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What is Bipolar Disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

Bipolar disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25.1  Some people have their first symptoms during childhood, while others may develop symptoms late in life.

Bipolar disorder is not easy to spot when it starts. The symptoms may seem like separate problems, not recognized as parts of a larger problem. Some people suffer for years before they are properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

How does bipolar disorder affect someone over time?

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

1. Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.

2. Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.

3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.

4. Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

Some people may be diagnosed with rapid-cycling bipolar disorder. This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.2 Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age. One study found that people with rapid cycling had their first episode about four years earlier, during mid to late teen years, than people without rapid cycling bipolar disorder.3 Rapid cycling affects more women than men.4

Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes than when the illness first appeared.5 Also, delays in getting the correct diagnosis and treatment make a person more likely to experience personal, social, and work-related problems.6

Proper diagnosis and treatment helps people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

What illnesses often co-exist with bipolar disorder?
Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear.7 Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs. However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder.8-10 Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.10, 11 These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Other illnesses can make it hard to diagnose and treat bipolar disorder. People with bipolar disorder should monitor their physical and mental health. If a symptom does not get better with treatment, they should tell their doctor.

What are the risk factors for bipolar disorder?
Scientists are learning about the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.

Genetics

Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the "building blocks" of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder.12 However, most children with a family history of bipolar disorder will not develop the illness.

Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:13

•  Missed work because of their illness
•  Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
•  Been treated or hospitalized for bipolar disorder.

The researchers also identified certain traits that appeared to run in families, including:

•  History of psychiatric hospitalization
•  Co-occurring obsessive-compulsive disorder (OCD)
•  Age at first manic episode
•  Number and frequency of manic episodes.

Scientists continue to study these traits, which may help them find the genes that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder.14, 15 Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain's structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia.16 This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Learning more about these differences, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Someday scientists may be able to predict which types of treatment will work most effectively. They may even find ways to prevent bipolar disorder.

Excerpts from National Institute of Mental Health, National Institute of Health
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Citations:
1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):593-602.
2. Akiskal HS. "Mood Disorders: Clinical Features." in Sadock BJ, Sadock VA (ed). (2005). Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins:Philadelphia.
3. Schneck CD, Miklowitz DJ, Miyahara S, Araga M, Wisniewski S, Gyulai L, Allen MH, Thase ME, Sachs GS. The prospective course of rapid-cycling bipolar disorder: findings from the STEP-BD. Am J Psychiatry. 2008 Mar;165(3):370-7; quiz 410.
4. Schneck CD, Miklowitz DJ, Calabrese JR, Allen MH, Thomas MR, Wisniewski SR, Miyahara S, Shelton MD, Ketter TA, Goldberg JF, Bowden CL, Sachs GS. Phenomenology of rapid-cycling bipolar disorder: data from the first 500 participants in the Systematic Treatment Enhancement Program. Am J Psychiatry. 2004 Oct;161(10):1902-1908.
5. Goodwin FK, Jamison KR. (2007) Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Second Edition. Oxford University Press:New York.
6. Constituency Survey: Living With Bipolar Disorder: How Far Have We Really Come? National Depressive and Manic-Depressive Association. 2001.
7. Bizzarri JV, Sbrana A, Rucci P, Ravani L, Massei GJ, Gonnelli C, Spagnolli S, Doria MR, Raimondi F, Endicott J, Dell'Osso L, Cassano GB. The spectrum of substance abuse in bipolar disorder: reasons for use, sensation seeking and substance sensitivity. Bipolar Disord. 2007 May;9(3):213-220.
8. Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher C, Vidaver R, Auciello P, Foy DW. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol. 1998 Jun;66(3):493-499.
9. Strakowski SM, Sax KW, McElroy SL, Keck PE, Jr., Hawkins JM, West SA. Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization. J Consult Clin Psychol. 1998 Sep;59(9):465-471.
10. Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med. 2005 Jan-Feb;67(1):1-8.
11. Kupfer DJ. The increasing medical burden in bipolar disorder. JAMA. 2005 May 25;293(20):2528-2530.
12. Nurnberger JI, Jr., Foroud T. Genetics of bipolar affective disorder. Curr Psychiatry Rep. 2000 Apr;2(2):147-157.
13. Potash JB, Toolan J, Steele J, Miller EB, Pearl J, Zandi PP, Schulze TG, Kassem L, Simpson SG, Lopez V, MacKinnon DF, McMahon FJ. The bipolar disorder phenome database: a resource for genetic studies. Am J Psychiatry. 2007 Aug;164(8):1229-1237.
14. Soares JC, Mann JJ. The functional neuroanatomy of mood disorders. J Psychiatr Res. 1997 Jul-Aug;31(4):393-432.
15. Soares JC, Mann JJ. The anatomy of mood disorders--review of structural neuroimaging studies. Biol Psychiatry. 1997 Jan 1;41(1):86-106.
16. Gogtay N, Ordonez A, Herman DH, Hayashi KM, Greenstein D, Vaituzis C, Lenane M, Clasen L, Sharp W, Giedd JN, Jung D, Nugent Iii TF, Toga AW, Leibenluft E, Thompson PM, Rapoport JL. Dynamic mapping of cortical development before and after the onset of pediatric bipolar illness. J Child Psychol Psychiatry. 2007 Sep;48(9):852-862.
 


