Bipolar disorder

Bipolar disorder also called bipolar affective disorder, previously known as manic depression or manic-depressive illness, is a serious mental illness that affects your moods, which can swing from one extreme to another ¹. People with bipolar disorder go through unusual mood changes. Sometimes they feel very happy and “up,” and are much more energetic and active than usual. This is called a manic episode. Sometimes people with bipolar disorder feel very sad and “down,” have low energy, and are much less active. This is called depression or a depressive episode. Symptoms of bipolar disorder depend on which mood you’re experiencing. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer).

If you have bipolar disorder, you may have episodes of depression more regularly than episodes of mania, or vice versa. Between episodes of depression and mania, you may sometimes have periods where you have a “normal” mood. During manic episodes, changes in mood are not so severe that they cause problems with functioning at work or socially.

The patterns are not always the same and some people may experience:

• rapid cycling – where a person with bipolar disorder repeatedly swings from a high to a low phase quickly without having a “normal” period in between. Some people with bipolar disorder develop “rapid cycling” where they experience four or more episodes of mania or depression within a 12-month period. Mood swings can occur very quickly, like a rollercoaster randomly moving from high to low and back again over a period of days or even hours. Rapid cycling can leave you feeling dangerously out of control and most commonly occurs if your bipolar disorder symptoms are not being adequately treated.
• mixed state – where a person with bipolar disorder experiences symptoms of depression and mania together; for example, overactivity with a depressed mood

If your mood swings last a long time but are not severe enough to be classed as bipolar disorder, you may be diagnosed with a mild form of bipolar disorder called cyclothymia (also called cyclothymic disorder).

Anyone can develop bipolar disorder. It often starts in a person’s late teen or early adult years. But children and older adults can have bipolar disorder too. The illness usually lasts a lifetime.

Symptoms of bipolar disorder depend on which mood you’re experiencing. Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even longer), and some people may not experience a “normal” mood very often.

People who have it go through unusual mood changes. They go from very happy, “up,” and active to very sad and hopeless, “down,” and inactive, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

The causes of bipolar disorder aren’t always clear. It runs in families. Abnormal brain structure and function may also play a role.

Bipolar disorder often starts in a person’s late teen or early adult years. But children and adults can have bipolar disorder too. The illness usually lasts a lifetime.

If you think you may have it, tell your health care provider. A medical checkup can rule out other illnesses that might cause your mood changes.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy). If not treated, bipolar disorder can lead to damaged relationships, poor job or school performance, and even suicide.

Most people with bipolar disorder are initially prescribed medications to stabilize the mood extremes. These medications are tailored to the individual needs of the person with bipolar disorder, and might include mood stabilizers and/or antipsychotics. Electroconvulsive therapy (ECT) is sometimes recommended by psychiatrists in circumstances where people don’t respond to other acute treatments for their mood episodes.

The goal of treatment is to prevent a relapse from happening, build resilience and help to improve quality of life. This may involve one or more of the following medications:

• antidepressants — may be given for short period of time and its important that they only be taken in combination with a mood stabilizer for people with bipolar disorders
• lithium, a common long-term mood stabilizer
• anticonvulsants such as sodium valproate, carbamazepine and lamotrigine
• antipsychotic medicines such as olanzapine, aripiprazole, quetiapine and risperidone

To manage bipolar disorder properly, it’s important to take your medication as directed. Tell your doctor if you’re concerned about any side effects. Your doctor may be able to change your treatment or suggest ways to manage the problem.

Psychological therapies or ‘talking therapies’ such as psychotherapy, cognitive behavioral therapy (CBT) and counseling can help to manage bipolar disorder alongside medications. These therapies can help to reduce the risk of relapse and improve quality of life. You learn how to think and respond to events in your life and to cope with stresses that have triggered episodes in the past.

Who’s affected with bipolar disorder?

Bipolar disorder is fairly common and one in every 100 adults will be diagnosed with the condition at some point in their life.

Bipolar disorder can occur at any age, although it often develops between the ages of 15 and 19 and rarely develops after 40. Men and women from all backgrounds are equally likely to develop bipolar disorder.

The pattern of mood swings in bipolar disorder varies widely between people. For example, some people only have a couple of bipolar episodes in their lifetime and are stable in between, while others have many episodes.

Can someone have bipolar disorder along with other problems?

Yes. Sometimes people having very strong mood episodes may have psychotic symptoms. Psychosis affects thoughts and emotions as well as a person’s ability to know what is real and what is not. People with mania and psychotic symptoms may believe they are rich and famous, or have special powers. People with depression and psychotic symptoms may believe they have committed a crime, they have lost all of their money, or that their lives are ruined in some other way.

Sometimes behavior problems go along with mood episodes. A person may drink too much or take drugs. Some people take a lot of risks, like spending too much money or having reckless sex. These problems can damage lives and hurt relationships. Some people with bipolar disorder have trouble keeping a job or doing well in school.

Types of bipolar disorder

There are four basic types of bipolar disorder; all of them involve clear changes in mood, energy, and activity levels ². These moods range from periods of extremely “up,” elated, and energized behavior (known as manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

Bipolar 1 disorder

Bipolar 1 Disorder is defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible.

During a manic episode, individuals often do not perceive that they are ill or in need of treatment and vehemently resist efforts to be treated. Individuals may change their dress, makeup, or personal appearance to a more sexually suggestive or flamboyant style. Some perceive a sharper sense of smell, hearing, or vision. Gambling and antisocial behaviors may accompany the manic episode. Some individuals may become hostile and physically threatening to others and, when delusional, may become physically assaultive or suicidal. Catastrophic consequences of a manic episode (e.g., involuntary hospitalization, difficulties with the law, serious financial difficulties) often result from poor judgment, loss of insight, and hyperactivity.

Mood may shift very rapidly to anger or depression. Depressive symptoms may occur during a manic episode and, if present, may last moments, hours, or, more rarely, days (“with mixed features” specifier).

Mean age at onset of the first manic, hypomanic, or major depressive episode is approximately 18 years for bipolar 1 disorder. Special considerations are necessary to detect the diagnosis in children. Since children of the same chronological age may be at different developmental stages, it is difficult to define with precision what is ”normal” or “expected” at any given point. Therefore, each child should be judged according to his or her own baseline. Onset occurs throughout the life cycle, including first onsets in the 60s or 70s. Onset of manic symptoms (e.g., sexual or social disinhibition) in late mid-life or late-life should prompt consideration of medical conditions (e.g., frontotemporal neurocognitive disorder) and of substance ingestion or withdrawal.

More than 90% of individuals who have a single manic episode go on to have recurrent mood episodes. Approximately 60% of manic episodes occur immediately before a major depressive episode. Individuals with bipolar 1 disorder who have multiple (four or more) mood episodes (major depressive, manic, or hypomanic) within 1 year receive the specifier “with rapid cycling.”

