Overview

Bipolar disorder is a mental health condition that causes unexpected fluctuations in a person’s state of mind, focus, and energy. It was initially referred to as manic-depressive disease or manic depression. Managing routine tasks may become challenging due to these changes in behaviour. Normally, people with bipolar disorder experience alternating episodes of both depression and mania.¹ People with other mental health disorders and overuse of drugs have a high risk of developing bipolar disorder. Bipolar disorder impacts approximately 0.53% of people worldwide. It is relatively a common psychiatric condition and a major cause of death due to suicide. This disorder is characterised by cognitive impairment and decreased functioning. Moreover, the recurrence of this condition affects the quality of life of individuals affected.²

Types of bipolar disorder

Bipolar disorder is subdivided into 4 types:

Bipolar I

Bipolar I is characterised by manic episodes lasting a week or longer, or severe manic symptoms requiring immediate medical treatment. Usually, there also exist depressive periods, which continue for at least two weeks. It is also possible to develop mixed-feature episodes of depression, which include both manic and depressed symptoms concurrently. "Rapid cycling" is when the person experiences four or more manic or depressive episodes in a year.³

Bipolar II

Individuals diagnosed with bipolar II might suffer from periods of depression and hypomania (similar to mania, but with a reduced severity and duration of symptoms). However, people with bipolar II never exhibit a complete manic episode. Bipolar II disorder can be more devastating than bipolar I disease, even though hypomania is less severe than mania. This is because bipolar II sufferers are more likely to have chronic depression.³

Cyclothymic disorder

A less severe version of bipolar disorder is called cyclothymic disorder, or cyclothymia. It is characterised by recurrent episodes of hypomanic and depressed mood swings for at least two years. Mood swings associated with cyclothymia can occur impulsively.⁴ 

Other specified and unspecified bipolar and related disorders

Unusual mood changes that do not meet the diagnostic standards for cyclothymia, bipolar I, or II are classified under this class.³

Symptoms of bipolar disorder

Symptoms of mania and depression should be evaluated in people with bipolar disorder:⁵

Understanding mania and hypomania

Mania and hypomania are two different phases, however, both exhibit similar symptoms. Compared to hypomania, mania is more intense and severe. Moreover, it has a prominent impact on the personal life of the individual affecting relationships, jobs, and social activities.⁶

Hypomania, a milder manic-like episode, is usually the characteristic feature of Bipolar II. It is possible to feel cheerful and productive while dealing with hypomania. Even in social or professional settings, people with hypomania can perform seamlessly. Everything may feel normal to the person experiencing hypomania. However, people around them notice unusual changes in the person. Hypomania might be accompanied by severe depression.³

Nevertheless, mania is a "natural" state that is associated with bipolar I disorder. Manic symptoms need to be differentiated from increased energy and disturbed behaviour resulting from substance abuse or other illnesses. Bipolar I disorder can be diagnosed with a single manic period alternatively with depression. The consequences of a manic episode might be severe ruining the affected individual's image and career. A physical attack on oneself or others is a more serious consequence.⁷

Causes of bipolar disorder

The causes of bipolar disorder are still unclear and being researched. However, some theorised causes of bipolar disorder are:

Genetic factors

Studies indicate that individuals with a blood relative, especially a first-degree relative suffering from bipolar disorder are more likely to develop the condition themselves. Small proteins called brain-derived neurotrophic factor (BDNF) are vital for learning and memory and significantly impact the survival and proliferation of neurons. Research has revealed that polymorphisms in the BDNF gene are linked to bipolar disorder.⁸

Childhood traumatic events

Bipolar disorder is more likely to occur later in life if childhood abuse or other traumatic events are experienced. Emotional abuse or neglect has been linked in a number of studies to the development of bipolar disorder. However, emotional abuse is the most common form of abuse that bipolar patients report.⁸

