What is Bipolar Disorder? Types, Causes and Symptoms

Bipolar disorder is a captivating study in human mood, behavior, and emotion. It stands as one of the most complex and intriguing disorders within the realm of psychiatry, compelling in its dynamism and dramatic in its presentation.

Characterized by alternating periods of elation and despondency, this condition manifests in a pendulum of moods that can swing from the ecstatic highs of mania to the debilitating lows of depression.  The narrative of bipolar disorder is woven with threads of creativity and despair, resilience and vulnerability, chaos and control. With the power to profoundly impact an individual’s thoughts, feelings, physical health, and relationships, bipolar disorder challenges our understanding of mental health and human behavior, posing pivotal questions about the interplay of biology, environment and brain function.

What is bipolar disorder?

Bipolar disorder, also known as manic-depressive illness, is a mental health condition characterized by marked fluctuations in mood, energy, and activity levels. These swings often result in difficulty in performing daily tasks, maintaining relationships, and even performing tasks necessary for self-care or employment. A diagnosis of bipolar disorder is made when a person experiences distinct periods of highly elevated mood (mania or hypomania) alternating with episodes of depression.

The etiology of bipolar disorder is complex, encompassing genetic, neurological, and environmental factors. It is believed that a combination of these factors contributes to the onset and progression of the disease.

Genetically, bipolar disorder has been associated with various genes, and it is often seen running in families. Neurologically, studies have found alterations in the structure and function of certain brain regions, particularly those associated with emotion regulation and reward processing.  Environmental factors such as stress, substance abuse, and major life changes can also trigger episodes.

Management of bipolar disorder is usually lifelong and typically involves a combination of medication and psychotherapy. Mood stabilizers, antipsychotics, and, in some cases, antidepressants are used to control manic or depressive episodes. Cognitive-behavioral therapy (CBT), family-focused therapy, and other forms of psychotherapy can help individuals and families to better understand the illness and manage its symptoms.

Despite the challenges associated with bipolar disorder, with proper treatment and support, individuals with this condition can lead fulfilling and productive lives. Continued research into the biological underpinnings and environmental triggers of bipolar disorder promises to further enhance our understanding of the disease and lead to more effective treatments in the future.

Types of bipolar disorder

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) identifies three primary types of bipolar disorder, each with its own unique symptom profile, duration and severity.

1. Bipolar I Disorder: This subtype is characterized by at least one manic episode, which is defined as a period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one week and present for most of the day, nearly every day. The manic episode may be preceded or followed by hypomanic or major depressive episodes. However,  the occurrence of a major depressive episode is not required for the diagnosis of Bipolar I Disorder. Manic episodes in Bipolar I Disorder are severe and may lead to dangerous behavior or result in hospitalization.
2. Bipolar II Disorder: Bipolar II Disorder is characterized by at least one hypomanic episode and at least one major depressive episode. Hypomanic episodes are similar to manic episodes but are less severe, shorter in duration (lasting at least four days), and do not cause significant impairment in social or occupational functioning. Hypomanic episodes do not reach the full severity of a manic episode and do not have psychotic features. In Bipolar II Disorder, the individual never has a full manic episode.
3. Cyclothymic Disorder: This subtype involves a chronic fluctuation between hypomanic and depressive symptoms for at least two years (one year for children and adolescents), but the symptoms do not meet the full criteria for hypomanic or depressive episodes. During the period of the disturbance, the hypomanic and depressive periods have been present for at least half the time, and the individual has not been without the symptoms for more than two months at a time.

Each of these subtypes represents a point along a spectrum of severity, from the most severe (Bipolar I) to the least severe (Cyclothymia). However, all forms of bipolar disorder significantly impact an individual’s life and require treatment.

In addition to these primary types, other classifications may be used when an individual does not meet the exact criteria for the above types but still experiences periods of clinically significant abnormal mood elevation. These classifications are “Other Specified Bipolar and Related Disorder” and “Unspecified Bipolar and Related Disorder.”

Understanding these types of bipolar disorder helps clinicians and researchers accurately diagnose, treat and study the disorder. Nevertheless,  it is important to note that there is significant individual variation within each subtype, and the course of the disorder can change over time.

Causes of bipolar disorder

Bipolar disorder is a complex condition with multiple contributing factors. The etiology is not entirely understood, but it appears to involve an interplay of genetic, neurochemical, and environmental components.