Females are more likely to experience rapid cycling and mixed states, and to have patterns of comorbidity that differ from those of males, including higher rates of lifetime eating disorders. Females with bipolar 1 or 2 disorder are more likely to experience depressive symptoms than males. They also have a higher lifetime risk of alcohol use disorder than are males and a much greater likelihood of alcohol use disorder than do females in the general population.

Suicide risk

The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. In fact, bipolar disorder may account for one-quarter of all completed suicides. A past history of suicide attempt and percent days spent depressed in the past year are associated with greater risk of suicide attempts or completions.

Functional consequences of bipolar 1 disorder

Although many individuals with bipolar disorder return to a fully functional level between episodes, approximately 30% show severe impairment in work role function. Functional recovery lags substantially behind recovery from symptoms, especially with respect to occupational recovery, resulting in lower socioeconomic status despite equivalent levels of education when compared with the general population. Individuals with bipolar 1 disorder perform more poorly than healthy individuals on cognitive tests. Cognitive impairments may contribute to vocational and interpersonal difficulties and persist through the lifespan, even during euthymic periods.

Comorbidity

Co-occurring mental disorders are common, with the most frequent disorders being any anxiety disorder (e.g., panic attacks, social anxiety disorder [social phobia], specific phobia), occurring in approximately three-fourths of individuals; ADHD, any disruptive, impulse-control, or conduct disorder (e.g., intermittent explosive disorder, oppositional defiant disorder, conduct disorder), and any substance use disorder (e.g., alcohol use disorder) occur in over half of individuals with bipolar 1 disorder. Adults with bipolar 1 disorder have high rates of serious and/or untreated co-occurring medical conditions. Metabolic syndrome and migraine are more common among individuals with bipolar disorder than in the general population. More than half of individuals whose symptoms meet criteria for bipolar disorder have an alcohol use disorder, and those with both disorders are at greater risk for suicide attempt.

Bipolar 2 disorder

Bipolar 2 disorder is defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes described above. Bipolar 2 disorder is not a milder form of bipolar 1 disorder, but a separate diagnosis. While the manic episodes of bipolar 1 disorder can be severe and dangerous, individuals with bipolar 2 disorder can be depressed for longer periods, which can cause significant impairment.

A common feature of bipolar 2 disorder is impulsivity, which can contribute to suicide attempts and substance use disorders. Impulsivity may also stem from a concurrent personality disorder, substance use disorder, anxiety disorder, another mental disorder, or a medical condition. There may be heightened levels of creativity in some individuals with a bipolar disorder. However, that relationship may be nonlinear; that is, greater lifetime creative accomplishments have been associated with milder forms of bipolar disorder, and higher creativity has been found in unaffected family members. The individual’s attachment to heightened creativity during hypomanic episodes may contribute to ambivalence about seeking treatment or undermine adherence to treatment.

Although bipolar 2 disorder can begin in late adolescence and throughout adulthood, average age at onset is the mid-20s, which is slightly later than for bipolar 1 disorder but earlier than for major depressive disorder. The illness most often begins with a depressive episode and is not recognized as bipolar 2 disorder until a hypomanic episode occurs; this happens in about 12% of individuals with the initial diagnosis of major depressive disorder. Anxiety, substance use, or eating disorders may also precede the diagnosis, complicating its detection. Many individuals experience several episodes of major depression prior to the first recognized hypomanic episode.

The number of lifetime episodes (both hypomanic and major depressive episodes) tends to be higher for bipolar 2 disorder than for major depressive disorder or bipolar 1 disorder. However, individuals with bipolar 1 disorder are actually more likely to experience hypomanic symptoms than are individuals with bipolar 2 disorder. The interval between mood episodes in the course of bipolar 2 disorder tends to decrease as the individual ages. While the hypomanic episode is the feature that defines bipolar 2 disorder, depressive episodes are more enduring and disabling over time. Despite the predominance of depression, once a hypomanic episode has occurred, the diagnosis becomes bipolar 2 disorder and never reverts to major depressive disorder.

Approximately 5%-15% of individuals with bipolar 2 disorder have multiple (four or more) mood episodes (hypomanic or major depressive) within the previous 12 months. If this pattern is present, it is noted by the specifier “with rapid cycling.” By definition, psychotic symptoms do not occur in hypomanic episodes, and they appear to be less frequent in the major depressive episodes in bipolar 2 disorder than in those of bipolar 1 disorder.

Switching from a depressive episode to a manic or hypomanic episode (with or without mixed features) may occur, both spontaneously and during treatment for depression. About 5%-15% of individuals with bipolar 2 disorder will ultimately develop a manic episode, which changes the diagnosis to bipolar 1 disorder, regardless of subsequent course.

Making the diagnosis in children is often a challenge, especially in those with irritability and hyperarousal that is nonepisodic (i.e., lacks the well-demarcated periods of altered mood). Nonepisodic irritability in youth is associated with an elevated risk for anxiety disorders and major depressive disorder, but not bipolar disorder, in adulthood. Persistently irritable youths have lower familial rates of bipolar disorder than do youths who have bipolar disorder. For a hypomanic episode to be diagnosed, the child’s symptoms must exceed what is expected in a given environment and culture for the child’s developmental stage. Compared with adult onset of bipolar 2 disorder, childhood or adolescent onset of the disorder may be associated with a more severe lifetime course. The 3-year incidence rate of first-onset bipolar 2 disorder in adults older than 60 years is 0.34%. However, distinguishing individuals older than 60 years with bipolar 2 disorder by late versus early age at onset does not appear to have any clinical utility.

Comorbidity

Bipolar 2 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 2 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 2 disorder have a higher rate of co-occurring anxiety disorders compared with those with bipolar 1 disorder, and the anxiety disorder most often predates the bipolar disorder. Anxiety and substance use disorders occur in individuals with bipolar 2 disorder at a higher rate than in the general population. Approximately 14% of individuals with bipolar 2 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.

Suicide risk

Suicide risk is high in bipolar 2 disorder. Approximately one-third of individuals with bipolar 2 disorder report a lifetime history of suicide attempt. The prevalence rates of lifetime attempted suicide in bipolar 2 and bipolar 1 disorder appear to be similar (32.4% and 36.3%, respectively). However, the lethality of attempts, as defined by a lower ratio of attempts to completed suicides, may be higher in individuals with bipolar 2 disorder compared with individuals with bipolar 1 disorder. There may be an association between genetic markers and increased risk for suicidal behavior in individuals with bipolar disorder, including a 6.5-fold higher risk of suicide among first-degree relatives of bipolar 2 probands compared with those with bipolar 1 disorder.

