Bipolar disorder, also known as manic depression, is a mood disorder, characterised by extreme shifts in mood, energy and functioning. More recently this term is also used to include the more subtle variants of the disorder, called the soft bipolar spectrum disorders. Bipolar disorder Type I is much less common than Major Depressive disorder, with 1% of the general population affected over time. Males and females are affected equally. The incidence of the soft bipolar spectrum disorders have not been established yet but it might be as high as 6% of the general population. It is also still unclear what the sex ratio of this disorder is.
As a group, the bipolar disorders entail episodes of depression as well as episodes of mania/euphoria or hypomania. The switches between these two states may be fairly sudden and dramatic, but are more commonly gradual in onset. Both mood states may occur at the same time. This is called a mixed episode.
Bipolar disorder tends to be a chronic, recurring condition and is generally considered to have a poorer long-term outcome than Major Depressive Disorder.
During a manic (“high”) episode a person displays behaviour that is out of character. He/she may be “overly” happy and/or highly irritable, have boundless energy, go for days without sleeping and lose their inhibitions in social settings. People with mania may develop unrealistic beliefs in their capabilities that may impair their judgement, the result of which is engagement in foolish activities or projects which often lead them into financial or other difficulties. As a manic episode develops, there may be an increase in the use of alcohol or stimulants, which may aggravate or prolong the episode. Typically a manic person denies that there is anything wrong or unusual with him/her. The changes in mood and behaviour are observable by others who know the person well.
During a hypomanic episode similar symptoms are present but only in a more subtle form. This sometimes makes it difficult to recognize and therefore contributes to the diagnosis being missed.
During the “low” phase the person is depressed, lacks energy and struggles to enjoy activities, which were previously enjoyable. In contrast to the classic unipolar form of depression, a person tends to sleep more and have an increased appetite with possible weight gain.
Some people can experience symptoms of depression and mania at the same time. This is called “black mania” or a mixed episode.
Each of the different phases of the disorder can disrupt the person’s work, school, family and social life. As such it can be very disabling, but if treated appropriately, it responds well. Treatment can help prevent future episodes.
Signs and symptoms of mania include:
Abnormally “high”, euphoric mood
Anger and/or aggression
Increased energy, activity and restlessness
Inflated self esteem and self confidence, feeling superior to others
Decreased need for sleep
More talkative than usual and talking rapidly and loudly
Racing thoughts or jumping from one idea to another, making it difficult for others to follow
Distractibility and difficulty concentrating
Increase in goal-directed activity
Excessive involvement in pleasurable activities that can have painful consequences (such as spending sprees or sexual indiscretions)
Abuse of drugs and alcohol
Denial that anything is wrong
Signs and symptoms of depression include:
Loss of interest or pleasure in activities previously enjoyed
Feelings of guilt, despair and worthlessness
Change in sleeping pattern – more commonly sleeping to much (hypersomnia)
Loss of energy
Change in appetite more commonly an increase in appetite resulting in weight gain
Difficulty concentrating and remembering
Restlessness or irritability
Thoughts of death or suicide
Some people may have psychotic symptoms during severe episodes of mania and depression. Common symptoms are delusions (false, strongly held beliefs that are not influenced by logical reasoning) and hallucinations (hearing, seeing or otherwise sensing things that are not there). These symptoms tend to reflect the mood state at the time. For example, during a manic phase a person may believe that he is the president or has special powers. Delusions of guilt or worthlessness may appear during depression.
As mentioned, the symptoms of hypomania are similar to that of a manic episode but less severe. Psychotic symptoms are not present and hospitalization is usually not needed. There is also less overall impairment of functioning. It may even be associated with good functioning and enhanced productivity.
There are four main types of bipolar disorder.
The person involved has one or more depressive episodes with at least one manic or mixed episode.
The person has one or more depressive episodes with at least one hypomanic episode. When four or more episodes of illness occur within a year, the person is said to have bipolar disorder with rapid cycling.
This is characterised by chronic fluctuating moods, involving periods of hypomania and depression. The depressive episode is not severe enough to meet the criteria for MDE. This is often considered a personality type.
Bipolar disorder NOS
This is an older term used to describe variants of bipolar disorder that do not meet the criteria for any of the abovementioned conditions. However, in the modern view of bipolar disorder this would constitute all the variants of what is now known as the soft bipolar spectrum.
Who suffers from bipolar disorder?
Although it is less common than Major depressive disorder, bipolar disorder is probably more common than previously thought. Approximately 1% of the population suffers from Bipolar I disorder. It is however suspected that the lifetime prevalence of the bipolar spectrum disorders (including bipolar disorder type II) can be as high as 6%.
In contrast to Major depressive disorder, bipolar disorder has an earlier onset. The onset is often before the age of 20, but may even start in early childhood, when it is often confused with ADHD. If the onset is after the age of fifty, it is usually due to another medical condition, such as multiple sclerosis or the effect of drugs, alcohol or steroids.
There is no single cause. The disorder tends to run in families, which suggests that there is a genetic link. In people predisposed to the disorder, the onset can be triggered by stressful life events, the use/abuse of drugs and/or prescription medication, including antidepressants and steroids.
An imbalance in various neurotransmitters (chemicals by which the brain cells communicate) may also be involved. There may also be disturbances in the production or release of certain hormones within the brain that contribute to causing bipolar disorder.
