Bipolar Disorders

People with a bipolar disorder experience both the lows of depression and the highs of mania.
Many describe their life as an emotional roller coaster, as they shift back and forth between
extreme moods. A number of sufferers eventually become suicidal. Their roller coaster ride also
has a dramatic impact on relatives and friends (Lee et al., 2011; Lowe & Cohen, 2010).

What Are the Symptoms of Mania?

Unlike people sunk in the gloom of depression, those in a state of mania typically experience
dramatic and inappropriate rises in mood and activity. The symptoms of mania span the same
areas of functioning—emotional, motivational, behavioral, cognitive, and physical—as those of
depression, but mania affects those areas in an opposite way (APA, 2013, 2012).

A person in the throes of mania has powerful emotions in search of an outlet. The mood of
euphoric joy and well-being is out of all proportion to the actual happenings in the person’s life.
Not every person with mania is a picture of happiness, however. Some instead become very
irritable and angry, especially when others get in the way of their exaggerated ambitions.

In the motivational realm, people with mania seem to want constant excitement, involvement,
and companionship. They enthusiastically seek out new friends and old, new interests and old,
and have little awareness that their social style is overwhelming, domineering, and excessive.

The behavior of people with mania is usually very active. They move quickly, as though there
were not enough time to do everything they want to do. They may talk rapidly and loudly, their
conversations filled with jokes and efforts to be clever or, conversely, with complaints and verbal
outbursts. Flamboyance is not uncommon: dressing in flashy clothes, giving large sums of
money to strangers, or even getting involved in dangerous activities. In the cognitive realm,
people with mania usually show poor judgment and planning, as if they feel too good or move
too fast to consider possible pitfalls. Filled with optimism, they rarely listen when others try to
slow them down. They may also hold an inflated opinion of themselves, and sometimes their
self-esteem approaches grandiosity. During severe episodes of mania, some have trouble
remaining coherent or in touch with reality. Finally, in the physical realm, people with mania feel
remarkably energetic. They typically get little sleep yet feel and act wide awake (Armitage &
Arnedt, 2011). Even if they miss a night or two of sleep, their energy level may remain high.

Diagnosing Bipolar Disorders

People are considered to be in a full manic episode when for at least one week they display an
abnormally high or irritable mood, increased activity or energy, and at least three other
symptoms of mania (see Table 6-4). The episode may even include psychotic features such as
delusions or hallucinations. When the symptoms of mania are less severe (causing little
impairment), the person is said to be experiencing a hypomanic episode (APA, 2013, 2012).

DSM-5 distinguishes two kinds of bipolar disorders—bipolar I and bipolar II. People with
bipolar I disorder have full manic and major depressive episodes. Most of them experience an
alternation of the episodes; for example, weeks of mania may be followed by a period of
wellness, followed, in turn, by an episode of depression. Some, however, have mixed episodes,
in which they display both manic and depressive symptoms within the same episode—for
example, having racing thoughts amidst feelings of extreme sadness (Mazza et al., 2012;
Mitchell et al., 2011). In bipolar II disorder, hypomanic—that is, mildly manic—episode
alternate with major depressive disorder over the course of time.

Facts

Prevalence The 12-month prevalence of bipolar II disorder, internationally, is 0.3%. In the

United States, 12-month prevalence is 0.8%. The prevalence rate of pediatric bipolar II disorder
is difficult to establish. DSM-IV bipolar I, bipolar II, and bipolar disorder not otherwise specified
yield a combined prevalence rate of 1.8% in U.S. and non-U.S. community samples, with higher
rates (2.7% inclusive) in youths age 12 years or older.