Functional consequences of bipolar 2 disorder

Although many individuals with bipolar 2 disorder return to a fully functional level between mood episodes, at least 15% continue to have some inter-episode dysfunction, and 20% transition directly into another mood episode without inter-episode recovery. Functional recovery lags substantially behind recovery from symptoms of bipolar 2 disorder, especially in regard to occupational recovery, resulting in lower socioeconomic status despite equivalent levels of education with the general population. Individuals with bipolar 2 disorder perform more poorly than healthy individuals on cognitive tests and, with the exception of memory and semantic fluency, have similar cognitive impairment as do individuals with bipolar 1 disorder. Cognitive impairments associated with bipolar 2 disorder may contribute to vocational difficulties. Prolonged unemployment in individuals with bipolar disorder is associated with more episodes of depression, older age, increased rates of current panic disorder, and lifetime history of alcohol use disorder.

Cyclothymic disorder

In cyclothymic disorder also called cyclothymia, you’ve had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

Cyclothymic disorder usually begins in adolescence or early adult life and is sometimes considered to reflect a temperamental predisposition to other disorders. Cyclothymic disorder usually has an insidious onset and a persistent course. There is a 15%-50% risk that an individual with cyclothymic disorder will subsequently develop bipolar 1 disorder or bipolar 2 disorder. Onset of persistent, fluctuating hypomanic and depressive symptoms late in adult life needs to be clearly differentiated from bipolar and related disorder due to another medical condition and depressive disorder due to another medical condition (e.g., multiple sclerosis) before the cyclothymic disorder diagnosis is assigned. Among children with cyclothymic disorder, the mean age at onset of symptoms is 6.5 years of age.

Comorbidity

Substance-related disorders and sleep disorders (i.e., difficulties in initiating and maintaining sleep) may be present in individuals with cyclothymic disorder. Most children with cyclothymic disorder treated in outpatient psychiatric settings have comorbid mental conditions; they are more likely than other pediatric patients with mental disorders to have comorbid attention-deficit/hyperactivity disorder (ADHD).

Other Specified and Unspecified Bipolar and Related Disorders

Other Specified and Unspecified Bipolar and Related Disorders— defined by bipolar disorder symptoms that do not match the three categories listed above. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing’s disease, multiple sclerosis or stroke.

Bipolar disorder signs and symptoms

Bipolar disorder is characterized by extreme mood swings. These can range from extreme highs (mania) to extreme lows (depression). Bipolar disorder symptoms can cause unpredictable changes in your mood and behavior, resulting in significant distress and difficulty in life. Bipolar disorder can be an important factor in suicide, job loss, ability to function, and family discord.

Bipolar “mood episodes” include unusual mood changes along with unusual sleep habits, activity levels, thoughts, or behavior. People may have manic episodes, depressive episodes, or “mixed” episodes. A mixed episode has both manic and depressive symptoms. These mood episodes cause symptoms that last a week or two or sometimes longer. During an episode, the symptoms last every day for most of the day.

Mood episodes are intense. The feelings are strong and happen along with extreme changes in behavior and energy levels.

People having a manic episode may:

• Feel very “up” or “high”
• Feel “jumpy” or “wired”
• Have trouble sleeping
• Become more active than usual
• Talk really fast about a lot of different things
• Be agitated, irritable, or “touchy”
• Feel like their thoughts are going very fast
• Think they can do a lot of things at once
• Do risky things, like spend a lot of money or have reckless sex

People having a depressive episode may:

• Feel very “down” or sad
• Sleep too much or too little
• Feel like they can’t enjoy anything
• Feel worried and empty
• Have trouble concentrating
• Forget things a lot
• Eat too much or too little
• Feel tired or “slowed down”
• Have trouble sleeping
• Think about death or suicide.

Other features of bipolar disorder:

• Signs and symptoms of bipolar 1 and bipolar 2 disorders may include other features, such as anxious distress, melancholy, psychosis or others. The timing of symptoms may include diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during pregnancy or change with the seasons.

Depression

You may initially be diagnosed with clinical depression before having a future manic episode (sometimes years later), after which you may be diagnosed with bipolar disorder.

During an episode of depression, you may have overwhelming feelings of worthlessness, difficulty in day-to-day activities, such as work, school, social activities or relationships, which can potentially lead to thoughts of suicide.

A major depressive episode includes five or more of these symptoms:

• Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
• Marked loss of interest or feeling no pleasure in all — or almost all — activities
• Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)
• Either insomnia or sleeping too much
• Either restlessness or slowed behavior
• Fatigue or loss of energy or lacking energy
• Feelings of worthlessness or excessive or inappropriate guilt
• Feelings of guilt and despair
• Feeling pessimistic about everything
• Decreased ability to think, concentrate, remember things or indecisiveness
• Thinking about, planning or attempting suicide
• Self-doubt
• Being delusional, having hallucinations and disturbed or illogical thinking
• Lack of appetite
• Difficulty sleeping
• Waking up early

If you’re feeling suicidal or having severe depressive symptoms, contact your healthcare provider or your local mental health emergency services as soon as possible.

Mania

During a manic phase of bipolar disorder, you may feel very happy and have lots of energy, ambitious plans and ideas. You may spend large amounts of money on things you can’t afford and wouldn’t normally want.

Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common characteristics of this phase.

You may feel very creative and view the manic phase of bipolar as a positive experience. However, you may also experience symptoms of psychosis, where you see or hear things that aren’t there or become convinced of things that aren’t true.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work, school and social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

• Abnormally upbeat, jumpy or wired
• Feeling very happy, elated or overjoyed
• Increased activity, energy or agitation
• Feeling full of energy
• Not eating
• Exaggerated sense of well-being and self-confidence (euphoria)
• Feeling self-important
• Decreased need for sleep or not feeling like sleeping
• Unusual talkativeness or talking very quickly
• Racing thoughts
• Feeling full of great new ideas and having important plans
• Distractibility (being easily distracted)
• Being easily irritated or agitated
• Being delusional, having hallucinations and disturbed or illogical thinking
• Poor decision-making or doing things that often have disastrous consequences — for example, going on buying sprees, spending large sums of money on expensive and sometimes unaffordable items, taking sexual risks or making foolish investments.
• Making decisions or saying things that are out of character and that others see as being risky or harmful.

Symptoms in children and teens

Symptoms of bipolar disorder can be difficult to identify in children and teens. It’s often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.

Children and teens may have distinct major depressive or manic or hypomanic episodes, but the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift during episodes. Some children may have periods without mood symptoms between episodes.

The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

Bipolar Disorder and Other Illnesses

Some bipolar disorder symptoms are similar to other illnesses, which can make it hard for a doctor to make a diagnosis. In addition, many people with bipolar disorder may also have another health condition that needs to be treated along with bipolar disorder, such as anxiety disorder, substance abuse, or an eating disorder. People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.

