Bipolar Disorder

What is bipolar disorder?

Bipolar disorder, also known as bipolar affective disorder and, less commonly, as manic depression, is a mental health condition that causes dramatic changes in mood that, in turn, affect people’s ability to carry out day-to-day tasks.

It is characterized by serious mood swings between depression and mania that last several weeks or months. These mood swings are more extreme than those experienced by most people.[1]

According to the World Health Organization (WHO), bipolar disorder currently affects 60 million people around the world.[2]

Bipolar disorder affects men and women equally. It is most common for symptoms to begin during someone’s late teenage or early adult years, but children and older adults can also develop bipolar disorder.

There is no known cure for bipolar disorder. People with the condition are likely to experience recurrences throughout their life which, if left untreated, can be highly disruptive and potentially lead to hospitalization and even suicide. However, there are effective treatments that can reduce the frequency and severity of mood swings.[3]

Symptoms of bipolar disorder

People with bipolar disorder experience mania (highs) and depression (lows). For more information on the following points, also see our signs of bipolar disorder resource.

Mania

Manic episodes can feel like an intense state of wellbeing, with unusual reserves of energy. However, mania can cause people to lose touch with day-to-day reality and with how other people feel. After a manic episode, people can feel embarrassed or ashamed about their behavior and unable to manage plans that were made while experiencing mania.

Hypomania

The symptoms of hypomania are similar to mania, but less extreme. Episodes of hypomania last for a few days rather than weeks or months, as is common with mania. It is unusual to have any psychotic symptoms with hypomania.

Depression

Periods of extreme low mood or depression can last for at least two weeks, with symptoms interfering with day-to-day life.

The contrast between the ‘high’ of mania or hypomania may make an episode of depression even harder to cope with.

Mixed features

Mixed features, also known as mixed episodes or mixed states, are when people feel symptoms of depression and mania or hypomania at the same time.

Psychotic symptoms

In very severe cases, symptoms of psychosis may develop. In a psychotic episode, a person loses touch with reality. They may see, hear or believe things that the people around them do not.

Types of bipolar disorder

There are various types of bipolar disorder. These include:

Bipolar I

This form of bipolar disorder is defined by:[4][5]

  • Manic episodes that last at least seven days
  • It is common to experience periods of depression, as well, though not in every case
  • Without treatment, a manic episode may last up to six months
  • Manic episodes may be severe enough to require hospitalization

Bipolar II

This form of bipolar disorder is defined by:[4]/[5]

  • More than one episode of severe depression
  • Episodes of mania, known as hypomania, that are less severe than those seen in Bipolar I disorder

Rapid cycling

Rapid cycling is the name for experiencing multiple episodes of mania, hypomania or depression within a year. According to John Hopkins Medicine, the average person with bipolar disorder will experience nine episodes over a lifetime. Someone with rapid cycling may experience four or more episodes a year.[6]

Around 10 to 20 percent of people with bipolar disorder experience rapid cycling. It is more common in people with bipolar II disorder and also more commonly experienced by women.[7]

Cyclothymic disorder

Cyclothymic disorder, also referred to as cyclothymia, is similar to bipolar disorder. It is characterized by emotional highs and lows that are not as severe as bipolar disorder, but can still affect day-to-day life.

Cyclothymic disorder often goes undiagnosed, but in less than half of cases it can develop into bipolar disorder.[8]

For more information, see the resource on cyclothymic disorder.

Causes of bipolar disorder

The causes of bipolar disorder are not yet fully understood. Lifetime prevalence is around 3 to 5 percent.

There appears to be a genetic link, as the chance of developing bipolar disorder is greater if a family member is also affected.[9] If one parent has bipolar disorder, there is a 25 percent chance a child will develop it. If both parents have bipolar disorder there is a chance of up to 50 percent that a child will develop bipolar disorder.[10]

Bipolar disorder may be caused by a problem with the way the brain controls mood. This is why medication is often used to control symptoms.

High-stress situations and life-changing events may trigger an episode of depression or mania.[11]

Diagnosing bipolar disorder

There is no medical or blood test to diagnose bipolar disorder. A doctor or other mental health practitioner will make a diagnosis based on conversations with the person affected.[12]

DSM-5 criteria (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) for diagnosing bipolar disorder require one episode of mania, or one episode of hypomania and one episode of depression.[5]

ICD-10 criteria (International Statistical Classification of Diseases and Related Health Problems, tenth revision) for diagnosing bipolar disorder require two or more episodes of significantly disturbed activity, consisting of mania, or hypomania and depression. The ICD-10 also classifies episodes of only mania or hypomania as bipolar.[13]

It is possible for a person with bipolar disorder to experience an initial episode of depression, and they will therefore not be diagnosed with bipolar disorder. In such cases, treatment with antidepressants may trigger a first episode of mania.