Psychological stress

Studies suggest a link between the onset of bipolar disorder and psychological stressors and it has been found that the first occurrence of bipolar disorder may develop within 6 months of stressful events. Certain circumstances such as childbirth or early parental death increase the chances of developing bipolar disorder.⁸

Substance abuse

Abuse of substances such as cannabis, opiates, cocaine, sedatives, and alcohol before age 25 is associated with a higher risk of bipolar disorder later in life.⁸ 

Comorbid conditions

There is evidence that bipolar disorder frequently coexists with several psychological and physical disorders including headaches, asthma, obesity, irritable bowel syndrome (IBS), and migraines.⁸

Diagnosis of bipolar disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, is the primary tool used in the diagnosis of bipolar disorder in many countries. Others may use the International Classification of Disease (ICD)-10 or -11 (most notably the UK). By asking questions and filling out diagnostic forms, patients can communicate their thoughts, feelings, and behavioural patterns. To rule out other medical disorders that cause similar symptoms, doctors will ask questions about the symptoms, and lab testing with physical examinations may be performed.⁹ 

Treatment of bipolar disorder

Individuals with bipolar disorder can benefit from treatment. Medication and psychotherapy, commonly known as talk therapy, are typically used in conjunction as part of an efficient treatment strategy. Those who receive long-term treatment can help manage their symptoms.

Pharmacotherapy

Certain drugs can help to alleviate bipolar symptoms. However, it may take time to identify an effective personalised treatment regimen. The patient should cooperate with their psychiatrist to find the drugs that work best for them.

Manic or hypomanic episodes

The initial course of treatment intends to stabilise an anxious or acutely agitated individual to support them in calming down and reducing the likelihood of risky behaviour. Mood stabilisers and antipsychotic medications can be used in combination with benzodiazepines to lessen anxiety and induce sleep. Higher doses are given in manic episodes. Mood stabilisers like lithium or valproate, or antipsychotics like aripiprazole, quetiapine, or risperidone are examples of first-line monotherapy.² Lithium, within two weeks of starting, may lessen the severity of symptoms. However, it may cause thyroid or kidney problems, so consulting with your healthcare provider if any unwanted signs are experienced is necessary.³

Acute bipolar depression

Antidepressants used in treatment for bipolar disorder include either monotherapy with quetiapine, olanzapine, or combination therapy with olanzapine-fluoxetine, lithium plus lamotrigine.²

Psychotherapy

Psychotherapy provides support to recognise and modify unwanted feelings, thoughts, and behaviours. This includes cognitive behavioural therapy (CBT), interpersonal and social rhythm therapy (IPSRT), and family-focused therapy.¹

Electroconvulsive treatment (ECT)

ECT is mainly considered in refractory bipolar depression or high-risk patients with suicidal tendencies.¹ For all cases of bipolar disorder that did not respond to standard pharmacological treatment, including acute depressive, mixed, and manic episodes, ECT proved to be quite beneficial. There is almost no chance of ECT-induced mania, and mood instability is unlikely to occur.¹⁰ However, ECT is very rarely used and is often only considered after other treatment methods such as psychotherapy and pharmacotherapy have failed to help.

Summary

Bipolar disorder is one of the world's top ten causes of disability. It is characterised by manic or hypomanic episodes alternating with periods of depression. There are four subtypes of bipolar disorder, all of which involve significant variations in mood, energy, and activity levels. Manic episodes are periods when a person feels extremely happy, agitated, or full of energy, while depressive episodes are marked by feelings of being “down,” depressed, uncaring, or hopeless. Hypomanic episodes are less intense and shorter in duration compared to full manic episodes. In addition to experiencing intense emotional episodes, individuals with bipolar disorder often face abnormal shifts in sleep and activity patterns and may engage in harmful or unwanted behaviours. A diagnosis of bipolar disorder requires at least one manic or hypomanic episode. To identify the specific subtype, mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). Treatment focuses on symptom management and may include medications such as mood stabilisers, antipsychotics, or antidepressants, as well as therapies like psychotherapy and electroconvulsive therapy (ECT).