Some conditions can worsen bipolar disorder symptoms or make treatment less successful. Examples include:

• Anxiety disorders
• Eating disorders
• Attention-deficit/hyperactivity disorder (ADHD)
• Alcohol or drug problems
• Physical health problems, such as heart disease, thyroid problems, headaches or obesity

Psychosis

Sometimes, a person with severe episodes of mania or depression also has psychotic symptoms, such as hallucinations or delusions. The psychotic symptoms tend to match the person’s extreme mood. For example:

• Someone having psychotic symptoms during a manic episode may believe she is famous, has a lot of money, or has special powers.
• Someone having psychotic symptoms during a depressive episode may believe he is ruined and penniless, or that he has committed a crime.

As a result, people with bipolar disorder who also have psychotic symptoms are sometimes misdiagnosed with schizophrenia.

Anxiety and ADHD

Anxiety disorders and attention-deficit hyperactivity disorder (ADHD) are often diagnosed among people with bipolar disorder.

Substance Abuse

People with bipolar disorder may also misuse alcohol or drugs, have relationship problems, or perform poorly in school or at work. Family, friends and people experiencing symptoms may not recognize these problems as signs of a major mental illness such as bipolar disorder.

Causes of bipolar disorder

The exact cause of bipolar disorder is unknown. Experts believe there are a number of factors that work together to make a person more likely to develop bipolar disorder. These are thought to be a complex mix of physical, environmental and social factors.

Genetics

Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.

Family genes may be one factor because bipolar disorder sometimes runs in families. However, it is important to know that just because someone in your family has bipolar disorder, it does not mean other members of the family will have it as well.

Furthermore, genes are not the only factor. Studies of identical twins have shown that one twin can develop bipolar disorder while the other does not. Though people with a parent or sibling with bipolar disorder are more likely to develop it, most people with a family history of bipolar disorder will not develop it. It is believed that a number of genetic and environmental factors are thought to act as triggers ³.

Brain structure and function

Another factor that may lead to bipolar disorder is the brain structure or the brain function of the person with the disorder. Research shows that the brain structure and function of people with bipolar disorder may differ from those of people who do not have bipolar disorder or other mental disorders. Learning about the nature of these brain changes helps researchers better understand bipolar disorder and, in the future, may help predict which types of treatment will work best for a person with bipolar disorder.

Scientists are finding out more about the disorder by studying it. This research may help doctors do a better job of treating people. Also, this research may help doctors to predict whether a person will get bipolar disorder. One day, doctors may be able to prevent the illness in some people.

Risk factors for developing bipolar disorder

Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first episode include:

• Having a first-degree relative, such as a parent or sibling, with bipolar disorder
• Periods of high stress, such as the death of a loved one or other traumatic event
• Drug or alcohol abuse.

Bipolar disorder triggers

A stressful circumstance or situation often triggers the symptoms of bipolar disorder.

Examples of stressful triggers include:

• the breakdown of a relationship
• physical, sexual or emotional abuse
• the death of a close family member or loved one

These types of life-altering events can cause episodes of depression at any time in a person’s life.

Bipolar disorder may also be triggered by:

• physical illness
• sleep disturbances
• overwhelming problems in everyday life, such as problems with money, work or relationships

Bipolar disorder complications

If a person is not treated, episodes of bipolar-related mania can last for between 3 and 6 months. And episodes of depression tend to last longer, often 6 to 12 months. But with effective treatment, episodes usually improve within about 3 months. Most people with bipolar disorder can be treated using a combination of different treatments.

Left untreated, bipolar disorder can result in serious problems that affect every area of your life, such as:

• Problems related to drug and alcohol use
• Suicide or suicide attempts
• Legal or financial problems
• Damaged relationships
• Poor work or school performance

Co-occurring conditions

If you have bipolar disorder, you may also have another health condition that needs to be treated along with bipolar disorder. Some conditions can worsen bipolar disorder symptoms or make treatment less successful. Examples include:

• Anxiety disorders
• Eating disorders
• Attention-deficit/hyperactivity disorder (ADHD)
• Alcohol or drug problems
• Physical health problems, such as heart disease, thyroid problems, headaches or obesity

Bipolar disorder prevention

There’s no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.

If you’ve been diagnosed with bipolar disorder, some strategies can help prevent minor symptoms from becoming full-blown episodes of mania or depression:

• Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you’re falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.
• Avoid drugs and alcohol. Using alcohol or recreational drugs can worsen your symptoms and make them more likely to come back.
• Take your medications exactly as directed. You may be tempted to stop treatment — but don’t. Stopping your medication or reducing your dose on your own may cause withdrawal effects or your symptoms may worsen or return.

Bipolar disorder diagnosis

Some people have bipolar disorder for years before the illness is diagnosed. This is because bipolar symptoms may seem like several different problems. Family and friends may notice the symptoms but not realize they are part of a bigger problem. A doctor may think the person has a different illness, like schizophrenia or depression.

People with bipolar disorder often have other health problems as well. This may make it hard for doctors to recognize the bipolar disorder. Examples of other illnesses include substance abuse, anxiety disorders, thyroid disease, heart disease, and obesity.

To determine if you have bipolar disorder, your evaluation may include:

• Physical exam. Your doctor may do a physical exam and lab tests to identify any medical problems that could be causing your symptoms.
• Psychiatric assessment. Your doctor may refer you to a psychiatrist, who will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms.
• Mood charting. You may be asked to keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.
• Criteria for bipolar disorder. Your psychiatrist may compare your symptoms with the criteria for bipolar and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Diagnosis of bipolar disorder in children

Although diagnosis of children and teenagers with bipolar disorder includes the same criteria that are used for adults, symptoms in children and teens often have different patterns and may not fit neatly into the diagnostic categories.

Also, children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems, which can make diagnosis more complicated. Referral to a child psychiatrist with experience in bipolar disorder is recommended.

Bipolar disorder differential diagnosis

• Major Depressive Disorder: The depressive episodes observed in major depressive disorder and bipolar disorder can be indistinguishable, and thus a longitudinal history is paramount. Those with bipolar disorder will report either a manic or hypomanic episode, which excludes the diagnosis of major depressive disorder.
• Schizophrenia: Thought disorders can have mood features that can look like bipolar affective disorder; however, the mood symptomatology only manifests in the setting of the thought disorder and not often.
• Substance-induced bipolar disorder: Mania and depression can both precipitate in the setting of substance use. A thorough laboratory evaluation should rule out the possibility of substance use to narrow the differential.
• Personality disorders: Particularly borderline personality disorder and histrionic personality disorder, personality disorders have overlapping features with mania, hypomania, and depression.
• Attention-deficit/hyperactivity disorder (ADHD): ADHD can present with similar symptoms as mania in children and adolescents; however, there is a less episodic and undulant presentation than that witnessed in bipolar disorder.