Treatment and management of bipolar disorder

There is no known cure for bipolar disorder. Treatment aims to stabilize mood and prevent episodes of mania and depression from becoming extreme and to allow the individual to live without disruption.

Medical treatments for bipolar disorder

Medications to stabilize mood are a common way of treating bipolar disorder. Some people with the condition need a combination of medications to control mood swings in the most effective way for them.[5][14][15]

Lithium

Lithium has been used to stabilize moods for over 50 years, though how it works isn’t fully known. It is mainly used for preventing and stabilizing mania by evening out mood swings, although it can also be prescribed to treat depression.[16]

Getting the right dose for each person is very important. If the dose is too low, the drug won’t be effective. If the dose is too high, lithium becomes toxic. People taking lithium need regular blood tests to check the dosage and to ensure the kidneys and thyroid are working properly.

Side effects of normal dosage can include:[17][18]

  • Feeling thirsty
  • Urinating more often than usual
  • Nausea
  • Feeling tired
  • Gaining weight
  • Slightly shaky hands
  • Hypothyroidism and goiter (enlarged thyroid gland) can develop with long term use

If there is too much lithium in the body, side effects can include:

  • Feeling very thirsty
  • Diarrhea or vomiting
  • Noticeable shaking of limbs
  • Muscle twitches
  • Being confused

The amount of lithium in the body is affected by how much liquid and salt the person takes in. Drinking plenty of non-alcoholic fluids and avoiding a low salt diet is recommended.

Lithium use is declining in the United States because of concerns over its side effects and the availability of medications like valproate. However, it is still considered an effective treatment.[19]

Taking lithium reduces the chances of having a manic episode within the next year by 30 to 40 percent.

Anticonvulsant medication

Valproate is an anticonvulsant medication which was originally developed to treat epilepsy. It is increasingly used to treat bipolar disorder as a mood stabilizer, particularly in the United States. It is not yet clear how the drug works.

Valproate is used to treat mania, rapid cycling and mixed episodes. It is sometimes prescribed along with lithium, as there is a suggestion that the two work more effectively together.[20]

Valproate can cause damage to a developing fetus, and should not be taken by women of childbearing age.[21]

Other side effects may include:

  • Nausea
  • Feeling shaky
  • Diarrhea
  • Increased appetite and associated weight gain
  • Changes to levels of ammonia and platelets in the blood

Carbamazepine and lamotrigine are anticonvulsants that are also used as mood stabilizers. Carbamazepine is thought to be more effective at treating rapid cycling than lithium and causes fewer side effects. Lamotrigine is generally prescribed for treating bipolar II disorder.[14]

Antipsychotic medication

Antipsychotic medications, such as olanzapine and quetiapine, are used to treat mania. They can also be used in conjunction with mood stabilizers to prevent mania occurring.[22]

Antipsychotic medications help by treating psychotic symptoms, such as hearing voices, delusions and racing thoughts. They can also help to prevent extreme mood swings and, in some cases, can be used to treat severe depression.[15]

These medications work by blocking dopamine in the brain. Side effects may include:

  • Feeling sleepy and sluggish
  • Weight gain
  • Lack of interest in sexual activity
  • Increased chance of developing diabetes
  • High doses can cause limbs to be stiff and shaky

Antidepressants

Antidepressant medications are used to treat moderate to severe episodes of depression.

For some people, there is a risk that treatment with antidepressants alone can trigger an episode of mania or make rapid cycling more likely. For this reason, it’s recommended that antidepressants, such as fluoxetine[23], should be prescribed alongside a mood stabilizer.[24]

SSRI antidepressants can take two to six weeks to start affecting mood. They are thought to work by increasing levels of serotonin in the brain.

There are many potential side effects when using SSRIs, though most wear off after a few weeks. These side effects include:[15][23]

  • Anxiety
  • Nausea
  • Upset stomach
  • Dizziness
  • Not sleeping enough or sleeping too much
  • Low sex drive

It is important not to stop taking SSRIs too soon so as to prevent a recurrence of depression. A course of six to nine months is usually recommended, though in more severe cases, it may be advisable to continue taking SSRIs for longer. A doctor should be consulted before stopping treatment with SSRIs.[25][26]

Cognitive treatments for bipolar disorder

In between episodes of mania, or hypomania and depression, cognitive, or psychotherapy, treatments can help. Psychotherapy usually takes place in sessions of one hour over periods of several months.[26]

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy is a form of talking therapy that focuses on how thoughts and beliefs affect feelings and behavior. CBT teaches participants coping skills to recognize and deal with problems.[27]

For people with bipolar disorder, CBT can help improve awareness of behavior, compliance with treatment plans and day-to-day coping skills. When used alongside medication, a study of 19 randomized control trials found that CBT is effective in reducing the relapse rate and the severity of symptoms.[28]

Self monitoring

Learning to recognize signs of moods swinging out of control is an important step in managing bipolar disorder. Recognizing early signs can lead to intervention and prevent full episodes of mania and depression, and avoid potential hospitalization.

