Bipolar Disorder

Diagnosis

Basics

Bipolar disorder, also known as manic-depressive illness, is a psychiatric disease characterized by periods of abnormally elevated moods, often followed by episodes of depression. An individual with manic-depressive illness has episodes of mania characterized by an abnormally elevated mood, sleeplessness, racing thoughts, and pressured speech. In severe cases, thoughts become increasingly chaotic, and may become completely removed from reality. Without treatment, the disorder often has disastrous consequences: during manic episodes, peoples' actions may cause them to lose jobs, destroy relationships, go into debt, and even put themselves into dangerous situations. Hospitalization is sometimes required to prevent such consequences or suicide.

Cycles of manic and depressive episodes may occur occasionally or several times a year depending on the individual. Most people feel no symptoms between episodes. If untreated, episodes generally become progressively more frequent and severe. Medications and psychotherapy help to stabilize moods and alleviate symptoms.

Bipolar disorder affects about 1% of the adult population. Manic depressive illness is recognized worldwide, and is about evenly distributed between men and women. The disorder typically begins in adolescence or early adulthood.

Causes

Manic-depressive illness is known to have a strong genetic basis. Bipolar disorder tends to run in families. More than two-thirds of people with the disorder have a close relative with it or with depression. Twin studies also support the genetic basis of the disorder: both members of a set of identical twins are more likely to have depression (33%-90%) than both members of a set of non-identical twins (5%-25%). Although the exact pattern of transmission remains unknown, some genes have recently been identified that are associated with the disease. It appears that multiple genes are involved, a particular mix of which determines the various features of the illness.

Symptoms

The manic phase of the illness is characterized by a persistent, abnormally elevated mood [Table 1]. Manic episodes tend to arise over a period of days to weeks. The person often seems to be euphoric, but may instead be intensely agitated. Affected individuals usually experience increased energy, with rapid, loud speech, a reduced need for sleep, and distractibility. The person may afterwards describe racing thoughts or ideas that seemed to take flight. During an episode, he or she may feel that even mundane conversations or ordinary details are intensely interesting. The person may make wild plans and take action on them, such as flying out of the country without adequate preparation, making crazy business investments, or going on extensive shopping sprees to the point of debt. The manic individual typically does not realize that thoughts are irrational, and will deny having a problem. In milder cases or early in the episode, activities may be channeled productively into work or creative pursuits. Oftentimes, however, thoughts progress too rapidly, irrationally, and chaotically to be constructive. If untreated, an episode may last for weeks, or even as long as a year.

A depressive phase usually follows the manic episode. When present, symptoms are identical to those of unipolar depression. Depressive episodes may follow the manic episode. During a depressive episode, an overwhelmingly sad mood and profound loss of interest in activities takes over. Physical symptoms, such as changes in sleep and eating habits, are common, and the person may have thoughts of death and suicide.

Severe states of mania or depression may involve psychotic symptoms in which the individual is unable to separate fantasy from reality. During manic or depressive episodes, a person may experience delusions (for example, beliefs of communicating with aliens or of having god-like powers) or hallucinations (such as hearing imaginary voices or seeing things that aren't there). Psychotic symptoms often provoke anxiety, and may involve fears of being harmed by others. When such symptoms are present, the disease resembles schizophrenia, and may respond to medications used for treating schizophrenia.

The frequency and duration of episodes of mania and depression vary among individuals. The manic and depressive episodes of each cycle typically occur within three months of each other. Between these cycles, most people feel well, and will have no symptoms. Some people experience many cycles of mania and depression each year. People with rapid cycles should be checked carefully for underlying thyroid disease or a drug-induced cause.

Table 1. Signs and Symptoms of Manic and Depressive Episodes

Manic episodes	Depressive episodes
Increased energy Euphoric feelings Agitation Less need for sleep Inflated beliefs in abilities Poor judgment Increased sex drive Denial that problem exists	Sad or empty mood Loss of interest in normal activities Feelings of guilt, worthlessness, or hopelessness Difficulty concentrating Restlessness or irritability Sleep disturbances (can be too much or too little) Changes in appetite Thoughts of death or suicide

Risk Factors

People with a family history of bipolar disorder have an increased risk for the disease. More than two-thirds of people with bipolar disorder have a close relative with the disorder, or with depression. Genetic and twin studies have both shown that bipolar disorder is at least partially heritable.