Without treatment, mood episodes tend to recur for people with either type of bipolar disorder
(Ketter, 2010). If people experience four or more mood episodes within a one-year period, their
disorder is further considered to be rapid cycling. Surveys from around the world indicate that
between 1 and 2.6 percent of all adults suffer from a bipolar disorder at any given time (Khare et
al., 2011; Merikangas et al., 2011). The disorders are equally common in women and men, but
they are more common among people with low incomes than those with higher incomes (Sareen
et al., 2011). Onset usually occurs between the ages of 15 and 44 years. In most untreated cases,
the manic and depressive episodes eventually subside, only to recur at a later time (Weiner et al.,
2011). When a person experiences numerous periods of hypomanic symptoms and mild
depressive symptoms, but not full-blown episodes, DSM-5 assigns a diagnosis of cyclothymic
disorder. The symptoms of this milder form of bipolar disorder continue for two or more years,
interrupted occasionally by normal moods that may last for only days or weeks. This disorder,
like bipolar I and bipolar II disorders, usually begins in adolescence or early adulthood and is
equally common among women and men. At least 0.4 percent of the population develops
cyclothymic disorder. In some cases, the milder symptoms eventually blossom into a bipolar I or
bipolar II disorder (Goto et al., 2011).

There is little to no evidence of bipolar gender differences, whereas some, but not all, clinical
samples suggest that bipolar II disorder is more common in females than in males, which may
reflect gender differences in treatment seeking or other factors.

Differential Diagnosis

Major depressive disorder. Perhaps the most challenging differential diagnosis to consider is
major depressive disorder, which may be accompanied by hypomanic or manic symptoms
that do not meet full criteria (i.e., either fewer symptoms or a shorter duration than required
for a hypomanic episode). This is especially true in evaluating individuals with symptoms of
irritability, which may be associated with either major depressive disorder or bipolar II
disorder. Cyclothymic disorder.

In cyclothymic disorder, there are numerous periods of hypomanic symptoms and numerous
periods of depressive symptoms that do not meet symptom or duration criteria for a major
depressive episode. Bipolar II disorder is distinguished from cyclothymic disorder by the
presence of one or more major depressive episodes. If a major depressive episode occurs
after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II disorder
is given.

Schizophrenia spectrum and other related psychotic disorders. Bipolar II disorder must be
distinguished from psychotic disorders (e.g., schizoaffective disorder, schizophrenia, and
delusional disorder). Schizophrenia, schizoaffective disorder, and delusional disorder are all
characterized by periods of psychotic symptoms that occur in the absence of prominent mood
symptoms. Other helpful considerations include the accompanying symptoms, previous
course, and family history. Panic disorder or other anxiety disorders. Anxiety disorders need
to be considered in the differential diagnosis and may frequently be present as co-occurring
disorders.

Substance use disorders. Substance use disorders are included in the differential diagnosis.
Attention-deficit/hyperactivity disorder. Attention-deficit/hyperactivity disorder (ADHD)
may be misdiagnosed as bipolar II disorder, especially in adolescents and children. Many
symptoms of ADHD, such as rapid speech, racing thoughts, distractibility, and less need for
sleep, overlap with the symptoms of hypomania. The double counting of symptoms toward
both ADHD and bipolar II disorder can be avoided if the clinician clarifies whether the
symptoms represent a distinct episode and if the noticeable increase over baseline required
for the diagnosis of bipolar II disorder is present.

Personality disorders. The same convention as applies for ADHD also applies when
evaluating an individual for a personality disorder such as borderline personality disorder,
since mood lability and impulsivity are common in both personality disorders and bipolar II
disorder. Symptoms must represent a distinct episode, and the noticeable increase over
baseline required for the diagnosis of bipolar II disorder must be present. A diagnosis of a
personality disorder should not be made during an untreated mood episode unless the lifetime
history supports the presence of a personality disorder. Other bipolar disorders. Diagnosis of
bipolar II disorder should be differentiated from bipolar I disorder by carefully considering
whether there have been any past episodes of mania and from other specified and unspecified
bipolar and related disorders by confirming the presence of fully syndromal hypomania and
depression.