Bipolar disorder DSM-5

Bipolar 1 disorder DSM-5 diagnostic criteria

For a diagnosis of bipolar 1 disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic
or major depressive episodes.

Bipolar 1 disorder diagnosis is confirmed if:

• (A) Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode” below).
• (B) The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

The essential feature of a manic episode is a distinct period during which there is an abnormally, persistently elevated, expansive, or irritable mood and persistently increased activity or energy that is present for most of the day, nearly every day, for a period of at least 1 week (or any duration if hospitalization is necessary), accompanied by at least three additional symptoms from Criterion B. If the mood is irritable rather than elevated or expansive, at least four Criterion B symptoms must be present.

Mood in a manic episode is often described as euphoric, excessively cheerful, high, or “feeling on top of the world.” In some cases, the mood is of such a highly infectious quality that it is easily recognized as excessive and may be characterized by unlimited and haphazard enthusiasm for interpersonal, sexual, or occupational interactions. For example, the individual may spontaneously start extensive conversations with strangers in public. Often the predominant mood is irritable rather than elevated, particularly when the individual’s wishes are denied or if the individual has been using substances. Rapid shifts in mood over brief periods of time may occur and are referred to as lability (i.e., the alternation among euphoria, dysphoria, and irritability). In children, happiness, silliness and “goofiness” are normal in the context of special occasions; however, if these symptoms are recurrent, inappropriate to the context, and beyond what is expected for the developmental level of the child, they may meet Criterion A. If the happiness is unusual for a child (i.e., distinct from baseline), and the mood change occurs at the same time as symptoms that meet Criterion B for mania, diagnostic certainty is increased; however, the mood change must be accompanied by persistently increased activity or energy levels that are obvious to those who know the child well.

During the manic episode, the individual may engage in multiple overlapping new projects. The projects are often initiated with little knowledge of the topic, and nothing seems out of the individual’s reach. The increased activity levels may manifest at unusual hours of the day.

Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked grandiosity, and may reach delusional proportions (Criterion B1). Despite lack of any particular experience or talent, the individual may embark on complex tasks such as writing a novel or seeing publicity for some impractical invention. Grandiose delusions (e.g., of having a special relationship to a famous person) are common. In children, overestimation of abilities and belief that, for example, they are the best at a sport or the smartest in the class is normal; however, when such beliefs are present despite clear evidence to the contrary or the child attempts feats that are clearly dangerous and, most important, represent a change from the child’s normal behavior, the grandiosity criterion should be considered satisfied.

One of the most common features is a decreased need for sleep (Criterion B2) and is distinct from insomnia in which the individual wants to sleep or feels the need to sleep but is unable. The individual may sleep little, if at all, or may awaken several hours earlier than usual, feeling rested and full of energy. When the sleep disturbance is severe, the individual may go for days without sleep, yet not feel tired. Often a decreased need for sleep heralds the onset of a manic episode.

Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individuals may talk continuously and without regard for others’ wishes to communicate, often in an intrusive manner or without concern for the relevance of what is said. Speech is sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with dramatic mannerisms, singing, and excessive gesturing. Loudness and forcefulness of speech often become more important than what is conveyed. If the individual’s mood is more irritable than expansive, speech may be marked by complaints, hostile comments, or angry tirades, particularly if attempts are made to interrupt the individual. Both Criterion A and Criterion B symptoms may be accompanied by symptoms of the opposite (i.e., depressive) pole (“with mixed features” specifier).

Often the individual’s thoughts race at a rate faster than they can be expressed through speech (Criterion B4). Frequently there is flight of ideas evidenced by a nearly continuous flow of accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is severe, speech may become disorganized, incoherent, and particularly distressful to the individual. Sometimes thoughts are experienced as so crowded that it is very difficult to speak.

Distractibility (Criterion B5) is evidenced by an inability to censor immaterial external stimuli (e.g., the interviewer’s attire, background noises or conversations, furnishings in the room) and often prevents individuals experiencing mania from holding a rational conversation or attending to instructions.

The increase in goal-directed activity often consists of excessive planning and participation in multiple activities, including sexual, occupational, political, or religious activities. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers), without regard to the intrusive, domineering, and demanding nature of these interactions. They often display psychomotor agitation or restlessness (i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously. Some individuals write excessive letters, e-mails, text messages, and so forth, on many different topics to friends, public figures, or the media.

The increased activity criterion can be difficult to ascertain in children; however, when the child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for projects, develops previously absent and developmentally inappropriate sexual preoccupations (not accounted for by sexual abuse or exposure to sexually explicit material), then Criterion B might be met based on clinical judgment. It is essential to determine whether the behavior represents a change from the child’s baseline behavior; occurs most of the day, nearly every day for the requisite time period; and occurs in temporal association with other symptoms of mania.

The expansive mood, excessive optimism, grandiosity, and poor judgment often lead to reckless involvement in activities such as spending sprees, giving away possessions, reckless driving, foolish business investments, and sexual promiscuity that is unusual for the individual, even though these activities are likely to have catastrophic consequences (Criterion B7). The individual may purchase many unneeded items without the money to pay for them and^ in some cases, give them away. Sexual behavior may include infidelity or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually transmitted diseases or interpersonal consequences.

The manic episode must result in marked impairment in social or occupational functioning or require hospitalization to prevent harm to self or others (e.g., financial losses, illegal activities, loss of employment, self-injurious behavior). By definition, the presence of psychotic features during a manic episode also satisfies Criterion C.

Manic symptoms or syndromes that are attributable to the physiological effects of a drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects of medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or another medical condition do not count toward the diagnosis of bipolar 1 disorder. However, a fully syndromal manic episode that arises during treatment (e.g., with medications, electroconvulsive therapy, light therapy) or drug use and persists beyond the physiological effect of the inducing agent (i.e., after a medication is fully out of the individual’s system or the effects of electroconvulsive therapy would be expected to have dissipated completely) is sufficient evidence for a manic episode diagnosis (Criterion D). Caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a manic or hypomanic episode, nor necessarily an indication of a bipolar disorder diathesis. It is necessary to meet criteria for a manic episode to make a diagnosis of bipolar 1 disorder, but it is not required to have hypomanic or major depressive episodes. However, they may precede or follow a manic episode. Full descriptions of the diagnostic features of a hypomanic episode may be found within the text for bipolar 1I disorder, and the features of a major depressive episode are described within the text for major depressive disorder.

Manic Episode

• Criterion A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
• Criterion B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
  7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
• Criterion C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
• Criterion D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
  • Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar 1 diagnosis.

Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar 1 disorder.

Hypomanic Episode

• Criterion A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
• Criterion B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
  7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
• Criterion C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
• Criterion D. The disturbance in mood and the change in functioning are observable by others.
• Criterion E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
• Criterion F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).
  • Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.