Having certain co-existing medical conditions, or taking certain medications, may increase your risk for a manic syndrome [Table 2] [Table 3]. Thyroid disease, kidney problems, AIDS, and stroke may cause manic symptoms. High levels of digoxin, a common heart and blood pressure medication, can also give rise to mania. Antidepressants and stimulant medications, including drugs such as amphetamines and cocaine, can also cause or mimic a manic episode.

Table 2. Medical Conditions that May Cause Manic Symptoms

Neurological disorders	Metabolic disorders	Other disorders
Extrapyramidal diseases (e.g., Huntington's, postencephalic Parkinson's) Central nervous system infections (general paresis, viral encephalitis) Cerebral neoplasms Cerebral trauma Cerebrovascular accidents Kleine-Levin syndrome Klinefelter's syndrome Multiple sclerosis Pick's disease Temporal lobe epilepsy Thalamotomy	Wilson's disease Vitamin B12 deficiency	Carcinoid syndrome Dialysis dementia Hyperthyroidism Pellagra Postpartum mania Uremia and hemodialysis

Table 3. Medications and Substances That May Produce Manic Symptoms

Amphetamines Corticosteroids (including ACTHa) Methylphenidate Baclofen Cyclosporine Metrizamide (following myelography) Bromide Disulfiram Opiates and opioids Bromocriptine Hallucinogens (intoxication and flashbacks) Phencyclidine (PCP) Captopril Hydralazine Procarbazine Cimetidine Isoniazid Procyclidine Cocaine Levodopa Yohimbine

^a ACTH, adrenocorticotropic hormone

Diagnosis

Bipolar disorder is diagnosed on the basis of symptoms that occur during a manic episode, a history of previous episodes, and family history. A diagnosis may be made solely by the presence of a manic episode; depression need not have occurred. Mania is usually described as an intensely happy or euphoric mood, but it can instead manifest as extreme irritability. According to the psychiatric definition of the disease, mania must be present for at least one week, or be severe enough to warrant hospitalization.

In addition to the mood abnormality, other symptoms must also be present before a diagnosis can be made.

Some of these additional symptoms include:

• Inflated self-esteem
• Decreased need for sleep
• Rapid speech
• Racing thoughts
• Easy distractibility
• Increase in activities (whether social or work-related)
• Increase in activities that may lead to problems (for example, buying sprees or sexual indiscretions)

The doctor will have to rule out the possibility that the patient's symptoms are a result of an underlying medical or drug-related condition. A drug screen should be part of the workup, as amphetamines or cocaine can precipitate manic symptoms. Prescription drugs can also cause manic symptoms. For example, high levels of digoxin, a common heart and blood pressure medication, can trigger a manic episode.

The doctor will also have to check for underlying medical conditions that may be causing manic symptoms. An initial episode that occurs after the age of 40 is particularly suggestive of mania secondary to another cause. Thyroid disease, AIDS, and stroke are all conditions that your doctor will have to check for before making a diagnosis.

Treatment

Urgent Care

Someone with bipolar disorder may need to be hospitalized immediately if it seems that they may be a danger to themselves or others, or if they are psychotic. A person who is experiencing a particularly severe episode of manic-depressive illness should be brought to the hospital immediately to prevent suicide or possible violence to another person. An acute episode is treated with medications and a low-stimulation environment. Depending on the individual's symptoms and history, longer-term hospitalization may be required.

Even in the absence of a crisis, you should seek immediate help at the first sign of a manic episode, as episodes can progress rapidly, with potentially serious consequences.

Family and friends must be aware that someone with bipolar disorder may attempt suicide [Table 4]. Bipolar disorder carries a high risk of suicide. Individuals at particularly high risk are those who express a desire to commit suicide, and who have devised a plan to carry it out. People who are impulsive and have irrational thoughts are also in danger, and may need to be hospitalized to protect themselves.

Table 4. Warning Signs Requiring Urgent Care

Expression of suicidal intent Evidence of plans to carry out suicide: e.g., a stash of pills, a weapon Extreme agitation Extreme weight loss Hallucinations or delusions (imaginary thoughts or beliefs, such as hearing voices or believing one has god-like powers) Characteristics that can lead to dangerous decisions (e.g., hypersexuality)

Self Care

Avoid using drugs and alcohol excessively. People with bipolar disorder are at a high risk for drug and alcohol abuse, as they may attempt to use those substances in an attempt to self-medicate. Such efforts complicate treatment efforts, and are usually destructive to their lives.

Learn as much as you can about bipolar disorder. Learning about the disease and recognizing one's own warning signs is very important for managing the problem and knowing when to seek professional care. Sometimes joining a support group or organization for mental disorders can be helpful.

