Diagnosis and Treatment of Bipolar Disorder

Introduction. Bipolar Disorder

Bipolar disorder, or manic-depressive illness (MDI), is a severe and usually persistent mental disorder. There are four types of mood episodes in bipolar disorder: mania, hypomania, depression, and mixed episodes. 

The episodes can appear few times per year, rarely once in few years.

The in-depth diagnosis is the key element in the treatment of bipolar disorder allowing the differentiation from other psychiatric conditions.

Treatment of bipolar disorder, especially in cases with rare episodes, might lead to a full cure without the need of ongoing medication. However, in most of the cases bipolar disorder requires life-long psychiatric monitoring and complementary treatment with psychotherapy and sociotherapy.

Mania and Hypomania in Bipolar Disorder

The elevated level of energy and mood, sometime euphoria, depending on the intensity of the symptoms are called hypomania or mania.

Mania

The term “mania” describes a state of extreme euphoria, unjustified optimism, and hyperactivity. Both, mania and hypomania are combined with increased speed of thinking, talking as well as increased motor activities. The patient may stay awake for several nights not feeling tired. His sexual drive can be increased, and the inhibition (conscious control of his actions) decreased. His judgment will be always impaired.

Some of the patients will develop delusions and sometimes even hallucinations. Delusions are irrational thoughts; in mania this is usually the delusion of grandeur. The existence of delusional (psychotic) symptoms can be confusing and lead to misdiagnosis of schizophrenia.

Hypomania

A hypomanic episode is different from full mania. Its symptoms are less severe. The person can experience such state as very productive, being optimistic and feeling happy. The hypomania doesn`t include psychotic symptoms (i.e. delusions) and the patient is able to keep some level of control.

Depression in Bipolar Disorder

In the past, bipolar depression was not differentiated from regular depression. The results of research suggest that there are significant differences between the two. For example, certain symptoms are more common in bipolar depression than in regular depression. Bipolar depression is more likely to involve irritability, unpredictable mood swings, and feelings of restlessness.

The patients suffering from bipolar depression are more likely to develop psychotic symptoms with delusional thoughts and/or delusions.

The depressive phase of bipolar disorder can be very severe including risk of suicide. In fact, people suffering from bipolar disorder are more likely to attempt suicide than those suffering from regular depression. Furthermore, their suicide attempts tend to be more lethal.

Diagnosis of Bipolar Disorder I and II

The current psychiatric diagnostic manuals, ICD 10 and DSM V, describe two types of bipolar disorder

Bipolar I Disorder

is the classic manic-depressive form of the illness characterized by episodes of mania and depression

Bipolar II Disorder

shows episodes of hypomania and milder depression

Mixed Episode in BD

A mixed episode of bipolar disorder is characterized by the coexistence of manic and depressive symptoms. The patient experiencing a mixed episode might be hyperactive, being unable to sleep or concentrate, feeling at the same time very anxious and depressed. This combination of high energy and low mood increases the risk of suicide.

Mixed bipolar episodes can resemble ADD or ADHD. Although BD II is a full recognized diagnostic entity, it is less reliably diagnosed than Bipolar I. The main reason is that the symptoms are less obvious than those of bipolar disorder I.

Diagnostic Criteria for Bipolar Disorder I

The most precise criteria for identifying the BP disorder diagnosis have been outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-V).

Elevated mood and drive, irritability

The periods of abnormally and persistently elevated mood abnormally increased goal-directed activity or energy must last at least 1 week. The symptoms have to be present most of the day, nearly every day. In the phase of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms should be present to a significant degree and represent a noticeable change from usual behaviour.

Additional symptoms

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity
• Excessive involvement in activities that have a high potential for painful consequences
• The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization
• The episode is not attributable to the physiological effects of a substance or to another medical condition.

Diagnostic Criteria for depressive episode in Bipolar Disorder I

Five (or more) of the following symptoms have been present during the same 2-week period:

• Depressed mood most of the day, nearly every day
• Markedly diminished interest or pleasure in all, or almost all, activities
• Significant weight loss
• Insomnia 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
• Diminished ability to think or concentrate
• 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
• Significant distress or impairment in social, occupational, or other important areas of functioning
• The episode is not attributable to the physiological effects of a substance or another medical condition.