Note: Criteria A-‘F constitute a hypomanic episode. Hypomanic episodes are common in bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder.

Major Depressive Episode

• Criterion A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms
  is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
• Criterion B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Criterion C. The episode is not attributable to the physiological effects of a substance or another medical condition.

Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

Bipolar 2 disorder DSM-5 diagnostic criteria

For a diagnosis of bipolar 2 disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode.

Bipolar 2 disorder diagnosis is confirmed if:

• (A). Criteria have been met for at least one hypomanic episode (Criteria A-F under “Hypomanic Episode” below) and at least one major depressive episode (Criteria A-C under “Major Depressive Episode” below).
• (B). There has never been a manic episode.
• (C). The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
• (D). The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Bipolar 2 disorder is characterized by a clinical course of recurring mood episodes consisting of one or more major depressive episodes (Criteria A-C under “Major Depressive Episode”) and at least one hypomanic episode (Criteria A-F under “Hypomanic Episode”). The major depressive episode must last at least 2 weeks, and the hypomanic episode must last at least 4 days, to meet the diagnostic criteria. During the mood episode(s), the requisite number of symptoms must be present most of the day, nearly every day, and represent a noticeable change from usual behavior and functioning. The presence of a manic episode during the course of illness precludes the diagnosis of bipolar 2 disorder (Criterion B under “Bipolar 2 Disorder”). Episodes of substance/medication-induced depressive disorder or substance/medication-induced bipolar and related disorder (representing the physiological effects of a medication, other somatic treatments for depression, drugs of abuse, or toxin exposure) or of depressive and related disorder due to another medical condition or bipolar and related disorder due to another medical condition do not count toward a diagnosis of bipolar 2 disorder unless they persist beyond the physiological effects of the treatment or substance and then meet duration criteria for an episode. In addition, the episodes must not be better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum or other psychotic disorders (Criterion C under “Bipolar 2 Disorder”). The depressive episodes or hypomanic fluctuations must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion D under “Bipolar 2 Disorder”); however, for hypomanic episodes, this requirement does not have to be met. A hypomanic episode that causes significant impairment would likely qualify for the diagnosis of manic episode and, therefore, for a lifetime diagnosis of bipolar 1 disorder. The recurrent major depressive episodes are often more frequent and lengthier than those occurring in bipolar 1 disorder.

Individuals with bipolar 2 disorder typically present to a clinician during a major depressive episode and are unlikely to complain initially of hypomania. Typically, the hypomanic episodes themselves do not cause impairment. Instead, the impairment results from the major depressive episodes or from a persistent pattern of unpredictable mood changes and fluctuating, unreliable interpersonal or occupational functioning. Individuals with bipolar 2 disorder may not view the hypomanic episodes as pathological or disadvantageous, although others may be troubled by the individual’s erratic behavior. Clinical information from other informants, such as close friends or relatives, is often useful in establishing the diagnosis of bipolar 2 disorder.

A hypomanic episode should not be confused with the several days of euthymia and restored energy or activity that may follow remission of a major depressive episode. Despite the substantial differences in duration and severity between a manic and hypomanic episode, bipolar 2 disorder is not a “milder form” of bipolar 1 disorder. Compared with individuals with bipolar 1 disorder, individuals with bipolar 2 disorder have greater chronicity of illness and spend, on average, more time in the depressive phase of their illness, which can be severe and/or disabling. Depressive symptoms co-occurring with a hypomanic episode or hypomanic symptoms co-occurring with a depressive episode are common in individuals with bipolar 2 disorder and are over represented in females, particularly hypomania with mixed features. Individuals experiencing hypomania with mixed features may not label their symptoms as hypomania, but instead experience them as depression with increased energy or irritability.

Hypomanic Episode

• Criterion A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
• Criterion B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
  7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
• Criterion C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
• Criterion D. The disturbance in mood and the change in functioning are observable by others.
• Criterion E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
• Criterion F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).

Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis.

Major Depressive Episode

• Criterion A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to a medical condition.
  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide.
• Criterion B. The symptoms cause clinically significant distress or impairment in social, occupational,
  or other important areas of functioning.
• Criterion C. The episode is not attributable to the physiological effects of a substance or another
  medical condition.

Note: Criteria A-C above constitute a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

Cyclothymic disorder DSM-5 diagnostic criteria

• Criterion A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
• Criterion B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual
  has not been without the symptoms for more than 2 months at a time.
• Criterion C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
• Criterion D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
• Criterion E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
• Criterion F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Specify if: With anxious distress

The essential feature of cyclothymic disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms that are distinct from each other (Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a hypomanic episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a major depressive episode. During the initial 2-year period (1 year for children or adolescents), the symptoms must be persistent (present more days than not), and any symptom-free intervals last no longer than 2 months (Criterion B). The diagnosis of cyclothymic disorder is made only if the criteria for a major depressive, manic, or hypomanic episode have never been met (Criterion C).

If an individual with cyclothymic disorder subsequently (i.e., after the initial 2 years in adults or 1 year in children or adolescents) experiences a major depressive, manic, or hypomanic episode, the diagnosis changes to major depressive disorder, bipolar 1 disorder, or other specified or unspecified bipolar and related disorder (subclassified as hypomanic episode without prior major depressive episode), respectively, and the cyclothymic disorder diagnosis is dropped.

The cyclothymic disorder diagnosis is not made if the pattern of mood swings is better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders (Criterion D), in which ease the mood symptoms are considered associated features of the psychotic disorder. The mood disturbance must also not be attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) (Criterion E). Although some individuals may function particularly well during some of the periods of hypomania, over the prolonged course of the disorder, there must be clinically significant distress or impairment in social, occupational, or other important areas of functioning as a result of the mood disturbance (Criterion F). The impairment may develop as a result of prolonged periods of cyclical, often unpredictable mood changes (e.g., the individual may be regarded as temperamental, moody, unpredictable, inconsistent, or unreliable).

Bipolar disorder treatment

Right now, there is no cure for bipolar disorder, but treatment can help control symptoms. Most people can get help for mood changes and behavior problems. Steady, dependable treatment works better than treatment that starts and stops.

Treatment is best guided by a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist) who is skilled in treating bipolar and related disorders. You may have a treatment team that also includes a psychologist, social worker and psychiatric nurse.

Bipolar disorder is a lifelong condition. Treatment is directed at managing symptoms.

The primary treatments for bipolar disorder include medications and psychological counseling (psychotherapy) to control symptoms, and also may include education and support groups.

