Bipolar Disorder

• Bipolar I disorder. Mood swings with bipolar I cause significant difficulty in your job, school or relationships. Manic episodes can be severe and dangerous.
• Bipolar II disorder. Bipolar II is less severe than bipolar I. You may have an elevated mood, irritability and some changes in your functioning, but generally you can carry on with your normal daily routine. Instead of full-blown mania, you have hypomania — a less severe form of mania. In bipolar II, periods of depression typically last longer than periods of hypomania.
• Cyclothymia. Cyclothymia is a mild form of bipolar disorder. With cyclothymia, hypomania and depression can be disruptive, but the highs and lows are not as severe as they are with other types of bipolar disorder.Bipolar disorder symptoms reflect a range of moods.

The exact symptoms of bipolar disorder vary from person to person. For some people, depression causes the most problems; for other people manic symptoms are the main concern. Symptoms of depression and symptoms of mania or hypomania may also occur together. This is known as a mixed episode.

Manic phase of bipolar disorder

Signs and symptoms of the manic or hypomanic phase of bipolar disorder can include:

• Euphoria
• Extreme optimism
• Inflated self-esteem
• Poor judgment
• Rapid speech
• Racing thoughts
• Aggressive behavior
• Agitation or irritation
• Increased physical activity
• Risky behavior
• Spending sprees or unwise financial choices
• Increased drive to perform or achieve goals
• Increased sex drive
• Decreased need for sleep
• Inability to concentrate
• Careless or dangerous use of drugs or alcohol
• Frequent absences from work or school
• Delusions or a break from reality (psychosis)
• Poor performance at work or school

Depressive phase of bipolar disorder

Signs and symptoms of the depressive phase of bipolar disorder can include:

• Sadness
• Hopelessness
• Suicidal thoughts or behavior
• Anxiety
• Guilt
• Sleep problems
• Low appetite or increased appetite
• Fatigue
• Loss of interest in daily activities
• Problems concentrating
• Irritability
• Chronic pain without a known cause
• Frequent absences from work or school
• Poor performance at work or school

Other signs and symptoms bipolar disorder

Signs and symptoms of bipolar disorder can also include:

• Seasonal changes in mood. As with seasonal affective disorder (SAD), some people with bipolar disorder have moods that change with the seasons. Some people become manic or hypomanic in the spring or summer and then become depressed in the fall or winter. For other people, this cycle is reversed — they become depressed in the spring or summer and manic or hypomanic in the fall or winter.
• Rapid cycling bipolar disorder. Some people with bipolar disorder have rapid mood shifts. This is defined as having four or more mood swings within a single year. However, in some people moods shifts occur much more quickly, sometimes within just hours.
• Psychosis. Severe episodes of either mania or depression may result in psychosis, a detachment from reality. Symptoms of psychosis may include false but strongly held beliefs (delusions) and hearing or seeing things that aren't there (hallucinations). In some people, sudden psychosis (a psychotic break) is the first sign of bipolar disorder.

Symptoms in children and adolescents

Instead of clear-cut depression and mania or hypomania, the most prominent signs of bipolar disorder in children and adolescents can include explosive temper, rapid mood shifts, reckless behavior and aggression. In some cases, these shifts occur within hours or less — for example, a child may have intense periods of giddiness and silliness, long bouts of crying and outbursts of explosive anger all in one day. Changing sleep patterns are also a common indicator of childhood bipolar disorder.

Causes

Several factors seem to be involved in causing and triggering bipolar episodes:

• Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
• Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a significant role in bipolar disorder and other mood disorders.
• Hormones. Imbalanced hormones may be involved in causing or triggering bipolar disorder.
• Inherited traits. Bipolar disorder is more common in people who have a blood relative (such as a sibling or parent) with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.
• Environment. Stress, abuse, significant loss or other traumatic experiences may play a role in bipolar disorder.