National Institute of Mental Health
Information Resources and Inquiries Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
FAX: 301-443-4279
http://www.nimh.nih.gov
nimhinfo@nih.gov

National Depressive and Manic Depressive Association
730 Franklin Street, Suite 501
Chicago, IL 60610
Phone: 312-642-0049; 1-800-826-3632
FAX: 312-642-7243
http://www.ndmda.org

National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
Phone: 703-524-7600; 1-800-950-NAMI (6264)
FAX: 703-524-9094
http://www.nami.org

National Foundation for Depressive Illness, Inc.
P.O. Box 2257
New York, NY 10116
Phone: 212-268-4260; 1-800-239-1265
FAX: 212-268-4434
http://www.depression.org

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314-2971
Phone: 703-684-7722; 1-800-969-NMHA (6642)
FAX: 703-684-5968
http://www.nmha.org

Reduce stress in your life, and try to develop regular sleep patterns. Psychosocial stress may be associated with the onset of manic and depressive episodes. Work with your doctor to identify specific stressors, and to develop skills for coping with them. It may be necessary, for example, to take time off rather than "toughing it out" if mood symptoms hinder your ability to work.

Sleep disturbances may signal the early phase of a manic or depressive episode. Recognizing these disturbances and making an effort to maintain regular sleep patterns is thought to be important in preventing symptoms from escalating into a full-blown episode.

Limit your intake limit of common stimulants. Alcohol, caffeine, and some over-the-counter medications, even in small amounts, may interfere with sleep patterns or mood, and possibly trigger a relapse.

Learn to recognize the early warning signs of relapse. Warning signs of relapse vary from patient to patient, and may include thoughts of death (or sudden optimism), or slight changes in sleep patterns (a common indicator), mood, energy, self-esteem, sexual interest, concentration, willingness to take on new projects, and dress or grooming.

Seek out the support of family members and friends.

Call your doctor if you feel strong changes in your usual mood, including suicidal or violent feelings.

Drug Therapy

Your doctor is the best source of information on the drug treatment choices available to you.

Other Therapies

Psychotherapy can be a helpful adjunct to drug treatment. Counseling can help individuals gain further insight into the nature of their problem, and can help them better cope with the disorder. It can also help people recognize early symptoms so that they can seek prompt medical assistance.

Electroconvulsive shock treatment (ECT) can be used for severe depression that does not respond to medications. ECT may be used for people with severe depression and mania who are unresponsive to medication. The procedure involves passing an electric current through electrodes placed on the head to induce a seizure. It is typically given in a series of five to eight treatments, with one treatment given on alternate days. Muscle soreness may result because of the seizure-induced muscle contractions. Temporary memory loss may occur, but is usually not permanent. Because the treatment is done under a general anesthesia, it involves similar risks as other minor medical procedures involving anesthesia, including a very small risk of death.

Despite generalized fears of ECT, most psychiatrists consider it to be a safe and effective treatment that works more rapidly than medications or counseling. It is most commonly used for individuals who are at extreme risk for suicide, for people who have lost a dangerous amount of weight, or for those who are extremely agitated.

Alternative Medicine

Avoid St. John's wort if you are taking medication for bipolar disorder, and discuss any use of complementary/alternative medications (herbs, teas, etc.) with your physician. St. John's wort (Hypericum perforatum), an herbal remedy used for various anxiety and depressive conditions, can potentially interact with drugs prescribed for bipolar disorder. Talk to your doctor before taking any alternative medications.

Some patients use omega-3 fatty acid supplements (fish oil or flaxseed oil) as a complementary treatment for bipolar disorder. The results of a recent study suggest that omega-3 fatty acids may temper the symptoms of bipolar disorder.

A variety of commercially available fish oil and flaxseed oil supplements contain omega-3 fatty acids. Flaxseed oil should not be cooked because doing so destroys the omega-3 fatty acids contained therein.

Prognosis

Manic-depressive episodes recur periodically throughout life. If untreated, cycles of mania and depression tend to recur more frequently, and become more severe over time. Suicide rates tend to be high with this disorder, making proper diagnosis and effective treatment particularly important. Although all symptoms may not be completely eliminated, medications can usually stabilize moods so that a person can lead a normal life.

Follow-up

Patients should follow up with their doctors at regular intervals, and when symptoms recur. After an initial episode, individuals should work closely with their physicians to achieve a maintenance regimen so that episodes do not recur. Medications may need to be periodically adjusted. Patients who are maintained on lithium must have their blood tested routinely to ensure a proper dosage.