Summary of the problem
Bipolar disorder is classified into four distinct categories: bipolar I disorder, bipolar II disorder, bipolar disorder not otherwise classified and cyclothymic disorder. To understand the classification system, it is important to understand the different kinds of episodes that make up a particular diagnosis.
Bipolar I Disorder
Bipolar I disorder is characterized by at least one manic or mixed episode with or without a history of a major depressive episode. About 1% of the adults in the United States have the diagnosis of bipolar I disorder. However, because of the difficulty in diagnosing the condition, many people wait several years before an accurate diagnosis is made. People who have bipolar I disorder have discrete periods of time when they their mood is elevated, or irritable. They may also be so hyper that they are not acting like themselves, or others maybe concerned by their level of activity. They may or may not have all of the following symptoms as well:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
When someone has had three (if mood is euphoric) or four (if mood is irritable) of the above symptoms for at least a week, and has functional impairment, they are said to have had a manic episode. Symptoms do not always have to last a week to meet criteria for a manic episode. If someone has hospitalized or comes to the attention of law enforcement because of manic symptoms, the duration of the symptoms can be less than one week and still meet criteria for a manic episode. People with bipolar I disorder generally have both manic and depressive episodes. About 10% have only manic episodes.
Depressive Episodes
A major depressive episode is characterized by either or both depressed mood, and/or lack of interest in previously pleasurable activities. Symptoms should last at least most of the day, nearly every day, for a two week period and are distinctly different from normal mood and functioning. In addition, a person also has at least three (if both depressed mood and lack of interest are present) or four (if only one of the two core symptoms is present) of the following symptoms:
- Problems with decreased or increased weight. Similarly, decreased or increased appetite compared to when well.
- Problems with sleep, either less (insomnia) or more (hypersomnia) than when well.
- Difficulty concentrating, thinking or problems making decisions
- Psychomotor retardation (not just feeling slowed down, but also appearing slowed down to others), or psychomotor agitation (appearing restless)
- Feelings of guilt or worthlessness
- Decreased energy
- Frequent thoughts of death or suicide. Thoughts can be with or without plans or intentions. Or a suicide attempt
Mixed Episodes
Mixed episodes occur when someone has symptoms that meet criteria for both manic and depressive episodes at the same time. For example, someone experiencing a mixed episode may feel irritable, have a decreased need for sleep, and racing thoughts, be easily distracted and impulsive. However, they may at the same time feel depressed, have no desire to do anything, have a suppressed appetite, feel fatigued during the day, and have thoughts of wanting to end their lives.
Bipolar II Disorder
Bipolar II disorder requires that someone have at least one hypomanic and one major depressive episode. Hypomanic episodes are ones in which people may experience less severity, number and duration of manic symptoms. Symptoms last at least four days, but do not cause functional impairment. They are, however, distinctly different from the normal mood and functioning. If at any time in their life some meets criteria for a full manic or mixed episode, they are considered to have bipolar I disorder. Bipolar II disorder effects another 3-4% of the United States population. Although seemingly less symptomatic than bipolar I disorder, there is evidence that bipolar II disorder has a higher suicide rate.
Bipolar Disorder Not Otherwise Specified (BP-NOS)
Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when someone does not meet criteria for either bipolar I or II disorder yet still have some symptoms. The number, duration or severity of symptoms may not qualify for a diagnosis of bipolar I or II. However, the person is clearly experiencing distinct mood episodes that are different from their normal level of functioning or mood.
Cyclothymic Disorder, or Cyclothymia
Cyclothymia is a milder form of bipolar disorder. A person with cyclothymia may shift back an from between episodes of hypomania and mild depression of a period of at least two years. However, the symptoms do not meet requirements for any other type of bipolar disorder.
What Causes Bipolar Disorder?