Risk factors

Factors that may increase the risk of developing bipolar disorder include:

• Having blood relatives such as a parent or sibling with bipolar disorder
• Periods of high stress
• Drug or alcohol abuse
• Major life changes, such as the death of a loved one
• Being between the ages of 15 and 30

Conditions that commonly occur with bipolar disorder

If you have bipolar disorder, you may also have another health condition that's diagnosed before or after your diagnosis of bipolar disorder. Such conditions need to be diagnosed and treated because they may worsen existing bipolar disorder. They include:

• Anxiety disorders. Examples include post-traumatic stress disorder (PTSD), social phobia and generalized anxiety disorder.
• Attention-deficit/hyperactivity disorder (ADHD). ADHD has symptoms that overlap with bipolar disorder. For this reason, bipolar disorder can be difficult to differentiate from ADHD. Sometimes one is mistaken for the other. In some cases, a person may be diagnosed with both conditions.
• Addiction or substance abuse. Many people with bipolar disorder also have alcohol or drug problems. Street drugs or alcohol may seem to ease symptoms, but they can actually trigger, prolong or worsen depression or mania.
• Physical health problems. People diagnosed with bipolar disorder are more likely to have certain other health problems, including heart disease, thyroid problems and obesity.

Complications

Left untreated, bipolar disorder can result in serious problems that affect every area of your life. These can include:

• Problems related to substance and alcohol abuse
• Legal problems
• Financial problems
• Relationship troubles
• Isolation and loneliness
• Poor work or school performance
• Frequent absences from work or school
• Suicide

Diagnosis

When doctors suspect someone has bipolar disorder, they typically do a number of tests and exams. These can help rule out other problems, pinpoint a diagnosis and also check for any related complications. These can include:

• Physical exam. This may involve measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
• Lab tests. These may include blood and urine tests. These tests can help identify any physical problems that could be causing your symptoms.
• Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms and possible episodes of mania or depression.
• Mood charting. To identify exactly what's going on, your doctor may have you keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.

Diagnostic criteria for bipolar disorder

To be diagnosed with bipolar disorder, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment. Diagnostic criteria for bipolar disorder are based on the specific type of bipolar disorder.

• Bipolar I disorder: You've had at least one manic or one mixed episode. You may or may not have had a major depressive episode. Because bipolar I varies from person to person, there are more specific subcategories of diagnosis based on your particular signs and symptoms.
• Bipolar II disorder: You've had at least one major depressive episode and at least one hypomanic episode (but not a fully manic or mixed episode). With bipolar II, symptoms cause distress or difficulty in some area of your life — such as relationships or work. Bipolar II disorder also has subcategories based on your particular signs and symptoms.
• Cyclothymic disorder: You've had numerous hypomanic episodes and periods of depression — but you've never had a full manic episode, a major depressive episode or a mixed episode. For a diagnosis of cyclothymic disorder, symptoms last two years or more (one year in children and adolescents). During that time, symptoms never go away for more than two months. Symptoms cause significant distress or difficulty in some area of your life — such as in relationships or at work.

The DSM has very specific criteria for manic, hypomanic, major depressive and mixed episodes:

Criteria for a manic episode

A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

• Inflated self-esteem or grandiosity
• Decreased need for sleep (for example, you feel rested after only three hours of sleep)
• Unusual talkativeness
• Racing thoughts
• Distractibility
• Increased goal-directed activity (either socially, at work or school, or sexually)
• Engagement in pleasurable activities that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

To be considered a manic episode:

• The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in usual social activities or relationships; to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
• Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below).
• Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.

Criteria for a hypomanic episode

A hypomanic episode is a distinct period of elevated, expansive, or irritable mood that lasts at least four days, and is different from the usual nondepressed mood. During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

• Inflated self-esteem or grandiosity
• Decreased need for sleep (for example, you feel rested after only three hours of sleep)
• Unusual talkativeness
• Racing thoughts
• DistractibilityI
• ncreased goal-directed activity (either socially, at work or school, or sexually)
• Engagement in pleasurable activities that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

To be considered a hypomanic episode:

• The mood disturbance must be severe enough to cause a noticeable and uncharacteristic change in functioning.
• The episode isn't severe enough to cause significant difficulty at work, at school or in usual social activities or relationships; to require hospitalization; or to trigger a break from reality (psychosis).
• Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below).
• Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.