1. Genetic factors: Bipolar disorder is known to run in families, indicating a genetic predisposition. Studies involving twins, families, and adopted individuals have provided evidence of a heritable component, with first-degree relatives of individuals with bipolar disorder having a higher likelihood of developing the disorder.  Nevertheless, the relationship is not straightforward as not everyone with a family history of bipolar disorder will develop the condition. It is suggested that the disorder is polygenic, i.e., associated with multiple genes, each contributing a small risk.
2. Neurochemical factors: Neurotransmitters, the brain’s chemical messengers, play a significant role in mood regulation. Imbalances in key neurotransmitters such as serotonin, norepinephrine, and dopamine have been implicated in bipolar disorder. However, the exact nature of these imbalances and their relationship to the pathophysiology of bipolar disorder is not entirely clear. Additionally, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, a critical component of the stress response system, has been associated with bipolar disorder.
3. Neuroanatomical factors: Brain imaging studies have revealed structural and functional differences in the brains of individuals with bipolar disorder. For example, alterations in the prefrontal cortex, a brain region involved in decision-making and social behavior, and the amygdala, which plays a key role in emotional regulation, have been reported. It is important to note that these differences do not confirm a cause-effect relationship, as it remains unclear whether these changes are a cause or a consequence of the disorder.
4. Environmental factors: Certain life events and experiences may trigger the onset of bipolar disorder in individuals who are genetically predisposed. These can include stressful events, trauma, substance misuse, irregular sleep patterns, and other major life changes. It is not yet fully understood how these environmental factors interact with genetic and biological factors to trigger bipolar disorder.
5. Epigenetic factors: Epigenetics, the study of changes in gene expression without alterations in the DNA sequence, is a rapidly evolving field that may offer new insights into the etiology of bipolar disorder. Environmental factors may interact with an individual’s genetic predisposition through epigenetic mechanisms, leading to changes in gene expression that contribute to the disorder’s onset and progression.

It is likely that bipolar disorder results from a complex interaction of genetic susceptibility, neurobiological factors, and environmental influences. Ongoing research in genetics, neurobiology, and environmental triggers is essential to enhance our understanding and treatment of this multifaceted condition.

Symptoms of bipolar disorder

Bipolar disorder is a mental health condition characterized by distinct periods of dramatically contrasting moods, namely manic or hypomanic episodes and depressive episodes.  The specific symptoms experienced during these episodes, as well as their duration and intensity, define the various types of bipolar disorder.

1. Manic Episodes: Mania, typically seen in Bipolar I Disorder, involves an unusually elevated, expansive, or irritable mood that lasts for at least one week (or any duration if hospitalization is necessary). The symptoms are severe enough to cause noticeable difficulty at work, at school, or in social activities or relationships, and may require hospitalization to prevent harm to oneself or others. Symptoms include:
   • Inflated self-esteem or grandiosity
   • Decreased need for sleep (feeling rested after only a few hours of sleep)
   • More talkative than usual or feeling pressure to keep talking
   • Flight of ideas or subjective experience that thoughts are racing
   • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
   • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
   • Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
2. Hypomanic Episodes: Hypomania, typically seen in Bipolar II Disorder, involves similar symptoms to mania, but the symptoms are not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization, and there are no psychotic features. A hypomanic episode lasts at least four consecutive days.
3. Major Depressive Episodes: These episodes involve a depressed mood or loss of interest or pleasure in nearly all activities, along with at least five of the following symptoms, for a two-week period:
   • Depressed mood most of the day, nearly every day
   • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
   • Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
   • Insomnia or hypersomnia nearly every day
   • Psychomotor agitation or retardation nearly every day
   • Fatigue or loss of energy nearly every day
   • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
   • Diminished ability to think or concentrate, or indecisiveness, nearly every day
   • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

We must to note that not everyone with bipolar disorder will experience all these symptoms, and the severity and frequency of symptoms can vary widely from person to person. Additionally, some people may experience what is known as ‘mixed features’, where they exhibit symptoms of both mania and depression simultaneously.

Lastly,  some individuals may experience periods of stable mood between episodes, while others may have rapid cycling, with multiple episodes of mania or depression occurring within a year. The specific presentation of symptoms can significantly influence the course of treatment and prognosis, thus necessitating a comprehensive and detailed clinical assessment.

How is bipolar disorder diagnosed?