Diagnostic Criteria for Bipolar Disorder II

The criteria for diagnosis of bipolar II are:

Criteria for hypomanic episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

Additional symptoms

• During the above-described period, three (or more) of the following symptoms have persisted:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual
• Flight of ideas
• Distractibility
• Increase in goal-directed activity or psychomotor agitation
• Excessive involvement in activities that have a high potential for painful consequences

The episode is:

• associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
• not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
• not attributable to the physiological effects of a drug abuse or a medication

Rapid cycling

The course of bipolar disorder with four or more episodes withing 12 months is called rapid cycling. The other criteria for the diagnosis of rapid cycling is the demarcation between the episodes either by period of remission or switch to the opposite polarity. Mood switches in rapid cycling can last from days to months.

Rapid cycling is more commonly observed in women. Furthermore, women tend to have a higher frequency of depressive and mixed episodes compared to men. Interestingly, men often have their initial encounter with bipolar disorder during a manic state, whereas women tend to experience their first episode in a depressive state.

Diagnosis of Bipolar Disorder

The first step in properly treated bipolar disorder is getting the correct diagnosis. A thorough diagnostic approach is important because bipolar disorder can resemble other serious psychiatric conditions. Diagnoses such as schizophrenia, schizoaffective disorder, ADHD, or depression can be misdiagnosed as BD.

At CHMC the procedure to secure the BP disorder diagnosis follows the international medical standard, which includes psychiatric exploration, physical examination, a set of laboratory tests, EEG and brain scan. Those tests can help rule out other contributing factors, especially physical illnesses such as metabolic and hormonal diseases, inflammatory processes on the central nervous system and other root causes.

Psychiatric consultation

It is important to see an experienced psychiatrist trained in diagnosing and treating bipolar disorder. A psychiatric evaluation at CHMC includes the patient’s medical and personal history collected from his relatives and friends.

Proper diagnosis and treatment help people with bipolar disorder to control their symptoms. In most cases, treatment helps reduce the frequency and severity of episodes, and in the best-case scenario the illness can be lifelong completely suppressed.

Untreated manic or depressive episodes can last for months. Ignoring the problem won`t make it go away. Bipolar disorder tends to worsen if it is not treated.

Untreated bipolar disorder leads usually to more frequent and more severe episodes, than when the illness first appeared. In the worst-case scenario, the condition can evolve in developing the rapid cycling. Also, delays in getting the correct diagnosis and treatment make the patient more likely to experience personal, social, and work-related problems.

Risk for bipolar disorder in “normal” people

Bipolar disorder can affect anyone. The disorder results from a combination of several factors, with genetics being the strongest. Identical twins have a 50% correlation. However, genetic predisposition does not guarantee the onset of the disorder. The predisposition can be compared to someone walking on ice; in some cases, the ice may be thin but won’t break if the person moves smoothly. On the other hand, people without genetic predisposition but with tiggering physical illnesses and psychological pressure can develop bipolar disorder. This pressure can arise from challenging life circumstances, trauma, physical illness, or drug use.

Once the disorder is activated, it typically persists, and untreated first episodes rarely remain dormant.

Risk factors for bipolar disorder

Bipolar disorder, named for mood swings, involves manic highs and depressive lows. Typically emerging near age 25, it impacts various demographics, including genders, races, and socioeconomic groups.

Multiple factors contribute to bipolar disorder’s onset, including genetics, stress, and life changes. Family history increases risk; those with affected relatives have a higher chance of developing the disorder. Another risk factors are pre-existent psychiatric comorbidities such as anxiety, depression and behavioral disturbances.

Abuse of alcohol and drugs can add to the risk of BD onset. Studies show that about 50% of people with bipolar disorder have a substance abuse or alcohol problem. Also, people suffering of bipolar disorder tend to use alcohol or drugs, especially during the depressive periods trying to enhance their mood. Conversely, manic episodes’ recklessness leads to substance misuse.

Effective treatment for bipolar disorder

People with bipolar disorder need an ongoing treatment due to the chronic nature of the illness. If left untreated, the symptoms of BD worsen, thus early diagnosis and treatment are crucial.

There is no one-size-fits-all approach for treatment of bipolar disorder because the symptoms of bipolar disorder varies in different people. The symptoms diverge widely in their pattern, severity, and frequency. Each type of bipolar disorder mood episode has a unique set of symptoms.

Bipolar treatment in the acute phase

In the acute phase of bipolar disorder I the hospitalization and a quick adjustment of the medication are necessary. In this phase the leading role belongs to the psychiatrists.