Criteria for a major depressive episode

To be diagnosed with a major depressive episode, you must have five (or more) of the following symptoms over a two-week period. At least one of the symptoms is either depressed mood or loss of interest or pleasure. Symptoms can be based on your own feelings or on the observations of someone else. They include:

• Depressed mood most of the day, nearly every day, such as feeling sad, empty or tearful (in children and adolescents, depressed mood can appear as constant irritability)
• Diminished interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
• Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
• Insomnia or increased desire to sleep nearly every day
• Either restlessness or slowed behavior that can be observed by others
• 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 or suicide, or a suicide attempt

To be considered a major depressive episode:

• Symptoms don't meet the criteria for a mixed episode (see criteria for mixed episode below)
• Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships with others
• Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or a having a medical condition such as hyperthyroidism
• Symptoms are not caused by grieving, such as after the loss of a loved one

Criteria for mixed episode

• The criteria are met both for a manic episode and for a major depressive episode nearly every day during at least a one-week period
• The mood disturbance must be severe enough to cause noticeable difficulty at work, at school, or in usual social activities or relationships; to require hospitalization to prevent harm to self or others; or to cause a break from reality (psychosis)
• Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or a having a medical condition such as hyperthyroidism

Diagnosis in children

The same official criteria used to diagnose bipolar disorder in adults are used to diagnose children and adolescents. However, bipolar symptoms in children and adolescents often have different patterns than they do in adults, and may not fit neatly into the categories used for diagnosis. While adults generally tend to have distinct periods of mania and depression, children and adolescents may have erratic, rapid changes in mood, behavior and energy levels.

It's often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. To make it even more difficult, children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems such as oppositional defiant disorder (ODD).

Although bipolar disorder can occur in young children, diagnosis in children preschool age or younger is especially difficult. The current criteria used for diagnosis have not been proved in young children, and a wide range of issues other than bipolar disorder can cause mood and behavior problems at this age.

Treatments and drugs

Bipolar disorder requires lifelong treatment, even during periods when you feel better. Treatment is usually guided by a psychiatrist skilled in treating the condition. You may have a treatment team that also includes psychologists, social workers and psychiatric nurses. The primary treatments for bipolar disorder include medications; individual, group or family psychological counseling (psychotherapy); or education and support groups.

• Hospitalization may be needed if you are behaving dangerously, you feel suicidal or you become detached from reality (psychotic).
• Initial treatment generally involves taking medications to balance your moods right away. Once your symptoms are under control, you'll work with your doctor to find the best long-term treatment.
• Continued treatment (maintenance treatment) is used to manage bipolar disorder on a long-term basis. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
• Substance abuse treatment may be necessary if you have problems with alcohol or drugs. Otherwise, it can be very difficult to manage bipolar disorder.

Medications

A number of medications are used to treat bipolar disorder. If one doesn't work well for you, there are a number of others to try. Your doctor may suggest combining medications for maximum effect. Medications for bipolar disorder include those that prevent the extreme highs and lows that can occur with bipolar disorder (mood stabilizers) and medications that help with depression or anxiety.

Medications for bipolar disorder include:

• Lithium. Lithium (Lithobid, others) is effective at stabilizing mood and preventing the extreme highs and lows of certain categories of bipolar disorder and has been used for many years. Periodic blood tests are required, since lithium can cause thyroid and kidney problems. Common side effects include tremor, weight gain and digestive issues.
• Anticonvulsants. These mood stabilizing medications include valproic acid (Depakene), divalproex (Depakote) and lamotrigine (Lamictal). The medication asenapine (Saphris) may be helpful in treating mixed episodes. Depending on the medication you take, side effects can vary. Common side effects include weight gain, tremor and drowsiness. Rarely, certain anticonvulsants cause more serious problems, such as skin rashes, blood disorders or liver problems.
• Antidepressants. Depending on your symptoms, your doctor may or may not recommend you take an antidepressant. In some people with bipolar disorder, antidepressants can trigger manic episodes, but may be OK if taken along with a mood stabilizer. The most common antidepressant side effects include reduced sexual desire and problems reaching orgasm. Older antidepressants, which include tricyclics and MAO inhibitors, can cause a number of potentially dangerous side effects and require careful monitoring.
• Antipsychotics. Certain antipsychotic medications, such as olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel), may help people who don't gain benefits from anticonvulsants. Side effects depend on the medication, but can include weight gain, sleepiness, tremors, dry mouth, blurred vision and sexual side effects. Weight gain in children is a significant concern. Antipsychotic use may also affect memory and attention and cause involuntary facial or body movements.
• Symbyax. This medication combines the antidepressant fluoxetine and the antipsychotic olanzapine - it works as a depression treatment and a mood stabilizer. Side effects can include weight gain, drowsiness, dry mouth, increased appetite and fatigue. This medication may also cause sexual problems similar to those caused by antidepressants.
• Benzodiazepines. These anti-anxiety medications may help with anxiety and improve sleep. Examples include clonazepam, lorazepam (Ativan), diazepam (Valium), chlordiazepoxide (Librium) and alprazolam (Xanax). Benzodiazepines are generally used for relieving anxiety only on a short-term basis. Side effects can include drowsiness, reduced muscle coordination, and problems with balance and memory.