Keeping a mood diary is helpful to track long-term mood changes, as well as possible triggers.

Other forms of psychotherapy

Psychoeducation can help by providing more information about bipolar disorder to the person with the condition, as well as their family and friends.[29]

Led by a therapist, group psychoeducation brings together people with similar experiences to share knowledge about how bipolar disorder can affect behavior and how to manage symptoms.

Family therapy can help by working together as a family to strengthen relationships, identify risks and develop support skills.

Other treatments for bipolar disorder

There are other potential treatments for bipolar disorder if medication and psychotherapeutic interventions are not successful, or if the condition is extreme.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy is a treatment that sends electrical current through the brain to trigger an epileptic seizure. The electricity is administered under general anesthetic and with the use of muscle relaxants, so the body does not convulse.[30]

ECT is only advised for rapid, short-term relief of severe depression, mania or psychosis, where other interventions have failed and/or when the condition is considered life-threatening.

ECT causes memory loss, which is usually short-term but can be very disorienting.

New treatments

There is ongoing research into new mood-stabilizing drugs. Other, non-medication therapies, are also being investigated, including vagal nerve stimulation, transcranial magnetic stimulation and light therapy.

Self care in the management of bipolar disorder

As well as monitoring day-to-day behavior for signs of mood changes, the knowledge gained from such monitoring can be used to avoid triggering an episode of mania or depression.[31]

It can help to have someone to confide in. Close relationships with people who understand the condition and the individual’s experience and trigger points, can be useful as a support network.

Too much activity can trigger a manic episode, so it’s helpful to maintain a balance between work and activity, and relaxation and fun.

Stress and bipolar disorder

Stress is a common trigger, and avoiding highly stressful situations is recommended. However, it’s not possible to avoid all stress, so a useful tool may be to learn relaxation techniques or take advice on handling stress from a qualified therapist.[32][33]

Healthy lifestyle

There is no specific diet recommended for bipolar disorder. However, maintaining a healthy diet will help with overall wellness.[34][35] This includes:

  • Eating a balance of foods rich in nutrients, such as fruits, vegetables, pulses, whole grains, fish, eggs, low-fat meat, nuts and seeds
  • Avoiding food that is high in saturated and trans fats, such as red meat, as well as simple carbohydrates such as refined sugar

Lithium can affect salt levels in the body, so care should be taken not to eat too much or too little.[17]

Caffeine may contribute to a manic or hypomanic episode by disrupting normal sleep patterns.[36]

Exercising for 20 minutes, three times a week, helps to maintain fitness. Exercise also releases endorphins into the brain, which improve mood.[37]

Pregnancy and bipolar disorder

Women with bipolar disorder who are pregnant, or plan to become pregnant, should talk to their doctor to assess whether their medications are suitable and to discuss how to manage mood during and after pregnancy.[38]

Women of childbearing age should not take valproate. If taken while pregnant, there is a high risk of harm to the developing fetus.[20]

Lithium is safer than other mood stabilizers to take during pregnancy. There is a low risk to the fetus of developing a heart valve defect during the first three months, but lithium is safe after 26 weeks. Babies should not be breastfed if the mother is taking lithium.[18]

Postpartum illnesses are more common for women with bipolar disorder than for the general population. Postpartum depression and postpartum psychosis are both serious conditions which could affect a woman’s ability to take care of herself and/or her baby.[39]

Postpartum depression

Around 25 percent of women with bipolar disorder who give birth will experience postpartum depression.[39]

Postnatal depression can start at any point in the first year after birth. As well as the usual symptoms of depression, postnatal depression symptoms can include difficulty bonding with the baby and disturbing thoughts about causing the baby harm.[40]

Postpartum psychosis

25 percent of women with bipolar disorder who give birth will experience postpartum psychosis. Women who have previously had a severe postpartum illness, and women who have a mother or sister who experienced a severe postpartum illness, are at even higher risk.[39]

Symptoms generally begin in the first few days after birth, though they can develop up to six months later. Symptoms are similar to psychosis, including hallucinations and delusions.[41]

Use of drugs and alcohol in bipolar disorder

Problems with substance abuse are common among people with bipolar disorder. Among those with the condition, approximately 42 percent also misuse alcohol, 20 percent also misuse cannabis and 17 percent also misuse other illegal drugs.[42]

People with bipolar disorder may self-medicate with alcohol or illegal drugs to ease distress caused by their symptoms. However, misusing alcohol and drugs can have serious social and health consequences.[43]

Bipolar disorder in children and teenagers

Usually, symptoms of bipolar disorder first appear around the ages of 15 to 19, though signs can be seen in younger children.

