Understanding Bipolar Disorder
Bipolar disorder is a psychological condition in which a person alternates between different mood episodes. While colloquial language suggests that being moody is enough to make a person “bipolar,” these episodes are defined by a specific set of criteria that includes many additional symptoms beyond changes in mood.
What Is Bipolar Disorder?
There are three different bipolar disorders listed in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM):
Bipolar I Disorder
Bipolar II Disorder
All of the bipolar disorders involve alternating mood episodes of one of three types:
Major Depressive Episode
Earlier versions of the DSM included “Mixed Episode” as a fourth type of mood episode, though it was removed as a diagnosis from the fifth edition of the guide (DSM-5) published in 2013. Instead, each of the above episodes can now be specified as having “mixed features.”
Bipolar I disorder is diagnosed when a person has had at least one manic episode, while bipolar II disorder is diagnosed when a person has had at least one hypomanic episode but has never had a manic episode. Cyclothymic disorder is diagnosed when a person has had periods of hypomania and periods of depression not severe enough to meet criteria for a major depressive episode.
To be diagnosed with a major depressive episode, a person must have five or more of the following symptoms in the same two-week period:
- Daily depressed mood
- Fatigue or loss of energy nearly every day
- Frequent sleep disruption (insomnia or hypersomnia)
- Significant weight loss when not dieting or weight gain
- Diminished ability to think or concentrate, or indecisiveness
- Restlessness or lethargy (psychomotor agitation or retardation)
- Near-daily feelings of worthlessness or excessive or inappropriate guilt
- Consistently diminished interest or pleasure in most activities (anhedonia)
- Recurrent thoughts of death, recurrent suicidal ideation with or without a plan, or a suicide attempt
At least one of the symptoms must be depressed mood or anhedonia, which are considered the main clinical signifiers of depression. [Note to Bart: consider deleting this definition and linking to the depression article instead.]
To be diagnosed with a manic or hypomanic episode, a person must have three or more of the following persistent symptoms during the same period of time:
- Inflated self-esteem or grandiosity
- Decreased need for sleep to feel rested
- Increased desire to talk or pressure to keep talking
- Flight of ideas or subjective experience of racing thoughts
- Excessive involvement in high-risk or dangerous activities
- Increased goal-directed activity, psychomotor agitation, or restlessness
What distinguishes a manic from a hypomanic episode is the duration and severity of the episodes. A manic episode causes significant functional impairment and lasts for at least a week, while a hypomanic episode is not severe enough to cause functional impairment and only needs to last four days or longer.
Manic and depressive episodes are defined by holistic changes to thinking and behavior. A person who is depressed experiences a loss of mental and physical energy, while a person who is manic or hypomanic experiences the opposite. People in states of mania express increased energy in their speech and actions, and often engage in risky behavior.
Manic episodes are sometimes severe enough to lead to hospitalization. Mania can border on psychosis or even cross that border. A person in a severe manic episode might declare, “I am Jesus,” and walk into traffic, believing that the cars can’t hurt them. A person in a hypomanic episode never approaches psychosis. Hypomanic episodes can sometimes be benign, defined only by periods of increased productivity or adventure. At other times, they can be stressful.
Treatment for Bipolar Disorder
People in a severe manic episode may require hospitalization for their safety if their grandiosity reaches a delusional level. Most don’t realize they’re having a manic episode until they start to recover from it and realize that they had been in serious danger. People who have previously been treated for bipolar disorder may recognize the signs and seek treatment when those symptoms arise.
In general, most people with bipolar disorder only pursue treatment when they are not in a manic episode. This is for the simple reason that mania, especially hypomania, which does not cause painful social or occupational problems, often feels good. Mania can also be frightening, overwhelming, and exhausting. However, even when it doesn’t feel good to be manic, the way these episodes affect the mind makes it harder for a person to recognize that something is wrong—that something in themselves has changed, rather than something outside of themselves. This is especially true when they have never been in treatment before.
Hospitalization is also sometimes required for people who are experiencing a severe depressive episode. When depression causes a loss in functioning that puts a person at risk of irreversible harm to their health, or when a person is at risk of suicide or self-harm, inpatient treatment is required.
Inpatient Treatment for Bipolar Disorder
When people are in crisis and at risk of causing harm to themselves or others, they should receive inpatient treatment in a hospital or mental health facility until they are stable enough to be treated on an outpatient basis. Loved ones who fear for the safety of a family member with bipolar disorder can take steps to have that person admitted to treatment involuntarily if they are not willing to go into treatment on their own. This is also known as “commitment.”