Finding the right medication

Everyone's different, so finding the right medication or medications for you will likely take some trial and error. This requires patience, as some medications need eight weeks or longer to take full effect. Generally only one medication is changed at a time so your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. This can take months or longer, and medications may need to be adjusted as your symptoms change. Side effects improve as you find the right medications and doses that work for you, and your body adjusts to the medications.

Medications and pregnancy

A number of medications for bipolar disorder can cause birth defects.

• Use effective birth control (contraception) to prevent pregnancy. Discuss birth control options with your doctor, as birth control medications may lose effectiveness when taken along with certain bipolar disorder medications.
• If you plan to become pregnant, meet with your doctor to discuss your treatment options.
• Discuss breast-feeding with your doctor, as some bipolar medications can pass through breast milk to your infant.

Psychotherapy

Psychotherapy is another vital part of bipolar disorder treatment. Several types of therapy may be helpful. These include:

• Cognitive behavioral therapy. This is a common form of individual therapy for bipolar disorder. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. It can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
• Education. Counseling to help you learn about bipolar disorder (psychoeducation) can help you and your loved ones understand bipolar disorder. Knowing what's going on can help you get the best support and treatment, and help you and your loved ones recognize warning signs of mood swings.
• Family therapy. Family therapy involves seeing a psychologist or other mental health provider along with your family members. Family therapy can help identify and reduce stress within your family. It can help your family learn how to communicate better, solve problems and resolve conflicts.
• Group therapy. Group therapy provides a forum to communicate with and learn from others in a similar situation. It may also help build better relationship skills.
• Other therapies. Other therapies that have been studied with some evidence of success include early identification and therapy for worsening symptoms (prodrome detection) and therapy to identify and resolve problems with your daily routine and interpersonal relationships (interpersonal and social rhythm therapy). Ask your doctor if any of these options may be appropriate for you.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy can be effective for people who have episodes of severe depression or feel suicidal or people who haven't seen improvements in their symptoms despite other treatment. With ECT, electrical currents are passed through your brain. Researchers don't fully understand how ECT works. But it's thought that the electric shock causes changes in brain chemistry that leads to improvements in your mood. ECT may be an option if you have mania or severe depression when you're pregnant and cannot take your regular medications.

Hospitalization

In some cases, people with bipolar disorder benefit from hospitalization. Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you're having a manic episode or a deep depression. Partial hospitalization or day treatment programs also are options to consider. These programs provide the support and counseling you need while you get symptoms under control.

Treatment in children and adolescents

Children and adolescents with bipolar disorder are prescribed the same types of medications as those used in adults. However, there's very little research on the safety and effectiveness of bipolar medications in children, so treatment decisions are based on adult research. Treatments are generally decided on a case-by-case basis, depending on exact symptoms, medication side effects and other factors. As with adults, ECT may be an option for adolescents with severe bipolar I symptoms or for whom medications don't work.

Most children diagnosed with bipolar disorder require counseling as part of initial treatment and to keep symptoms from returning. Psychotherapy — along with working with teachers and school counselors — can help children develop coping skills, address learning difficulties and resolve social problems. It can also help strengthen family bonds and communication. Psychotherapy may also be necessary to resolve substance abuse problems, common in older children with bipolar disorder.