Both genetic and environmental factors can influence the occurrence and severity of bipolar disorder. An individual is at more risk to develop the disorder in their lifetimes if one or both of his or her parents have bipolar disorder. Environmental factors that can contribute to and exacerbate the condition include drugs and alcohol, sleep deprivation, stressors such as divorce, the death of a love one, trauma, and job loss.
How is Bipolar Disorder Diagnosed?
There is no one specific lab test or physical finding that determines the diagnosis of bipolar disorder. The diagnosis is made by careful evaluation by a doctor or mental health professional after an extensive diagnostic work up that may include gathering information about the patient’s current episodes, past medical and psychiatric history, social and family histories. Often times, patients with bipolar disorder do not recall the severity or duration of their manic symptoms. Getting input from family members or close friends should be an integral part of the diagnositic process. In addition, laboratory work up maybe necessary to rule out other medical conditions that can mimick the symptoms of mania or depression.
Bipolar disorder often develops in a person’s late teens or early adult years. However, symptoms may arise in childhood or later on in life.
Rarely, mania or depression may be very severe and include psychotic symptoms such as hallucinations or delusions. The psychotic symptoms tend to reflect the person’s mood. For example, a person experiencing severe depressive symptoms may also be convinced that he or she has done something very bad or committed a crime. On the other hand psychotic symptoms for a person having a manic episode may include believing he or she is famous, or has special powers. Consequently, people with bipolar disorder who have psychotic symptoms are sometimes misdiagnosed as having schizophrenia.
What Treatment Options Are Available for Bipolar Disorder?
There are several medications that are approved by the Food and Drug Administration (FDA) for the treatment of manic, depressive or mixed episodes of bipolar disorder (see below). More medication options are available for the treatment of mania than for depression. Sometimes the medications that we may use to treat depression may result in worsening of manic symptoms. Thus treating depression in bipolar disorder can be a fine balancing act where we want to eliminate the symptoms of depression but prevent the occurrence of mania. Your doctor should provide you information about treatment options, the benefits and risks involved with medications or other treatments for both manic and depressive symptoms.
In addition to medication management, psychotherapy should be an integral part of the management for bipolar disorder. Psychotherapy should include strategies to lessen stress and other triggers for mood episodes. It should be noted that bipolar disorder is an illness in which balance in one’s life is essential to keeping mental health. Lifestyle choices such as drug and alcohol consumption, regular exercise, sleep and meals should be addressed. Since people with bipolar disorder often have symptoms that affect not just their well-being but also the lives of family members, it is often important to include close family members, like a spouse or parent, in treatment considerations and monitoring of the course of this illness. In addition, many people who experience a manic episode do not recall the episode well (this is not due to denial) and often find the objective observations of loved ones useful.
FDA Approved Medications for Mania:
- Aripiprazole
- Carbamazepine
- Chlorpromazine
- Divalproex
- Lithium
- Olanzapine
- Quetiapine
- Risperidone
- Ziprasidone
FDA Approved Medication for Depression
- Olanzaoine-Fluoxetine combination
- Quetiapine
FDA Approved Medications for Preventing Recurrence
- Lithium
- Lamotrigine
- Olanzapine
- Aripiprazole
Resources:
Doing a mood chart on a daily basis can be helpful for several reasons:
- Allows one to prospectively monitor moods in the face of stressors one may experience. Retrospectively reporting usually has errors.
- Objectively monitoring factors that may contribute to manic or depressive symptoms, such as poor sleep or use of drugs and alcohol. This in turn may guide the individual to avoid triggers or do more of something that is beneficial to their mood.
- Establishing for individual what is normal (euthymic) mood versus a low or high mood. Often times, patients with bipolar disorder have difficulty recalling “when I last felt well.” They may experience rapid cycling, in which they may have four or more mood episodes in a year. Mood charting helps establish what is normal for the individual.
Listed below is a link for a monthly calendar you can use to monitor your mood:
At Fairfax Mental Health, our psychiatrists treat this and other conditions. Call us at 703-830-1500 to discuss your needs or schedule an appointment.
