Bipolar Disorder – Diagnosis, Symptoms, and Treatment

What is Bipolar Disorder?

Bipolar disorder is a psychiatric condition characterized by episodes of mania or hypomania and depression.  The disease is most commonly seen in individuals age 18-20.  Depression is typically the mood at the onset of the disorder.  Major depression is characterized by low mood, impaired sleep, appetite changes, weight changes, low energy, and abnormal concentration.  Mania is typically described as episodes of heightened or elevated mood, grandiose thoughts, nights with little sleep, pressured speech, and participation in risky behaviors.  Hypomania is a milder form of mania.

A significant portion of patients with bipolar disorder have another underlying psychiatric diagnosis, such as drug dependence and schizophrenia.  One of the most dreadful complications of the disease is suicide.

What Causes Bipolar Disorder?

The etiology of bipolar disorder is not entirely clear but involves an interplay between genetic factors, abnormal brain structure and function, and psychosocial factors.  The condition frequently runs in first-degree relatives and other close family members.  Stressful life events may include mistreatment during childhood or other trauma (e.g., military combat).

Bipolar disorder is frequently associated with other psychiatric features such as psychosis, delusions, and hallucinations.  Many patients also have a coexisting psychiatric diagnosis, such as:

• Anxiety disorder
• Drug dependence
• Attention deficit hyperactivity disorder (ADHD)

How Common is Bipolar Disorder?

Bipolar disorder is a relatively common psychiatric disorder that is most often managed by a psychiatry specialist.  Worldwide, the lifetime prevalence of the bipolar disease is approximately 1%-3%.  Men and women are equally affected.  Most patients are diagnosed around age 18-20.

In the United States, the lifetime prevalence of the bipolar disorder is about 1%.  Bipolar disorder is considered the 18th leading cause of disability.

Signs and Symptoms

Bipolar disorder is characterized by episodes of mania or hypomania and major depression.  Patients typically start with major depression, which frequently includes the following features:

• Depressed or low mood
• Changes in appetite
• Weight loss or gain
• Impaired sleep
• Low energy
• Impaired concentration
• Loss of interest in normal hobbies or activities (anhedonia)
• Feeling guilty
• Thoughts of suicide

In contrast, features of mania often include:

• Abnormally elevated mood (euphoria)
• Irritability
• Labile mood
• Grandiosity - exaggerated sense of self-confidence
• Disinhibition - neglect of social boundaries

Individuals with mania may pursue stimulation and activities such as flirting or renewing old relationships.  They may go several nights without getting significant sleep – they often participate in risky behaviors during this time, such as gambling or prostitution.

Hypomania is a milder form of mania that has no psychotic features and does not require hospitalization.

Diagnosis

The diagnosis of bipolar disorder is based on symptoms and physical examination findings.  Your doctor may order laboratory tests to rule out metabolic disorders that could mimic bipolar disease.  Commonly requested blood tests include a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and thyroid function (TSH, free T4).  Your doctor may also obtain a urine drug screen.

Specific criteria must typically be met according to the guidelines of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.  Bipolar disorder is categorized into two subtypes: bipolar I and bipolar II.  Bipolar I results in manic episodes with or without major depression and hypomania.  Bipolar II disorder is characterized by either hypomanic or major depressive episodes, but mania is typically absent.

The symptoms should not be caused by using a medication or being attributed to another medical or psychiatric condition.  Furthermore, symptoms generally occur on most days of the week for a sustained period.  By definition, bipolar disorder interferes with a person’s ability to function socially or work.

Patients who are being considered for treatment typically require an EKG (electrocardiogram) before initiation of therapy.  Lithium and antipsychotics may result in electrical abnormalities in the heart – therefore, some patients are precluded from the treatment due to underlying cardiac disease.

Bipolar Medications and Treatment

Bipolar disorder is typically treated with one or more of the following classes of medications:

• Lithobid (lithium)
• Anticonvulsants
  • Depakote (valproate)
  • Lamictal (lamotrigine)
• Antipsychotics
  • Abilify (aripiprazole)
  • Haldol (haloperidol)
  • Zyprexa (olanzapine)
  • Seroquel (quetiapine)
  • Risperdal (risperidone)
• Benzodiazepines
  • Ativan (lorazepam)
  • Xanax (alprazolam)
  • Klonopin (clonazepam)
  • Valium (diazepam)

Patients are regularly monitored for response to therapy and potential side effects of treatment.  Those taking long-term antipsychotic drugs are typically evaluated for movement abnormalities (extrapyramidal symptoms) such as akathisia, dystonia, and tardive dyskinesia.

References:

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013. - https://www.psychiatry.org/psychiatrists/practice/dsm
2. Grunze H, Vieta E, Goodwin GM, et al. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania. World J Biol Psychiatry 2009; 10:85. - https://www.ncbi.nlm.nih.gov/pubmed/19347775