The commitment process varies from state to state. Generally, it involves making a report to a magistrate or police officer that a person is at risk of harm to self or others due to a mental health condition. If the report is deemed valid, the person is transported to an emergency room or other secure location for an evaluation by a mental health professional. The evaluating clinician ultimately determines if the person meets the criteria for involuntary admission.
Inpatient treatment involves an intensive schedule of individual and group therapy, activity groups, and medication management. The purpose of inpatient treatment is stabilization. It is usually short-term, lasting only as long as is needed for a person to no longer present a risk of harm to themselves or others. Even when inpatient treatment is voluntary, treating staff rarely approve long admission periods. Inpatient treatment rarely lasts longer than two weeks, and usually is much shorter than that, lasting only for a few days.
Outpatient Treatment for Bipolar Disorder
Once a person has been stabilized in an inpatient treatment facility, or if their symptoms are not severe enough to require inpatient treatment, outpatient treatment is recommended to manage the symptoms of bipolar disorder. As with inpatient treatment, outpatient treatment usually involves a combination of medication and therapy.
Mood stabilizers are the most common medication prescribed for bipolar disorder. Even when a person is having a depressive episode, antidepressants are rarely prescribed to someone with bipolar disorder because they can trigger a manic episode. Physicians work closely with patients who have bipolar disorder to control their depressive symptoms and either manage or prevent manic symptoms from arising. Medications commonly prescribed to stabilize mood include:
- Aripiprazole (Abilify)
- Lamotrigine (Lamictal)
- Carbamazepine (Tegretol)
- Divalproex sodium (Depakote)
- Quetiapine fumarate (Seroquel)
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
Specific medications and medication regimens need to be tailored to the individual, especially in the case of bipolar disorder, which requires careful medication management to address both depressive and manic symptoms.
Therapy is an important component of bipolar disorder treatment. In addition to providing support and symptom monitoring, therapy can facilitate deeper healing and lasting resolution of the factors that trigger mood episodes. Two popular interventions for bipolar disorder are supportive psychotherapy and cognitive behavioral therapy (CBT).
Supportive psychotherapy uses the positive relationship with a therapist as a foundation for helping clients rebuild their capacity for self-care. In supportive therapy, clients work on gaining insight into their condition and improving emotional regulation and stress management skills. Clients can express and explore their thoughts and feelings without judgment in the safe space of the therapy room. Supportive therapists often help clients identify other services that may help and make referrals to those services.
The goal of CBT is to help clients examine, challenge, and ultimately change irrational thought patterns and cognitive distortions. By targeting negative thinking, CBT helps people alleviate the painful emotions and self-destructive behavior driven by these thoughts. This approach can help people with bipolar disorder identify triggers of depression and mania and develop ways to respond to them that disrupt the development of severe mood episodes.
Bipolar Disorder and Addiction
The statistics are alarming: 56 percent of people with a bipolar disorder develop a substance use disorder in their lifetimes. This may be due to the disorders having overlapping causes or due to people seeking relief from the symptoms of bipolar disorder through substance use. Either way, the result is that both disorders become even more dangerous than they are by themselves.
Substance abuse increases the chance that a person with a comorbid mental health disorder will harm themselves physically or have severe legal, occupational, and social problems. Not only do substances intensify disorienting effects of mania, they lower inhibition even further, making people more likely to act on dangerous impulses.
Substance abuse presents as much of a risk to people in a depressive episode: some substances immediately trigger negative mood symptoms, while nearly all of them cause dysphoria as their effects wear off. Withdrawal effects are even more significant for people with an underlying mood disorder.
This makes it even more urgent for people with co-occurring conditions to seek treatment for both. Research has disproven the traditional treatment theory that treating mental health conditions early in recovery jeopardizes recovery from substance use disorders. Instead, research has shown that treating both at the same time yields better overall treatment outcomes, with reduced recurrence of both substance use and mood episodes.
Bipolar disorder is a serious mental health condition that involves alternating manic and depressive episodes, each of which carry their own risks. Depressive episodes put people at risk of intentional self-harm and suicide, while manic episodes increase the risk of inadvertent self-harm through high-risk behavior.
When manic or depressive episodes are severe, hospitalization may be necessary for stabilization before a person with bipolar disorder can benefit from outpatient treatment. A combination of medication and therapy is used to treat the condition in both inpatient and outpatient treatment, with the addition of integrated substance abuse treatment for people with co-occurring bipolar and substance use disorders.
While bipolar disorder is challenging to live with, it responds well to the right treatment. It’s possible for people with bipolar disorder to leave the chaos behind and regain control of their lives.