Depending on your needs, bipolar disorder treatment may include:

• Medications. Often, you’ll need to start taking medications to balance your moods right away.
  • medicine to prevent episodes of mania and depression – these are known as mood stabilizers, and you take them every day on a long-term basis
  • medicine to treat the main symptoms of depression and mania when they happen
• Psychological treatment – such as talking therapies, which help you deal with depression and provide advice on how to improve relationships
• Continued treatment. Bipolar disorder requires lifelong treatment with medications, even during periods when you feel better. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
• Day treatment programs. Your doctor may recommend a day treatment program. These programs provide the support and counseling you need while you get symptoms under control.
• Substance abuse treatment. If you have problems with alcohol or drugs, you’ll also need substance abuse treatment. Otherwise, it can be very difficult to manage bipolar disorder.
• Hospitalization. Your doctor may recommend hospitalization if you’re behaving dangerously, you feel suicidal or you become detached from reality (psychotic). Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you’re having a manic or major depressive episode.
• Lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement, and advice on improving your diet and getting more sleep.

Most people with bipolar disorder can receive most of their treatment without having to stay in hospital. But hospital treatment may be needed if your symptoms are severe or you’re being treated under the Mental Health Act, as there’s a danger you may self-harm or hurt others.

In some circumstances, you could have treatment in a day hospital and return home at night.

Medication

There are several types of medication that can help. People respond to medications in different ways, so the type of medication depends on the patient. Sometimes a person needs to try different medications to see which works best.

Bipolar disorder requires lifelong treatment with medications, even during periods when you feel better. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.

Medications can cause side effects. Patients should always tell their doctors about these problems.

Also, patients should not stop taking a medication without a doctor’s help. Stopping medication suddenly can be dangerous, and it can make bipolar symptoms worse.

A number of medications are used to treat bipolar disorder. The types and doses of medications prescribed are based on your particular symptoms.

Medications may include:

• Mood stabilizers. You’ll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).
• Antipsychotics. If symptoms of depression or mania persist in spite of treatment with other medications, adding an antipsychotic drug such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may help. Your doctor may prescribe some of these medications alone or along with a mood stabilizer.
• Antidepressants. Your doctor may add an antidepressant to help manage depression. Because an antidepressant can sometimes trigger a manic episode, it’s usually prescribed along with a mood stabilizer or antipsychotic.
• Antidepressant-antipsychotic. The medication Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer.
• Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep, but are usually used on a short-term basis.

Finding the right medication

Finding the right medication or medications for you will likely take some trial and error. If one doesn’t work well for you, there are several others to try.

This process requires patience, as some medications need weeks to months to take full effect. Generally only one medication is changed at a time so that your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. Medications also may need to be adjusted as your symptoms change.

Lithium

Lithium is the main medicine used to treat bipolar disorder. Lithium is a long-term treatment for episodes of mania and depression. It’s usually prescribed for at least 6 months.

For lithium to be effective, the dosage must be correct. If it’s incorrect, you may get side effects such as diarrhea and getting sick. Tell your doctor immediately if you have side effects while taking lithium.

You’ll need regular blood tests at least every 3 months while taking lithium. This is to make sure your lithium levels are not too high or too low.

Your kidney and thyroid function will also need to be checked every 2 to 3 months if the dose of lithium is being adjusted, and every 12 months in all other cases.

While you’re taking lithium, avoid using non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, unless they’re prescribed by your doctor.

Lithium and the antipsychotic medicine aripiprazole are currently the only medicines that are officially approved for use in teenagers with bipolar disorder.

Side effects

Mild side effects often improve as you find the right medications and doses that work for you, and your body adjusts to the medications. Talk to your doctor or mental health professional if you have bothersome side effects.

Don’t make changes or stop taking your medications. If you stop your medication, you may experience withdrawal effects or your symptoms may worsen or return. You may become very depressed, feel suicidal, or go into a manic or hypomanic episode. If you think you need to make a change, call your doctor.

Medications and pregnancy

A number of medications for bipolar disorder can be associated with birth defects and can pass through breast milk to your baby. Certain medications, such as valproic acid and divalproex sodium, should not be used during pregnancy. Also, birth control medications may lose effectiveness when taken along with certain bipolar disorder medications.

• Discuss treatment options with your doctor before you become pregnant, if possible. If you’re taking medication to treat your bipolar disorder and think you may be pregnant, talk to your doctor right away.

Psychotherapy

Psychotherapy or “talk therapy” is a vital part of bipolar disorder treatment can help people with bipolar disorder. Psychotherapy can be provided in individual, family or group settings. Therapy can help them change their behavior and manage their lives. It can also help patients get along better with family and friends. Sometimes therapy includes family members.

Several types of therapy may be helpful. These include:

• Interpersonal and social rhythm therapy. Interpersonal and social rhythm therapy focuses on the stabilization of daily rhythms, such as sleeping, waking and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise.
• Cognitive behavioral therapy (CBT). The focus is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. CBT can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
• Psychoeducation. Learning about bipolar disorder (psychoeducation) can help you and your loved ones understand the condition. Knowing what’s going on can help you get the best support, identify issues, make a plan to prevent relapse and stick with treatment.
• Family-focused therapy. Family support and communication can help you stick with your treatment plan and help you and your loved ones recognize and manage warning signs of mood swings.

Other treatment options

Some people do not get better with medication and psychotherapy. Depending on your needs, other treatments may be added to your depression therapy.

• Electroconvulsive therapy (ECT) sometimes called “shock therapy” is a brain stimulation procedure that can help relieve severe symptoms of bipolar disorder. During electroconvulsive therapy (ECT) electrical currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can reverse symptoms of certain mental illnesses. ECT is usually only considered if an individual’s illness has not improved after other treatments such as medication or psychotherapy, can’t take antidepressants for health reasons such as pregnancy or in cases that require rapid response, such as with suicide risk or catatonia (a state of unresponsiveness).
• Transcranial Magnetic Stimulation (TMS) is a type of brain stimulation that uses magnetic waves, rather than the electrical stimulus of ECT, to relieve depression over a series of treatment sessions. Although not as powerful as ECT, TMS does not require general anesthesia and presents little risk of memory or adverse cognitive effects.
• Light Therapy is the best evidence-based treatment for seasonal affective disorder (SAD), and many people with bipolar disorder experience seasonal worsening of depression in the winter, in some cases to the point of SAD (seasonal affective disorder). Seasonal affective disorder (SAD) is a form of depression most often associated with fewer hours of daylight in the far northern and southern latitudes from late fall to early spring. Light therapy could also be considered for lesser forms of seasonal worsening of bipolar depression.