The symptoms for mania, hypomania and depression in bipolar disorder are similar to those in adults, although children and teenagers may behave more erratically. Moods may change more rapidly than in adults, and children may express mania and hypomania as temper tantrums and physical aggression.

See our resource on signs of bipolar disorder for more information about bipolar disorder in children, teenagers and young adults.

The American Academy of Child and Adolescent Psychiatry urges caution in looking for signs of bipolar disorder in toddlers and children under six years old.[44]

Bipolar disorder FAQs

Q: What is a bipolar personality?
A: Someone with bipolar disorder experiences extreme mood swings, from depressive lows to manic highs. These mood swings are more severe than those which people without bipolar disorder experience, and at worst, need to be treated in hospital. Bipolar is a condition, rather than a personality type. It needs treatment to allow someone to live a life free from disruption.

Q: What’s the difference between depression and bipolar?
A: Someone with bipolar disorder experiences manic episodes alongside depression. Someone with depression without mania does not have bipolar disorder. (See Diagnosing bipolar disorder.)

Q: Why is bipolar disorder sometimes called manic depression?
A: Manic depression is an old name for bipolar disorder, and comes from the two emotional states: mania and depression. Healthcare professionals now use the term bipolar, which also refers to the two extremes of emotional states.

Q: Is bipolar disorder a disability?
A: Bipolar disorder is a mental health condition. With effective treatment, it shouldn’t have a large effect on day-to-day life. However, if the symptoms of bipolar disorder are so severe that it interferes with everyday living or the ability to work, social security benefits may be available.[45]

Q: Can you work if you have bipolar disorder?
A: With effective treatment to keep symptoms under control, someone with bipolar disorder can continue to work as normal. If symptoms are not under control, it may affect:[45]

  • Working with other people
  • Concentration and memory
  • Understanding
  • Standards of behavior

In these circumstances, someone with bipolar disorder may find it difficult to work and may need time to recover.

Q: Is bipolar disorder curable?
A: Bipolar disorder is not curable, but symptoms can be controlled with treatment. (See Treatment of bipolar disorder.) Factors including effectiveness of treatment, social circumstances and genetics may mean that a person with bipolar disorder may experience only one or two episodes in a lifetime. Other people may experience bipolar disorder as a chronic lifetime condition.

Q: How do you know if you have bipolar disorder?
A: People with bipolar disorder experience extremes of emotion and mood, unlike others. If you think you have bipolar disorder, a doctor or other mental health professional can talk to you about it. (See Diagnosing bipolar disorder.)

Q: How do people act when they have bipolar disorder?
A: Unless someone with bipolar disorder is experiencing a manic or depressive episode, their behavior won’t be out of the ordinary. If someone is having a manic episode, you might notice their conversation is faster than usual, their train of thought jumps around and they’re easily distracted. They might also be sleeping less, be irritable and thinking up outlandish plans and adventures. (See Mania.) If someone is depressed, they may be slow and lacking motivation, have no interest in activities they usually enjoy and/or be tearful and upset. (See Depression.)

Q: Can you treat bipolar naturally?
A: Psychotherapy is recommended as a long-term treatment for bipolar as a way to manage and be aware of changing moods. Relaxation methods, like meditation may help maintain a healthy, balanced lifestyle. However, medication is recommended for stabilizing moods and particularly for treating mania. St John’s Wort, a commonly used complementary therapy for depression, may actually make psychotic symptoms worse.[46]

Q: What famous people have bipolar disorder?
A: Singer Demi Lovato[47], actors Jean-Claude Van Damme[48] and Catherine Zeta-Jones[49] and British actor, writer and comedian Stephen Fry[50] all have bipolar disorder. Winston Churchill is believed to have had the condition[51]. Carrie Fisher had bipolar disorder and often spoke openly about it[52].

Q: Are bipolar disorder and ADHD related?
A: ADHD is a behavioral disorder with symptoms present all the time whereas bipolar is a mood disorder with episodic symptoms. Although symptoms of mania are similar to those of ADHD, the two disorders are not the same.[53]

Q: Can bipolar disorder cause hallucinations?
A: If someone is experiencing psychosis during a manic episode, they may hallucinate. (See Psychotic symptoms.)

Q: Is bipolar disorder inherited?
A: The causes of the condition are not yet fully understood. There may be a genetic link with bipolar disorder as it does seem to run in families, but this hasn’t been confirmed.

Other names for bipolar affective disorder

  • Bipolar affective disorder in adults

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