Long term treatment of BD

Bipolar disorder is a complex psychological condition. Diagnosis can be tricky, and treatment is often difficult.

The patient suffering from BP, which is a lifelong and recurrent illness, needs long-term treatment to maintain control of symptoms. Patients, psychiatrists, and psychologists need to work together to build a trusted therapeutic alliance. Therefore, psychiatrists should closely monitor the mental health of their patients and adjust medication accordingly. Psychologists should address their patients’ concerns openly, thereby improving their insight and coping skills.

Since bipolar disorder is a chronic, relapsing illness, it`s important to continue treatment with medication even when the patient feels better. The appearance of two manic episodes makes life-long medication treatment necessary.

However, medication alone is not enough to prevent the relapses. The most effective treatment strategy involves a combination of medication, therapy, lifestyle changes, and social support.

Psychotherapy in bipolar disorder

Some think psychotherapy can cure bipolar disorder, but it’s not enough. Manic patients need medication since they lack insight and act irrationally.

The same counts for severe depressive phases. The pharmacological intervention is necessary especially in suicidal patients. The esential part of the treatment is the use of psychotherapy, especially during the stable phases. In long term treatment participation in support groups and psychoeducation are equally important.

The effective evidenced based methods in treatment of BD are:

• Cognitive-behavioral therapy (CBT) aims to change negative thoughts and behaviour.

• Family-focused therapy helps people with bipolar disorder learn about the illness.

• Psychotherapy focused on self-care and stress regulation helps manage stress.

Several clinical trials showed the highest effectiveness of therapy combining medication with psychotherapy.

Pregnancy and medication for bipolar disorder

The choice of medication in women with bipolar disorder should presume the future pregnancy. Most women are diagnosed with bipolar disorder while not being pregnant. Ideally the medication used in treatment of bipolar disorder in young women should ‘t have any teratogenic effects on the baby.

If a woman with bipolar disorder gets pregnant while being on medication, it’s recommendable to continue the medication with low spectrum of side effects on the embryo than stopping its intake. Therefore, discontinuing the medication during pregnancy contains the risk of manic or depressive episode and in consequence the use of higher dosage of medication to control the symptoms.

Integrating family in the treatment

Like other serious illnesses, dealing with bipolar disorder is difficult for spouses, family members and friends. Relatives and friends must cope with the person`s serious behavioral problems. Patients in manic state tend to go to wild spending sprees or other irrational behaviours, often breaching the social norms. Patient in the depressive phase goes to the other extrem. He withdraws socially and, in some cases, can get suicidal. Such extreme mood swings can end for the patient in total social and professional disaster. That’s why the involvement of family and friends into the treatment is crucial in the recovery process.

Prognosis of BP disorder treatment

Factors suggesting a worse prognosis include such attributes as poor job history, alcohol abuse, psychotic features, depressive features between periods of mania and depression, male sex, poor general health condition, inconsistent psychiatric treatment, or no treatment at all.

Factors correlating with positive outcome of the treatment are short duration of the episodes, late age of onset, few psychotic symptoms, good general health and consistent psychiatric monitoring.

The prerequisite for successful treatment of bipolar disorder without relapses is the consistent psychiatric monitoring by experienced psychiatrist.

Famous people who suffered from bipolar disorder

• Ernest Hemingway, American writer
• Graham Greene, English writer
• Jack Irons, drummer, formerly of Red Hot Chili Peppers and Pearl Jam
• Vivien Leigh, actress
• Jack London, American writer
• Edvard Munch, artist
• Edgar Allan Poe, poet and writer
• Jackson Pollock, American artist
• Robert Schumann, German composer
• Kurt Cobain, musician
• Vincent Van Gogh, artist
• Amy Winehouse, musician
• Virginia Woolf, writer

Read more about Bipolar Disorder:

Bipolar Disorder, Treatment with Medication

Causes of Bipolar Disorder

Risk Factors for Bipolar Disorder

History of Bipolar Disorder

What Is Mania and Hypomania?

Bipolar Disorder. Recollection of Facts

Useful links

International Society for Bipolar Disorders

International Society for Bipolar Disorders (ISBD) is a non-profit organization. The society sponsors research and education for bipolar disorders. ISBD members are mental health professionals as well as patients and their families. ISBD and has branches in fifty countries.