Bipolar disorder, also known as manic-depressive illness, is a psychiatric disease characterized by periods of abnormally elevated moods, often followed by episodes of depression. An individual with manic-depressive illness has episodes of mania characterized by an abnormally elevated mood, sleeplessness, racing thoughts, and pressured speech. In severe cases, thoughts become increasingly chaotic, and may become completely removed from reality. Without treatment, the disorder often has disastrous consequences: during manic episodes, peoples' actions may cause them to lose jobs, destroy relationships, go into debt, and even put themselves into dangerous situations. Hospitalization is sometimes required to prevent such consequences or suicide.
Cycles of manic and depressive episodes may occur occasionally or several times a year depending on the individual. Most people feel no symptoms between episodes. If untreated, episodes generally become progressively more frequent and severe. Medications and psychotherapy help to stabilize moods and alleviate symptoms.
Bipolar disorder affects about 1% of the adult population. Manic depressive illness is recognized worldwide, and is about evenly distributed between men and women. The disorder typically begins in adolescence or early adulthood.
Manic-depressive illness is known to have a strong genetic basis. Bipolar disorder tends to run in families. More than two-thirds of people with the disorder have a close relative with it or with depression. Twin studies also support the genetic basis of the disorder: both members of a set of identical twins are more likely to have depression (33%-90%) than both members of a set of non-identical twins (5%-25%). Although the exact pattern of transmission remains unknown, some genes have recently been identified that are associated with the disease. It appears that multiple genes are involved, a particular mix of which determines the various features of the illness.
The manic phase of the illness is characterized by a persistent, abnormally elevated mood Table 01. Manic episodes tend to arise over a period of days to weeks. The person often seems to be euphoric, but may instead be intensely agitated. Affected individuals usually experience increased energy, with rapid, loud speech, a reduced need for sleep, and distractibility. The person may afterwards describe racing thoughts or ideas that seemed to take flight. During an episode, he or she may feel that even mundane conversations or ordinary details are intensely interesting. The person may make wild plans and take action on them, such as flying out of the country without adequate preparation, making crazy business investments, or going on extensive shopping sprees to the point of debt. The manic individual typically does not realize that thoughts are irrational, and will deny having a problem. In milder cases or early in the episode, activities may be channeled productively into work or creative pursuits. Oftentimes, however, thoughts progress too rapidly, irrationally, and chaotically to be constructive. If untreated, an episode may last for weeks, or even as long as a year.
A depressive phase usually follows the manic episode. When present, symptoms are identical to those of unipolar depression. Depressive episodes may follow the manic episode. During a depressive episode, an overwhelmingly sad mood and profound loss of interest in activities takes over. Physical symptoms, such as changes in sleep and eating habits, are common, and the person may have thoughts of death and suicide.
Severe states of mania or depression may involve psychotic symptoms in which the individual is unable to separate fantasy from reality. During manic or depressive episodes, a person may experience delusions (for example, beliefs of communicating with aliens or of having god-like powers) or hallucinations (such as hearing imaginary voices or seeing things that aren't there). Psychotic symptoms often provoke anxiety, and may involve fears of being harmed by others. When such symptoms are present, the disease resembles schizophrenia, and may respond to medications used for treating schizophrenia.
The frequency and duration of episodes of mania and depression vary among individuals. The manic and depressive episodes of each cycle typically occur within three months of each other. Between these cycles, most people feel well, and will have no symptoms. Some people experience many cycles of mania and depression each year. People with rapid cycles should be checked carefully for underlying thyroid disease or a drug-induced cause.
Table 1. Signs and Symptoms of Manic and Depressive Episodes
Manic episodes Depressive episodes Increased energyEuphoric feelingsAgitationLess need for sleepInflated beliefs in abilitiesPoor judgmentIncreased sex driveDenial that problem exists Sad or empty moodLoss of interest in normal activitiesFeelings of guilt, worthlessness, or hopelessnessDifficulty concentratingRestlessness or irritabilitySleep disturbances (can be too much or too little)Changes in appetiteThoughts of death or suicide
People with a family history of bipolar disorder have an increased risk for the disease. More than two-thirds of people with bipolar disorder have a close relative with the disorder, or with depression. Genetic and twin studies have both shown that bipolar disorder is at least partially heritable.
Having certain co-existing medical conditions, or taking certain medications, may increase your risk for a manic syndrome Table 02. Thyroid disease, kidney problems, AIDS, and stroke may cause manic symptoms. High levels of digoxin, a common heart and blood pressure medication, can also give rise to mania. Antidepressants and stimulant medications, including drugs such as amphetamines and cocaine, can also cause or mimic a manic episode.
Table 2. Medical Conditions that May Cause Manic Symptoms
Neurological disorders Metabolic disorders Other disorders Extrapyramidal diseases (e.g., Huntington's, postencephalic Parkinson's)Central nervous system infections (general paresis, viral encephalitis)Cerebral neoplasmsCerebral traumaCerebrovascular accidentsKleine-Levin syndromeKlinefelter's syndromeMultiple sclerosisPick's diseaseTemporal lobe epilepsyThalamotomy Wilson's diseaseVitamin B12 deficiency Carcinoid syndromeDialysis dementiaHyperthyroidismPellagraPostpartum maniaUremia and hemodialysis
- Corticosteroids (including ACTHa)
- Metrizamide (following myelography)
- Opiates and opioids
- Hallucinogens (intoxication and flashbacks)
- Phencyclidine (PCP)
Bipolar disorder is diagnosed on the basis of symptoms that occur during a manic episode, a history of previous episodes, and family history. A diagnosis may be made solely by the presence of a manic episode; depression need not have occurred. Mania is usually described as an intensely happy or euphoric mood, but it can instead manifest as extreme irritability. According to the psychiatric definition of the disease, mania must be present for at least one week, or be severe enough to warrant hospitalization.
In addition to the mood abnormality, other symptoms must also be present before a diagnosis can be made.
Some of these additional symptoms include:
- Inflated self-esteem
- Decreased need for sleep
- Rapid speech
- Racing thoughts
- Easy distractibility
- Increase in activities (whether social or work-related)
- Increase in activities that may lead to problems (for example, buying sprees or sexual indiscretions)
The doctor will have to rule out the possibility that the patient's symptoms are a result of an underlying medical or drug-related condition. A drug screen should be part of the workup, as amphetamines or cocaine can precipitate manic symptoms. Prescription drugs can also cause manic symptoms. For example, high levels of digoxin, a common heart and blood pressure medication, can trigger a manic episode.
The doctor will also have to check for underlying medical conditions that may be causing manic symptoms. An initial episode that occurs after the age of 40 is particularly suggestive of mania secondary to another cause. Thyroid disease, AIDS, and stroke are all conditions that your doctor will have to check for before making a diagnosis.
Prevention and Screening
- Alcohol and AntidepressantsThe dos and don'ts of drinking when you take antidepressants are mostly don'ts.
- Antidepressant Treatment TimelineYou can expect to feel some relief from depression symptoms as early as the first week, but the full response could take months.
- Medications to Avoid While on AntidepressantsCould your antidepressant interact with something else you're taking?