Bipolar and related disorders

Watch video only
Maybe you’ve heard the term “bipolar” used flippantly to describe someone who’s moody, or who has mood swings, but the colloquial use of the term is really different from clinically diagnosed bipolar disorder.
Bipolar disorder, which used to be called manic depression, is a serious mental disorder that causes a person to have dramatic shifts in emotions, mood, and energy levels: moving from extreme lows to extreme highs.
But these shifts don’t happen moment to moment—they usually happen over several days or weeks. Now, bipolar and related disorders include several different conditions, but the most important ones are bipolar I disorder, bipolar II disorder, and cyclothymic disorder.
Now, let’s cover some important clinical features associated with these conditions. The first one is a major depressive episode, which is characterized by the low moods that are identical to those in a related disorder: major depressive disorder, also known as unipolar depression.
During major depressive episodes, individuals can feel hopeless and discouraged, lack energy and mental focus, and can have physical symptoms like eating and sleeping too much or too little.
But along with these lows, the thing that sets bipolar disorders apart from unipolar depression is that individuals can have periods of high moods, which are called manic episodes or hypomanic episodes, depending on their level of severity.
Manic episodes are described as an abnormally elevated mood that lasts for at least one week or requires hospitalization.
In a manic state, people can feel energetic, overly happy or optimistic, euphoric with really high self-esteem, or even unusually irritable.
And on the surface, these might seem like very positive characteristics, but when an individual is in a full manic episode, these symptoms can reach a dangerous extreme.
A person experiencing mania might invest all of their money in a risky business venture or behave recklessly. Individuals might talk pressured speech, where they talk constantly at a rapid-fire pace, or they might have racing thoughts and might feel “wired,” as if they don’t need sleep.
Manic episodes can also include delusions of grandeur: for example, they might believe that they are on a personal mission from god, or that they have supernatural powers.
And they might make poor decisions without any regard for later consequences. On the flip side, hypomanic episodes are described as an abnormally elevated mood that lasts for at least 4 consecutive days and doesn’t require hospitalization.
In a hypomanic state, individuals experience similar symptoms and feelings to the ones seen during manic episodes, but it's important to note that they are milder in severity.
Additionally, there are no psychotic features. Between major depressive episodes and manic or hypomanic episodes, individuals usually have a relatively stable mood, which is often described as euthymia.
One way to understand these swings is by charting them on a graph. So let’s say the y-axis is mood, with mania and depression being on the far ends of the axis, and the x-axis is time.
A neurotypical person (someone without a mental health disorder) might have normal ups and downs throughout their life, and they might even have some pretty serious lows once in a while, maybe after losing a job or moving to a new place and feeling lonely.
Now, the diagnosis of bipolar I disorder includes at least one manic episode, which may be preceded or followed by hypomanic or major depressive episodes.
On the flip side, the diagnosis of bipolar II disorder includes at least one hypomanic and one major depressive episode, but no manic episodes.
Finally, the diagnosis of cyclothymic disorder is based on frequent hypomanic and depressive symptoms over a 2-year period, which are not as severe as the ones seen in bipolar I and bipolar II disorders.
The symptoms must be present for at least half the time, meaning at least one year, and there shouldn’t be a period without symptoms for more than 2 months.
Now, sometimes, these conditions can be further described by additional clinical features, also known as specifiers. For example, some individuals might have bipolar disorder with anxious distress, so they might complain of feeling restless or experiencing fear that something terrible might happen.
Others may have bipolar disorder with melancholic features, meaning they might feel guilty for no apparent reason, wake up earlier than usual and experience more severe downs in the morning.
There are also rapid cycling features, where a person experiences 4 or more depressive, manic, or hypomanic episodes in the last 12 months.
There are also atypical features, where individuals have normal mood responses to positive events and situations. For example, when they hear their favorite song on the radio, they brighten up.
But, at the same time, they might be excessively sleepy during the day and feel heavy in their arms or legs, like they are weighed down.
Additionally, they might have a constant, unreasonable fear of rejection, which can severely impact their social relationships.
Like most mental health conditions, the exact underlying cause of bipolar disorder isn’t known, and there is no single “bipolar gene” identified, but it’s thought that there are genetic and environmental factors that play a part.
For example, one interesting clue is that people with family members who have bipolar disorder are 10 times more likely to have it themselves.
It’s also worth mentioning that people with bipolar disorder often have other disorders like anxiety disorders, substance use disorders, ADHD, and personality disorders as well, making diagnosis and treatment a real challenge.
Even though there’s no cure for bipolar disorder, identifying and treating individuals is really important, since there’s a real danger that the person could harm themselves or die by suicide.
One of the oldest treatments is also one of the most effective treatments, and that’s lithium salts. Lithium acts as a mood stabilizer—smoothing out the highs and lows that people with bipolar disorder experience.
That said, lithium is much better at treating manic rather than depressive episodes, and so individuals who take it often have to take other medications as well, which can be problematic since some antidepressants (like the SSRIs) can trigger manic episodes in individuals who are predisposed to them.
Other treatment options include antipsychotics, anticonvulsants, and benzodiazepines, but many of these—including lithium—have side effects that can be severe and lead to non-adherence (spontaneously quitting prescribed medications) which can be dangerous.
Psychological interventions like talk therapy or cognitive-behavioral therapy can be useful in treating unipolar depression, but they’re not particularly effective in treating the manic episodes of bipolar disorder.
Having said that, they can still be very helpful tools to help individuals with bipolar disorder in general—especially after a manic episode has ended.
They can also help an individual handle stressful situations that might otherwise lead a manic episode, thereby helping to prevent a potential manic episode in the first place.
Alright, as a quick recap… Bipolar I disorder, bipolar II disorder, and cyclothymic disorder are classified as bipolar and related disorders and they share some common clinical features, such as major depressive, manic, and hypomanic episodes.
Moreover, they can be associated with additional features, often referred to as specifiers. Some common examples of specifiers include anxious distress, melancholic features, rapid cycling, and atypical features.
Even though there’s no cure for bipolar disorder, identifying and treating individuals is really important, since there’s a real danger that the person could harm themselves or die by suicide.
Some pharmacological options include lithium, as well as antipsychotics, anticonvulsants, and benzodiazepines.