Comorbidity

Bipolar II disorder is more often than not associated with one or more co-occurring mental
disorders, with anxiety disorders being the most common. Approximately 60% of individuals
with bipolar II disorder have three or more co-occurring mental disorders; 75% have an
anxiety disorder; and 37% have a substance use disorder. Children and adolescents with
 bipolar II disorder have a higher rate of co-occurring anxiety disorders compared with those
with bipolar I disorder, and the anxiety disorder most often predates the bipolar disorder.
Anxiety and substance use disorders occur in individuals with bipolar II disorder at a higher
rate than in the general population. Approximately 14% of individuals with bipolar II
disorder have at least one lifetime eating disorder, with binge-eating disorder being more
common than bulimia nervosa and anorexia nervosa. These commonly co-occurring
disorders do not seem to follow a course of illness that is truly independent from that of the
bipolar disorder, but rather have strong associations with mood states. For example, anxiety
and eating disorders tend to associate most with depressive symptoms, and substance use
disorders are moderately associated with manic symptoms.

what are the causes?

Neurotransmitter.

 Some research did indeed find the norepinephrine activity of persons with mania to be
higher than that of depressed or control research participants (Post et al., 1980, 1978)./
 Research suggests that mania, like depression, may be linked to low serotonin activity
(Shastry, 2005; Sobczak et al., 2002). Perhaps low activity of serotonin opens the door to
a disorder of mood and permits the activity of norepinephrine (or perhaps other
neurotransmitters) to define the particular form the disorder will take (Benes, 2011;
Walderhaug et al., 2011). That is, low serotonin activity accompanied by low
norepinephrine activity may lead to depression; low serotonin activity accompanied by
high norepinephrine activity may lead to mania.
 Some studies suggest that, among bipolar individuals, irregularities in the transport of
these ions cause neurons to fire too easily (resulting in mania) or to stubbornly resist
firing (resulting in depression) (Manji & Zarate, 2011; Li & El-Mallakh, 2004; Sassi &
Soares, 2002).
 Brain structure the basal ganglia and cerebellum of these individuals tend to be smaller
than those of other people, and their amygdala, hippocampus, and prefrontal cortex each
 have certain structural abnormalities. It is not clear, however, what role such structural
abnormalities may play in bipolar disorders.
 Genetic Factors Many theorists believe that people inherit a biological predisposition to
develop bipolar disorders (Glahn & Burdick, 2011; Gershon & Nurnberger, 1995).
Family pedigree studies support this idea. Identical twins of persons with a bipolar
disorder have a 40 percent likelihood of developing the same disorder, and fraternal
twins, siblings, and other close relatives of such persons have a 5 to 10 percent
likelihood, compared to the 1 to 2.6 percent prevalence rate in the general population.

Stress and Bipolar Disorder

The relationship of stressful events to the onset of episodes in bipolar disorder is also strong
(Alloy & Abramson, 2010; Ellicott, 1988; Goodwin & Jamison, 2007; Johnson, Gruber, &
Eisner, 2007; Johnson et al., 2008; ReillyHarrington, Alloy, Fresco, & Whitehouse, 1999).
However, several issues may be particularly relevant to the causes of bipolar disorders (Goodwin
& Ghaemi, 1998). First, typically negative stressful life events trigger depression, but a
somewhat different more positive set of stressful life events seems to trigger mania (Johnson et
al., 2008). Experience associated with striving to achieve important goals, such as getting
accepted into graduate school, obtaining a new job or promotion, or getting married, trigger
mania in vulnerable individuals. Second, stress seems to initially trigger mania and depression,
but as the disorder progresses, these episodes seem to develop a life of their own. In other words,
once the cycle begins, a psychological or pathophysiological process takes over and ensures the
disorder will continue (see, for example, Post, 1992; Post et al., 1989). Third, some precipitants
of manic episodes seem related to loss of sleep, as in the postpartum period (Goodwin &
Jamison, 2007; Harvey, 2008; Soreca et al., 2009) or as a result of jet lag—that is, disturbed
circadian rhythms. In most cases of bipolar disorder, nevertheless, stressful life events are
substantially indicated not only in provoking relapse but also in preventing recovery (Alloy,
Abramson, Urosevic, Bender, & Wagner, 2009; Johnson & Miller, 1997).
Treatement of bipolar disorder