Bipolar disorder is diagnosed using a combination of clinical assessments, patient history and observation. There is no specific lab test or biological marker for bipolar disorder, making its diagnosis complex and dependent on careful clinical evaluation.  The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, serves as the primary guide for clinicians in diagnosing bipolar disorder.

1. Clinical interview: A comprehensive interview is conducted to gather information about the individual’s medical history, psychiatric history, current symptoms, family history of psychiatric disorders, and any history of substance use. This assessment may also explore the individual’s daily routines, sleep patterns, life stressors, and other psychosocial factors.
2. Assessment of symptoms: To diagnose bipolar disorder, a healthcare provider would look for severe and prolonged instances of unusual mood states (mania/hypomania and depression). It is crucial to establish the presence of these episodes, their duration, the number of episodes, and the pattern of their occurrence.
   • For a diagnosis of Bipolar I disorder, at least one manic episode must have occurred in the individual’s lifetime.
   • For a diagnosis of Bipolar II disorder, at least one hypomanic episode and at least one major depressive episode must have occurred, without a full manic episode ever having occurred.
   • For a diagnosis of Cyclothymic Disorder, there should be a history of at least two years (one year for children and adolescents) of numerous periods with hypomanic symptoms and periods with depressive symptoms.
3. Mental status examination: This is a standard part of the clinical assessment, during which the clinician observes the individual’s appearance, mood, attitude, cognitive abilities, and thought content. This examination can help in assessing the individual’s current mental state and identifying any psychotic or manic symptoms.
4. Physical examination and lab tests: A physical examination and laboratory tests may be performed to rule out other medical conditions that could potentially cause similar symptoms, such as thyroid disease or a brain tumor. These tests might include blood tests, imaging studies, or neurological assessments.
5. Use of rating scales: Clinicians may use validated psychiatric rating scales to assess the severity of the individual’s symptoms. Examples include the Young Mania Rating Scale (YMRS) for mania, the Hamilton Depression Rating Scale (HAM-D), or the Montgomery-Åsberg Depression Rating Scale (MADRS) for depression.
6. Psychological assessment: Psychological testing and questionnaires can help assess the individual’s cognitive function, personality characteristics, and other relevant factors.
7. Family input: Information from family members or close friends can be extremely valuable in confirming symptoms and their duration, as individuals with bipolar disorder may lack awareness of their symptoms, particularly during manic episodes.

Diagnosing bipolar disorder can be particularly challenging due to its overlapping symptoms with other psychiatric disorders such as major depressive disorder, schizophrenia,  or borderline personality disorder. Additionally, comorbid conditions like anxiety disorders, substance use disorders, or ADHD can further complicate the diagnostic picture.

Thus, a thorough and comprehensive assessment by a qualified mental health professional is paramount. Early and accurate diagnosis is crucial for effective management and treatment of bipolar disorder.

How to treat bipolar disorder

Bipolar disorder is a complex and chronic condition that requires a comprehensive and multi-faceted approach to treatment. The primary goal of treatment is to help the individual manage and reduce symptoms, prevent future episodes, and improve quality of life. Treatment typically includes a combination of medication, psychotherapy, lifestyle modifications, and social support. It is essential that treatment plans are tailored to the individual’s needs and circumstances.