Lifestyle remedies

You'll probably need to make lifestyle changes to stop cycles of behavior that worsen your bipolar disorder, and to make sure you get the support you need from people in your life. Here are some steps to take:

• Stop drinking or using illicit drugs. One of the biggest concerns with bipolar disorder is the negative consequences of risk-taking behavior and drug or alcohol abuse. Get help if you have trouble quitting on your own.
• Steer clear of unhealthy relationships. Surround yourself with people who are a positive influence and won't encourage unhealthy behavior or attitudes that can worsen your bipolar disorder.
• Get regular exercise. Moderate, regular exercise can help steady your mood. Working out releases brain chemicals that make you feel good (endorphins), can help you sleep and has a number of other benefits.
• Get plenty of sleep. Sleeping enough is an important part of managing your mood. If you have trouble sleeping, talk to your doctor or mental health provider about what you can do.

Alternative medicine

Some alternative treatments may help, but there isn't much research on them. Most of the studies that do exist are on major depression, so it isn't clear how well most of these work for bipolar disorder.

• Omega-3 fatty acids. These oils may help improve brain function and depression associated with bipolar disorder. Bipolar disorder appears to be less common in areas of the world where people regularly eat fish rich in omega-3s. Omega-3s appear to have a number of health benefits, but more studies are needed to determine just how much they help with bipolar disorder.
• St. John's wort. This herb may be helpful with depression. However, it can also interact with antidepressants and other medications, and has the potential to trigger mania in some people.
• S-adenosyl-L-methionine (SAMe). This amino acid supplement appears to help brain function related to depression. It isn't clear yet whether it's helpful in people with bipolar disorder. As with St. John's wort, SAMe can trigger mania in some people.
• Herbal combinations. Herbal remedies that combine a number of different herbs, such as those used in traditional Chinese medicine, haven't been well studied. Some appear to help, but the risks and benefits still aren't clear.
• Acupuncture. This ancient Chinese practice of inserting tiny needles into the skin may relieve depression, but more studies are needed to confirm its benefits. However, it won't hurt for you to try it — acupuncture is safe and can be done along with other bipolar disorder treatments.
• Yoga. Yoga may help ease depression and mood swings associated with bipolar disorder. It also has a number of other health benefits.
• Massage therapy. Massage may also help relieve anxiety and stress, which can worsen bipolar symptoms.

Although some alternative medicine treatments can be a good addition to your regular treatment, take some precautions first:

• Don't stop taking your prescribed medications or skip therapy sessions. Alternative medicine is not a substitute for regular medical care when it comes to treating bipolar disorder.
• Be honest with your doctors and mental health providers. Tell them exactly which complementary treatments you use or would like to try.
• Be aware of potential dangers. Just because it's natural doesn't mean it's safe. Before using alternative medicine, be sure you know the risks, including possible interactions with medications.

Coping and support

Coping with bipolar disorder can be challenging. Here are some things that can help:

• Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan. Likewise, help educate your family and friends about what you're going through.
• Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
• Stay focused on your goals. Recovery from bipolar disorder can take time. Stay motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn ways to relax and manage stress. Yoga, tai chi, meditation, or other relaxation techniques can be helpful.

Prevention

There's no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.

If you've been diagnosed with bipolar disorder, some strategies can help prevent minor episodes from becoming full-blown episodes of mania or depression:

• Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You and your caregivers may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you're falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.
• Avoid drugs and alcohol. Even though you may feel better, using alcohol or street drugs makes your symptoms more likely to come back.
• Take your medications exactly as directed. Medications can have unwanted side effects, and you may feel unhappy about having a mental health condition that requires lifelong treatment. During periods when you feel better, you may be tempted to stop treatment. This can have immediate consequences — you may become very depressed, feel suicidal, or go into a manic or hypomanic episode. If you think you need to make a change, call your doctor.
• Check first before taking other medications. Call the doctor who's treating you for bipolar disorder before you take medications prescribed by another doctor. Sometimes other medications trigger episodes of bipolar disorder or may interfere with medications you're already taking to treat bipolar disorder.

References:

http://www.hse.ie/eng/health/az/B/Bipolar-disorder/Treating-bipolar-disorder.html

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

https://en.wikipedia.org/wiki/Bipolar_disorder

http://www.aware.ie/help/information/literature/bipolar-disorder/

http://www.helpguide.org/articles/bipolar-disorder/bipolar-disorder-signs-and-symptoms.htm