Treatment in children and teenagers

Treatments for children and teenagers are generally decided on a case-by-case basis, depending on symptoms, medication side effects and other factors. Generally, treatment includes:

• Medications. Children and teens with bipolar disorder are often prescribed the same types of medications as those used in adults. There’s less research on the safety and effectiveness of bipolar medications in children than in adults, so treatment decisions are often based on adult research.
• Psychotherapy. Initial and long-term therapy can help keep symptoms from returning. Psychotherapy can help children and teens manage their routines, develop coping skills, address learning difficulties, resolve social problems, and help strengthen family bonds and communication. And, if needed, it can help treat substance abuse problems common in older children and teens with bipolar disorder.
• Psychoeducation. Psychoeducation can include learning the symptoms of bipolar disorder and how they differ from behavior related to your child’s developmental age, the situation and appropriate cultural behavior. Understanding about bipolar disorder can also help you support your child.
• Support. Working with teachers and school counselors and encouraging support from family and friends can help identify services and encourage success.

Lifestyle and home remedies

You’ll probably need to make lifestyle changes to stop cycles of behavior that worsen your bipolar disorder. Here are some steps to take:

• Quit drinking or stop using recreational drugs. One of the biggest concerns with bipolar disorder is the negative consequences of risk-taking behavior and drug or alcohol abuse. Get help if you have trouble quitting on your own.
• Form healthy relationships. Surround yourself with people who are a positive influence. Friends and family members can provide support and help you watch for warning signs of mood shifts.
• Create a healthy routine. Having a regular routine for sleeping, eating and physical activity can help balance your moods. Check with your doctor before starting any exercise program. Eat a healthy diet. If you take lithium, talk with your doctor about appropriate fluid and salt intake. If you have trouble sleeping, talk to your doctor or mental health professional about what you can do.
• Check first before taking other medications. Call the doctor who’s treating you for bipolar disorder before you take medications prescribed by another doctor or any over-the-counter supplements or medications. Sometimes other medications trigger episodes of depression or mania or may interfere with medications you’re taking for bipolar disorder.
• Consider keeping a mood chart. Keeping a record of your daily moods, treatments, sleep, activities and feelings may help identify triggers, effective treatment options and when treatment needs to be adjusted.

Avoiding drugs and alcohol

Some people with bipolar disorder use alcohol or illegal drugs to try to take away their pain and distress. Both have well-known harmful physical and social effects and are not a substitute for effective treatment and good healthcare.

Some people with bipolar disorder find they can stop misusing alcohol and drugs once they’re using effective treatment.

Others may have separate but related problems of alcohol and drug abuse, which may need to be treated separately.

Avoiding alcohol and illegal drugs is an important part of recovery from episodes of manic, hypomanic or depressive symptoms, and can help you gain stability.

Alternative medicine

There isn’t much research on alternative or complementary medicine — sometimes called integrative medicine — and bipolar disorder. Most of the studies are on major depression, so it isn’t clear how these nontraditional approaches work for bipolar disorder.

If you choose to use alternative or complementary medicine in addition to your physician-recommended treatment, take some precautions first:

• Don’t stop taking your prescribed medications or skip therapy sessions. Alternative or complementary medicine is not a substitute for regular medical care when it comes to treating bipolar disorder.
• Be honest with your doctors and mental health professionals. Tell them exactly which alternative or complementary treatments you use or would like to try.
• Be aware of potential dangers. Alternative and complementary products aren’t regulated the way prescription drugs are. Just because it’s natural doesn’t mean it’s safe. Before using alternative or complementary medicine, talk to your doctor about the risks, including possible serious interactions with medications.

Coping and support

Coping with bipolar disorder can be challenging. Here are some strategies that can help:

• Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan and recognize mood changes. Help educate your family and friends about what you’re going through.
• Stay focused on your goals. Learning to manage bipolar disorder can take time. Stay motivated by keeping your goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
• Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn ways to relax and manage stress. Yoga, tai chi, massage, meditation or other relaxation techniques can be helpful.

Dealing with suicidal feelings

Having suicidal thoughts is a common depressive symptom of bipolar disorder. Without treatment, these thoughts may get stronger.

Some research has shown the risk of suicide for people with bipolar disorder is 15 to 20 times greater than the general population.

Studies have also shown that as many as 25-50% of people with bipolar disorder attempt suicide at least once.

The risk of suicide seems to be higher earlier in the illness, so early recognition and help may prevent it.

If you’re feeling suicidal or you’re having severe depressive symptoms, contact your doctor, care co-ordinator or the local mental health emergency services as soon as possible.

Living with bipolar disorder

Although bipolar disorder usually a long-term condition, effective treatments for bipolar disorder, combined with self-help techniques, can limit its impact on your everyday life.

Bipolar disorder is a condition of extremes. A person with bipolar disorder may be unaware they’re in the manic phase. After the episode is over, they may be shocked at their behavior. But at the time, they may believe other people are being negative or unhelpful.

Some people with bipolar disorder have more frequent and severe episodes than others.

The extreme nature of the condition means staying in a job may be difficult and relationships may become strained. There’s also an increased risk of suicide.

During episodes of mania and depression, someone with bipolar disorder may experience strange sensations, such as seeing, hearing or smelling things that are not there (hallucinations).

They may also believe things that seem irrational to other people (delusions). These types of symptoms are known as psychosis or a psychotic episode.

Stay active and eat well

Eating well and keeping fit can help reduce the symptoms of bipolar disorder, particularly the depressive symptoms. It may also give you something to focus on and provide a routine, which is important for many people.

A healthy diet, combined with exercise, may also help limit weight gain, which is a common side effect of medical treatments for bipolar disorder.

Some treatments also increase the risk of developing diabetes, or worsen the illness in people that already have it.

Maintaining a healthy weight and exercising are an important way of limiting that risk.

Annual health check

You should have a check-up at least once a year to monitor your risk of developing cardiovascular disease or diabetes.

This will include recording your weight, checking your blood pressure and having any appropriate blood tests.

Talk about it

Some people with bipolar disorder find it easy to talk to family and friends about their condition and its effects.

Other people find it easier to turn to charities and support groups.

Many organizations run self-help groups that can put you in touch with other people with the condition.

This enables you to share helpful ideas and helps you realize you’re not alone in feeling the way you do.

Bipolar disorder prognosis

Bipolar 1 disorder usually has a poor prognosis. 50% of patients experience a second episode within two years of the first episode ⁴.

Poor prognosis is associated with ⁴:

• Substance dependency
• Psychotic features
• Depression symptoms
• Interepisode depression
• Male gender

Patients with bipolar disorder are at higher risk for suicidal ideation and attempts, which lead to a poorer prognosis.

References

1. Bipolar Disorder. https://medlineplus.gov/bipolardisorder.html
2. Bipolar Disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
3. McIntyre RS, Konarski JZ, Soczynska JK, Wilkins K, Panjwani G, Bouffard B, Bottas A, Kennedy SH. Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization. Psychiatr Serv. 2006 Aug;57(8):1140-4. doi: 10.1176/ps.2006.57.8.1140
4. Jain A, Mitra P. Bipolar Affective Disorder. [Updated 2022 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558998