Bipolar Self-Assessment Checklist

Find out if you may be suffering from Bipolar Depression.  Please complete the questions below to determine if you are a potential candidate for the newest Bipolar Depression medication research study with PRI and are eligible for additional screening at one of our PRI locations. 

In the boxes below, please indicate Yes, No or Not Applicable as appropriate.
 

Yes

No

Not Applicable
Are you at least 18 years of age? *    
Do you have a history of seizures or any seizure disorder? *    
Are you currently pregnant or nursing a baby? *  

In the below boxes, indicate if you experience these symptoms: Never, Occasionally, or Frequently.
 
Never
Occasionally
Frequently
You had much more energy than usual?
You felt much more self-confident than usual?
You were much more active and/or did many more things than usual?
You were much more talkative or spoke much faster than usual?
You got much less sleep than usual and found you didn't really miss it?
Thoughts raced through your head and you couldn't slow your mind?
You were so irritable that you shouted at people or started arguments?
You did things that were unusual for you or that other people might have thought were excessive, foolish, or risky behaviors?
You felt so good, or so hyper, that other people thought you were not your normal self, or you were so hyper that you got into trouble?

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Bipolar Disorder ~ Definitions, Descriptions and Options!
Nader Oskooilar, M.D., Ph.D., Medical Director, Pharmacology Research Institute [PRI]

Bipolar disorder, or manic-depressive illness, is a brain disorder which causes significant and often disturbing mood swings. They are different than the mood swings that everybody might go through and they can frequently lead to personal pain and suffering, as well as impairment in social, interpersonal, and professional life. Bipolar disorder, like most psychiatric disorders, can be considered a continuum, where numerous types of the disorder, with different intensities and durations, can be visualized. Depressive episodes can range from mild to severe; while the upswing of the mood may be significant (mania in Bipolar I) or moderate (hypomania in Bipolar II or in cyclothymia). Also, there can be what we sometimes categorize as “mixed episodes” (simultaneous mixtures of depressive and manic/Hypomanic symptoms). Additionally, the mood swings can be protracted, rapid, or ultrarapid. Psychotic symptoms such as delusions may also accompany the episodes, especially in mania and severe cases of depression.

Common depressive symptoms in bipolar disorder include sadness, crying spells, severe anxiety, hopelessness, lack of motivation, loss of libido, poor sleep, fatigue, diminished concentration, difficulty making decisions, and disrupted appetite. Manic symptoms consist of increased energy, a decreased need for sleep, unusual hopefulness-to-grandiosity, a racing mind, impulsive decisions, euphoric mood, poor judgment, agitation, and unrealistic plans to delusional thinking. In hypomania, manic symptoms are less severe and the person usually does not require hospitalization.

