or hair are examined for the presence of drugs. Blood tests also include a check of thyroid stimulating hormone (TSH) level, since depression is sometimes linked to thyroid function.

Can brain scans or imaging tests help with the bipolar diagnosis?

While doctors don’t rely on brain scans or imaging tests for making a bipolar diagnosis, some high-tech neuroimaging tests may help doctors make specific neurologic diagnoses that can account for psychiatric symptoms. An MRI or CT scan is therefore sometimes ordered in patients who have had a sudden change in thinking, mood, or behavior to assure that a neurological disease is not the underlying cause.

According to the National Institute of Mental Health, studies are underway to examine whether electroencephalograms (EEGs) and magnetic resonance imaging (MRI) studies of the brain can reveal differences between bipolar disorder and related behavioral syndromes. But bipolar disorder remains a clinical diagnosis, and no imaging study or other lab test has yet been established to confirm its diagnosis or guide its treatment.

What can I do if I think a loved one has bipolar disorder?

If you suspect that a loved one has bipolar disorder, talk with the person about your concerns. Ask if you can make a doctor’s appointment for the person and offer to accompany the person to the visit. Here are some tips:

  1. Alert the doctor that this is a new problem and the doctor will need to allow sufficient time for the exam.
  2. Have your concerns written down on a sheet of paper to make sure you cover all areas.
  3. Be specific as to the problems of bipolar depression, hypomania, or mania.
  4. Give specific details of mood symptoms and behaviors to the doctor.
  5. Describe any severe mood changes, especially anger, depression, and aggressiveness.
  6. Describe personality changes, especially instances of elation, paranoia, illusions, and hallucinations.
  7. Be sure to discuss any use of alcohol or other drugs (likemarijuana, cocaine or amphetamines) that the person may be using since they can often cause changes in mood, which may be mistaken for the symptoms of bipolar disorder.

Treatment & Care

The best treatment for bipolar disorder is a combination of medication and counseling. Doctors often treat the mania symptoms associated with bipolar disorder with one set of drugs, and use other drugs to treat depression. Certain drugs are also used for “maintenance” — to maintain a steady mood over time.

Treatment

  1. Bipolar Treatments Treatment for bipolar disorder most often includes a combination of a mood-stabilizing drug and psychotherapy. Although drug treatment is primary, ongoing psychotherapy is important to help patients better cope with the condition.
  2. Medications If you have bipolar disorder, you will probably need medication. In reality, you may need bipolar medication for the rest of your life.
  3. Therapy Along with medication, ongoing psychotherapy, or “talk” therapy, is an important part of treatment for bipolar disorder. During therapy, you can discuss feelings, thoughts, and behaviors that cause you problems.
  4. Treating Bipolar Mania If you are suffering from mania, your doctor may initially treat you with an antipsychotic drug, benzodiazepine, and/or lithium to quickly control hyperactivity, sleeplessness, hostility, and irritability. Your doctor will also likely prescribe a mood stabilizer.
  5. Treating Bipolar Depression Today, the recommended treatments for bipolar depression may include lithium, an anticonvulsant, an antipsychotic medication, or a combination of these medications — all with the goal of modulating moods without igniting a manic episode.

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