1. Medication: Pharmacotherapy is the cornerstone of bipolar disorder treatment. Various classes of medication can be used, often in combination, to manage different aspects of the disorder:
   • Mood stabilizers: These medications aim to control manic or hypomanic episodes and prevent their recurrence. Lithium and certain anticonvulsant medications, such as valproate, lamotrigine, and carbamazepine, are commonly used.
   • Antipsychotics: Atypical antipsychotics, such as quetiapine, olanzapine, and risperidone, are often effective in treating both manic and depressive episodes and can be used alone or in combination with mood stabilizers.
   • Antidepressants: While the use of antidepressants in bipolar disorder is controversial due to the risk of inducing manic episodes, they may be used carefully in combination with a mood stabilizer or antipsychotic for severe or treatment-resistant depressive episodes.
   • Other medications: In some cases, other medications such as anti-anxiety drugs or sleep aids may be used short-term to manage acute symptoms like insomnia or anxiety.
2. Psychotherapy: Psychotherapy, or “talk therapy,” is an essential part of managing bipolar disorder. Different therapeutic approaches can be used, often in combination:
   • Cognitive Behavioral Therapy (CBT): CBT helps individuals identify and modify unhealthy thought patterns and behaviors and develop coping strategies for dealing with stress and managing symptoms.
   • Interpersonal and Social Rhythm Therapy (IPSRT): This therapy focuses on the stabilization of daily and social rhythms, such as sleep-wake cycles and mealtimes, which can help prevent manic and depressive episodes.
   • Family-focused therapy: This form of therapy involves family members and focuses on improving family communication, dealing with the impact of bipolar disorder on the family, and providing support for caregivers.
   • Psychoeducation: Educating the patient, and often family members, about the nature of bipolar disorder, its treatment, and the importance of adherence to treatment can improve outcomes.
3. Lifestyle modifications: Regular physical activity, a balanced diet, sufficient sleep, and avoidance of substances such as alcohol, caffeine, and illicit drugs can all contribute to better symptom management and overall health. Stress management techniques, such as meditation, relaxation exercises, and yoga, can also be beneficial.
4. Social support: Support from family, friends, and peer support groups can be immensely helpful for individuals with bipolar disorder. Connecting with others who are facing similar challenges can provide emotional support, practical advice and a sense of community.
5. Electroconvulsive Therapy (ECT) and Other Brain Stimulation Therapies: These treatments are typically reserved for severe cases where symptoms do not respond to medication and psychotherapy. ECT involves sending small electric currents through the brain to trigger a brief seizure, which changes brain chemistry to relieve symptoms. Other forms of brain stimulation, such as transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS), are also being explored as treatments for bipolar disorder.

Bipolar disorder is a lifelong condition, and ongoing treatment is typically required even during periods of remission to prevent new episodes and manage residual symptoms.  Furthermore, given the complexity and chronic nature of the disorder, a multidisciplinary team approach, including psychiatrists, psychologists, psychiatric nurses, social workers, and occupational therapists, can be beneficial in providing comprehensive care. The treatment plan should be regularly reviewed and adjusted as necessary, taking into account the evolving needs and circumstances of the individual.

Is bipolar disorder hereditary?

 

The etiology of bipolar disorder is complex and multifactorial, involving a combination of genetic and environmental influences. There is substantial evidence from twin, family, and adoption studies that supports a significant hereditary component in bipolar disorder, suggesting that genetic factors play a substantial role in its development.

1. Family studies: Bipolar disorder is more common in individuals who have a first-degree relative, such as a parent or sibling, with the disorder. According to research, children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the condition, compared to children who do not have a family history of bipolar disorder.
2. Twin studies: Monozygotic (identical) twin studies provide some of the strongest evidence for a genetic component in bipolar disorder. If one identical twin has bipolar disorder, the other twin has approximately a 40% to 70% chance of developing the disorder, a much higher rate than seen in dizygotic (fraternal) twins or non-twin siblings.
3. Adoption studies: Studies of children adopted away from their biological parents at birth demonstrate higher rates of bipolar disorder if a biological parent has the disorder, regardless of the mental health status of the adoptive parents. This supports the role of genetic factors independent of environmental influence.

However, it is important to note that bipolar disorder does not follow simple Mendelian patterns of inheritance, indicating that it is not caused by a single gene, but rather by multiple genes, each contributing a small effect. This is known as a polygenic inheritance pattern. Furthermore,  complex interactions between these genetic factors and environmental factors also contribute to the disorder’s onset and course.

Environmental factors may include stressful life events, substance abuse, and other factors that may act as triggers in individuals who are genetically predisposed to the disorder. These interactions between genetic and environmental factors fall within the realm of ‘gene-environment interaction’ and ‘gene-environment correlation’, both of which represent cutting-edge areas of research in the field of psychiatric genetics.

Support groups available for individuals with bipolar disorder

Indeed, several organizations and resources are available that provide support, education, and advocacy for individuals with bipolar disorder and their families. These include both online and in-person resources, some of which are outlined below:

1. National Alliance on Mental Illness (NAMI): NAMI is one of the largest grassroots mental health organizations in the United States. They offer a variety of resources, including education programs, support groups, and advocacy for individuals with mental illnesses and their families.
2. Depression and Bipolar Support Alliance (DBSA): The DBSA offers numerous resources, including peer-led support groups, educational materials, and personal wellness tools. Their support groups, which can be found across the U.S., provide a safe and supportive space for individuals to share experiences and coping strategies.
3. International Bipolar Foundation (IBPF): The IBPF provides education, advocacy, and support for individuals with bipolar disorder and their loved ones worldwide. Their services include online support groups, webinars, digital storytelling, and a variety of resources for understanding and managing bipolar disorder.
4. Mental Health America (MHA): MHA offers various resources, including information on understanding mental health conditions, treatment options, and strategies for living with a mental health condition. They also provide links to additional resources and tools for locating mental health services in your area.
5. American Psychiatric Association (APA): The APA provides a variety of resources, including educational materials on bipolar disorder, information on how to find a psychiatrist, and resources for family members and caregivers.
6. Online Platforms: There are various online platforms and forums where individuals with bipolar disorder can connect, share experiences, and provide mutual support. These include websites like HealthUnlocked, Psych Central, and Reddit (r/bipolar subreddit).
7. Crisis Lines: In times of crisis, hotlines such as the National Suicide Prevention Lifeline (1-800-273-TALK) and Crisis Text Line (Text HOME to 741741) in the U.S. provide immediate assistance.

In addition to these resources, many local communities offer support groups for individuals with bipolar disorder and other mental health conditions. It’s also worth noting that individual psychotherapy and family-focused therapy can serve as significant sources of support and education for individuals with bipolar disorder and their families.

As always,  it is recommended to consult with a healthcare provider for appropriate resources and referrals based on an individual’s specific needs and circumstances. With the right treatment and support, people with bipolar disorder can lead fulfilling and productive lives.

Is it possible to live a normal life with bipolar disorder?

Bipolar disorder is a lifelong condition that can significantly impact an individual’s quality of life. However, with appropriate management and support, it is indeed possible for individuals with bipolar disorder to lead full, productive and satisfying lives. Living a “normal” life with bipolar disorder involves effectively managing the condition, which can be achieved through a combination of strategies:

1. Medical management: Adherence to prescribed medication regimens is crucial in maintaining mood stability and preventing relapses of manic or depressive episodes. The type, dosage, and combination of medications will depend on individual circumstances and should be regularly reviewed and adjusted by the treating healthcare provider.
2. Psychotherapy: Regular participation in therapy can provide individuals with coping strategies for managing symptoms, dealing with life stressors, and navigating relationships and occupational responsibilities. Cognitive-behavioral therapy, interpersonal and social rhythm therapy, and family-focused therapy have all shown to be effective.
3. Lifestyle modifications: Regular physical activity, a balanced diet, adequate sleep, and avoidance of alcohol, illicit substances, and excessive caffeine can contribute to better overall health and mood stability. Regular routines for sleeping, eating, and physical activity can be particularly beneficial in maintaining mood stability.
4. Stress management: Developing and consistently using stress management techniques can help individuals with bipolar disorder manage triggers and maintain mood stability. Techniques might include mindfulness meditation, progressive muscle relaxation, and yoga.
5. Support networks: Strong support networks, including family, friends, peer support groups, and mental health professionals, can provide both emotional support and practical assistance.
6. Regular monitoring: Regular appointments with healthcare providers are important for monitoring symptoms, assessing the effectiveness and side effects of medications, and adjusting treatment plans as necessary.
7. Education: Understanding the nature of bipolar disorder, recognizing personal triggers for mood episodes, and being aware of early warning signs of an episode can enable individuals to seek help promptly and potentially mitigate the severity of episodes.
8. Employment and activity: Engaging in meaningful activities, including employment, volunteering, or creative pursuits, can contribute to self-esteem, provide a sense of routine and purpose, and help individuals with bipolar disorder lead fulfilling lives.

While living with bipolar disorder can be challenging, these strategies can help individuals manage their symptoms, reduce the frequency and severity of mood episodes, and mitigate the impact of the disorder on their quality of life.  Importantly, “normal” life does not mean a life without challenges or difficulties, but rather a life in which the individual can pursue their goals, maintain meaningful relationships, and contribute to their communities, despite the presence of a chronic illness.

Successful management of bipolar disorder requires long-term commitment and often a process of trial and error to find the right combination of strategies that work for each individual. Support from healthcare providers, family members, friends, and mental health organizations can be invaluable in this process.

Reference more:

• How to Live with Someone Who has Bipolar Disorder: https://lotusbuddhas.com/how-to-live-with-someone-who-has-bipolar-disorder.html
• Bipolar Disorder | Brain & Behavior Research Foundation: https://www.bbrfoundation.org/research/bipolar-disorder
• Researchers find first strong genetic risk factor for disorder: https://hms.harvard.edu/news/bipolar-breakthrough