Bipolar disorder is very prevalent in general population and has significant genetic underpinnings. All forms of bipolar disorder have a combined prevalence of 3-6.5%; the more severe and classic bipolar I disorder 0.5 to 1.5%. First degree relatives of a bipolar patient are eight-to-eighteen times more likely to have some kind of bipolar disorder. The risk of bipolar disorder in a monozygotic (identical) pair, where one of them is afflicted with bipolar disorder, is 33-90%; sorry, that was a bit too technical-sounding! There is also more prevalence of other mood disorders (such as clinical depression) in the blood relatives of bipolar patients. Bipolar disorder has the highest risk of suicide of all psychiatric disorders, including depression and schizophrenia; close to 20% of patients attempt to commit suicide, at least once in their lifetime. In 50% of bipolar patients, the first episode of mood disturbance is depression.

Accurate and timely diagnosis of bipolar disorder is of utmost significance. Unfortunately, it is often several years, from the first episode of the illness, before the correct diagnosis is made. This is due to several likely reasons; among them, denial of the illness, poor access to treatment, misdiagnosis and the resulting mistreatment, and atypical presentation of the disorder. The presentation of bipolar disorder can be confused with the symptoms in unipolar depression, substance abuse, alcohol dependency, medical conditions (e.g., lupus and delirium), ADHD, primary psychoses (such as schizophrenia), and borderline personality disorder. It is important to realize, however, that bipolar disorder is not always a diagnosis of exclusion; it can coexist with medical, and other psychiatric conditions (such as ADHD, substance abuse, and anxiety disorders). As a matter of fact, untreated bipolar patients are more likely to develop additional psychiatric disorders than the treated patients. Needless to say, the earlier the correct diagnosis is made, and treatment initiated, the more favorable is the course and the prognosis of the illness.

Fortunately, there is an armament of medications (mostly manufactured or discovered in the last two decades) available to treat bipolar disorder. Some of these medicines are not officially approved by FDA for bipolar disorder; they are effective but have not been submitted to the FDA for approval. Unfortunately, a significant minority of the bipolar patients do not respond well to the existing medications. They either cannot tolerate the medications or, they have only partial response to medications. These limitations, plus the fact that the patients often lack medical insurance (or adequate coverage), deprives many patients from appropriate diagnosis and treatment. Consequently, the patients, along with their loved ones and the society at large, continue to suffer from their pain and impairment.

One small, yet very significant, solution for many of these patients is to enroll in one of the many clinical trials specifically for Bipolar Disorder. At Pharmacology Research Institute, we have ongoing clinical trials for various psychiatric conditions, usually including Bipolar Disorder. Any interested individual can be promptly scheduled for a psychiatric evaluation by a competent and experienced board-certified psychiatrist here at PRI. An individual seeking such (confidential, no-cost) consultations can usually be properly diagnosed and, if interested, familiarized with available, or soon to be available, clinical trial treatment options.

The goal is full and transparent discussion, including the pros and cons, of the participation in clinical studies. Participation is totally voluntary. Study participants do not incur any costs for participation and most studies have some type of reimbursement for the patient’s time and transportation. In addition, once the clinical trial is over (on the average, two to three months, though at times longer), the participant may receive up to three months of aftercare (free-of-charge, compliments of PRI), where the psychiatrist will see the patient on a regular basis and make sure that the patient is stabilized with conventional treatments (such as commercially available medications, usually provided for free or with nominal cost to the patient), before he/she is transferred/referred to an appropriate outpatient mental health clinic/professional. Yes Bipolar Disorder is serious, very serious; but, with proper diagnosis, treatment and compliance, one’s quality of life can be very good!