Bipolar disorder is a lifelong condition. Bipolar I disorder is generally considered to have a poorer long-term outcome than Major Depressive Disorder. The reasons for this are unclear but may be a result of poor compliance with medical treatment. Bipolar II disorder and the soft bipolar spectrum disorders have a better outcome
The course varies from person to person. Bipolar disorder can start with major depression or a manic episode. Manic episodes usually begin suddenly with a rapid escalation of symptoms over a few days. They tend to be shorter and end more abruptly than depressive episodes. It is important to note that over a lifetime patients with bipolar mood disorder have a much higher likelihood of suffering from a depressive episode than from a hypomanic/manic episode. For some there may be long symptom-free periods between episodes. Episodes have been described to last for days, weeks or months. However, more recent research suggests that some individuals may experience several switches in mood state within one day. The average person with bipolar I disorder has four episodes (manic or depressed) during the first ten years of the illness. A minority of people may have several episodes of mania and depression with only brief periods of normal moods in between.
If properly controlled by medication, a person can lead a full, productive life. If left untreated, moods will continue to swing from one extreme to another and cause severe impairment in functioning. The time period between episodes usually narrows and episodes become more severe. In such cases, suicide is a real danger, especially if the person abuses substances and/or suffers from anxiety.
There is no diagnostic test. In order to make a diagnosis, an evaluation by a psychiatrist, who will take a detailed history and thoroughly assess symptoms, is essential.
It is very useful to get feedback from close family and friends, as a person with this disorder often lacks insight into his/her condition. They will often deny that anything is wrong and resist efforts to be treated. This resistance can often delay diagnosis and effective treatment.
Substance abuse or medical conditions such as thyroid problems can mimic bipolar disorder. These need to be ruled out and effectively treated.
There is no cure for bipolar disorder, but it responds well to treatment. It is a recurrent, lifelong illness. People suffering from bipolar disorder need long-term psychiatric care to monitor medication, enhance treatment compliance and prevent future episodes. A combination of medication and psychotherapy is optimal.
Treatment aims are to:
Effectively treat whatever the current (acute) episode is (mania, hypomania or depression)
Effectively reduce the risk and severity of further episodes with maintenance treatment and support
Vigilance is the key to preventing relapse. If early symptoms are reported to the doctor when first noticed, adjustments can be made to the treatment plan in order to prevent a “full-blown” episode.
In the maintenance phase, support is needed to continue the use of medication to prevent future episodes. This is often difficult as people feel so much better during these periods.
Medication - Manic episode
In the first instance a good assessment is essential. Medical conditions or drug intoxication need to be excluded before the diagnosis of a manic episode can be made. Commonly an acute episode of mania will require a period of hospitalisation.
Mood stabilizers are the mainstay of the medical treatment. Various drugs have mood stabilizing action. These include Lithium, some drugs used to treat epilepsy (anticonvulsants) and certain antipsychotics. Lithium remains the gold standard for an acute manic episode. As an alternative, the first line option from the anticonvulsant group is Valproate (Epilim), and from the antipsychotic group, Olanzepine (Zyprexa). In episodes where psychotic symptoms are present, antipsychotics are invariably prescribed until symptoms have subsided. Combinations of 2 or more mood stabilisers are commonly used
Benzodiazepines (tranquillisers) may be prescribed to manage agitation, psychosis or dangerous behaviour, while waiting for a mood stabiliser to take effect.
The depressive phase of bipolar disorder in general does not respond well to anti-depressants when used as a single agent. Moreover, when used without a mood stabilizing drug, antidepressants can trigger a manic or mixed episode. Therefore the first line treatment for a depressive episode remains a mood stabiliser. Anticonvulsants such as Lamotrigine (lamicitn) or antipsychotics such as Quetiapine (seroquel) are used in this context. When antidepressants are used, they are prescribed in conjunction with a mood stabiliser.
Electroconvulsive therapy (ECT)
ECT is a safe and effective treatment for both mania and depression. This is generally reserved for people in hospital and, as such, for more severe episodes.
Acute episodes represent only brief periods in the life of most people with bipolar disorder. To lengthen the time between episodes and minimise the effects of further episodes, the continued use of mood stabilising medication (maintenance therapy) is essential. This may be difficult, as maintenance therapy is needed in periods when people feel well. In this phase, people with bipolar disorder need ongoing psychotherapy to assist with understanding the risks of the illness and minimise early discontinuation.
Patients on lithium need regular blood tests to make sure that there is enough lithium in the body for it to work, but not too much which can be harmful and lead to serious side-effects. This monitoring is done in routine follow-up with a psychiatrist.
As bipolar disorder disrupts a person’s life and relationships, psychotherapy can help people regain control and re-establish relationships with others. Support should extend to the family and support structures to help all involved to come to terms with the illness. This also aims to help to motivate people for better treatment compliance.
Support groups offer a valuable opportunity to people to meet other people with bipolar disorder and to learn more about the disorder and how to live with it. The Western Cape Bipolar Association can be contacted for a list of support groups in the country. Visit their website at www.bipolar.co.za.
Previously reviewed by Dr Paul Carey, MRC Research Fellow
Reviewed by Dr Stefanie van Vuuren, Psychiatrist, MB ChB (Stell), M Med (Psig) (Stell), FC (Psych)SA, November 2010