When you get someone with bipolar disorder to start and

maintain healthy sleep patterns, it can be as potent as the right
medication.
Russ Federman, PhD

They may also benefit from family-focused therapy (FFT), a form of short-term therapy that
includes both them and their parents, partner, or other loved ones. This educates everyone about
common symptoms and how they cycle over time, early warning signs of new episodes, and how
to stop episodes from getting worse. Research shows this can help improve mood symptoms and
functioning.

I also encourage all my clients, especially my teens and young adults, to join a support group.
There’s still a lot of stigma associated with bipolar disorder. The truth is people who do not have
a lot of exposure to this disease do not understand it. It helps to meet and talk with others of a
similar age going through similar issues to find support.

Psychological treatment of bipolar disorder

More recently, psychological treatments have also been directed at psychosocial aspects of
bipolar disorder. In a new approach, Ellen Frank and her colleagues are testing a psychological
treatment that regulates circadian rhythms by helping patients regulate their eating and sleep
cycles and other daily schedules as well as cope more effectively with stressful life events,
particularly interpersonal issues (Frank et al., 2005; Frank et al., 1997; Frank et al., 1999). In an
evaluation of this approach, called interpersonal and social rhythm therapy (IPSRT), patients
receiving IPSRT survived longer without a new manic or depressive episode compared to
patients undergoing standard, intensive clinical management. Initial results with adolescents are
also promising (Hlastala, Kotler, McClellan, & McCauley, 2010). David Miklowitz and his
colleagues found that family tension is associated with relapse in bipolar disorder. Preliminary
studies indicate that treatments directed at helping families understand symptoms and develop
new coping skills and communication styles do change communication styles (Simoneau,
Miklowitz, Richards, Saleem, & George, 1999) and prevent relapse (Miklowitz, 2008; Miklowitz
& Goldstein, 1997). Miklowitz, George, Richards, Simoneau, and Suddath (2003) demonstrated
that their family-focused treatment combined with medication results in signifi cantly less
relapse 1 year following initiation of treatment than occurs in patients receiving crisis
management and medication over the same period . Specifi cally, only 35% of patients receiving
family therapy plus medication relapsed compared to 54% in the comparison group. Similarly,
family therapy patients averaged over a year and a half (73.5 weeks) before relapsing, signifi
cantly longer than the comparison group. Rea, Tompson, and Miklowitz (2003) compared this
approach to an individualized psychotherapy in which patients received the same number of
sessions over the same period and continued to find an advantage for the family therapy after 2
years. In another important study, Lam et al. (2003) and Lam, Hayward, Watkins, Wright, and
Sham (2005) showed that patients with bipolar disorders treated with cognitive therapy plus
medication relapsed signifi cantly less over both a 1-year follow-up and a 2-year followup
compared to a control group receiving just medication. Reilly-Harrington et al. (2007) found
some evidence that CBT is effective for bipolar patients with the rapid-cycling feature. In view
of the relative ineffectiveness of antidepressant medication for the depressive stage of bipolar
disorder reviewed above, Miklowitz et al. (2007) reported an important study showing that up to
30 sessions of an intensive psychological treatment was signifi cantly more effective than usual
and customary best treatment in promoting recovery from bipolar depression and remaining well.
The specifi city of this effect on bipolar depression, which is the most common stage of bipolar
disorder, combined with the lack of effectiveness of antidepressants, suggest that these
procedures will provide an important contribution to the comprehensive treatment of bipolar
disorder. Otto et al. (2008a, 2008b) have synthesized these evidence-based psychological
treatment procedures for bipolar disorder into a new treatment protocol.