Bipolar disorder: onset, causes, and mood episode characteristics

Bipolar Disorder generally sets in during adolescence or early adulthood though it may also occur late in one's life or during childhood. It results in terrible mood swings ranging from mania and euphoria to depression and suicidal tendencies. The earlier a person is diagnosed with bipolar disorder the better. Medication is available for bipolar disorder, which helps control the mood swings and even treats the condition. Diagnosis of bipolar disorders can be done only by specialized psychiatrists and is done according to the criteria established by the American Psychiatric Association in the Diagnostic and Statistic Manual of Mental Disorders.

Bipolar disorder, more commonly known as manic depression, is a major mood disorder that is distinguished by behavior that fluctuates from extreme highs (mania) to serious lows (depression) interspersed with periods of "normal" mood. This change in mood or "mood swing" can last for hours, days weeks or months. Persons suffering from this condition are unable to keep a sense of calm about their lives. It is not a character flaw or a sign of personal weakness.

Although "mania" is used freely in speech to refer to any type of passion or obsession, like soccer mania, in medicine, mania refers to behavior that includes profuse and rapidly changing ideas, exaggerated sexuality, extreme gaiety, intense irritability, and decreased sleep. Though "depression" is used to describe a feeling of sadness, in cases of bipolar disorder, the lows of depression are characterized by extreme hopelessness and a feeling of worthlessness accompanied often by thoughts of suicide. (David Guiness, 1998)

Manic depression typically begins in adolescence or early adulthood and continues throughout life. After pooling the data from 22 studies reporting average onset age in bipolar affective illness, the weighted mean was found to be 28.1 years. (Goodwin and Jamison, 1990)

Because manic and depressive episodes may be less extreme in the early stages, or if a person has periods of mild mania, the disorder, unfortunately, is often not recognized for years or even decades. Bipolar disorder affects women and men almost equally and tends to be genetic and can be inherited. Effective treatments exist to greatly alleviate the suffering and minimize the mood swings caused by manic depression. Left untreated, major mood disorders often lead to social and personal problems such as loneliness, divorce, job loss, substance abuse, and suicide. (Mark Halebsky, 1997)

Causes of Bipolar Disorder

Bipolar disorder does not seem to have any single clear cut cause but is rather a combination of factors. According to Durand and Barlow, most scientists believe in "an approach to the study of psychopathology that holds that psychological disorders are always the products of multiple interacting causal factors," which would mean physical, mental, environmental and emotional causes are involved. (Durand & Barlow, 2000)

Bipolar disorder has been found to be genetic and is inherited from family members. It has been found that In families of persons with bipolar disorder, first-degree relatives (parents, children, siblings) are more likely to have a mood disorder than the relatives of those who do not have bipolar disorder. (Davis & Palladino, 2000)

Twin studies indicate that "if one twin presents with a mood disorder, an identical twin is approximately three times more likely than a fraternal twin to have a mood disorder." (Durand & Barlow, 2000)

In considering bipolar disorder specifically, the concordance rate (when both twins have the disorder) is 80% for identical twins as compared to only 16% for fraternal twins. (Durand & Barlow, 2000) "Overwhelming evidence suggests that such disorders are familial and almost certainly reflect an underlying genetic vulnerability." (Durand & Barlow, 2000)

Some researchers believe that bipolar disorder is caused by biochemical instability in the transmission of nerve impulses in the brain triggered by an upsetting life experience, substance abuse, lack of sleep, or other excessive or extreme stimulation. It is possible that this neurotransmitter system may be inherited. Researchers have known for decades that a link exists between neurotransmitters and mood disorders, because drugs which alter these transmitters also relieve mood disorders. (Bernstein et al., 2000)

Some studies hypothesize that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the cause. Others indicate that an imbalance of these substances is the problem - i.e., that a specific level of a neurotransmitter is not as important as its amount in relation to the other neurotransmitters. (Durand & Barlow, 2000)

Still other studies have found evidence that a change in the sensitivity of the receptors on nerve cells may be the issue. (Bernstein et al., 2000)

In short, researchers are quite certain that the neurotransmitter system is at least part of the cause of bipolar disorder, but further research is still needed to define its exact role.

Findings suggest that bipolar disorder affect persons with an inborn vulnerability when they come into interaction with an environmental trigger. This idea is similar to theories about cause of other medical conditions such as cancer or heart disease. Here, the cause of bipolar disorder is psychological - mental, emotional or environmental. A "stressful life event" can range from a death in the family to the loss of a job, from the birth of a child to a move. It can be pretty much anything, but it cannot be precisely defined. Research has found that stressful life events can lead to the onset of symptoms in bipolar disorder. However, once the disorder is triggered and progresses, "it seems to develop a life of its own. Once the cycle begins, a psychological or pathophysiological process takes over and ensures that the disorder will continue." (Durand & Barlow, 2000)

This cause of bipolar disorder has been termed the "Diathesis-Stress Model." The word diathesis means, in simplified terms, a bodily condition that make a person more than usually susceptible to certain diseases. Thus the Diathesis-Stress Model says that "each person inherits certain physical predisposition that leave him or her vulnerable to problems that may or may not appear, depending on what kinds of situations that person confronts." (Bernstein et al., 2000)

Durand and Barlow define this model as a "hypothesis that both an inherited tendency and specific stressful conditions are required to produce a disorder." (Durand & Barlow, 2000)

Symptoms of Bipolar Disorder

The mood swings of manic depression are alternating cycles of depression and mania ranging from elation or irritability to sadness and hopelessness, and back again. The periods of highs and lows are called episodes, with each rotation from one extreme to the other called a cycle.

Cycles can be widely spaced, with long episodes of depression followed by long episodes of mania. Or each cycle can be very short. Cycles can include long or short periods of wellness or normality in which no symptoms are experienced. In some cases, bipolars experience both depressive and manic symptoms of bipolar disorder at the same time in what is called a "mixed state." (Goodwin and Jamison, 1990)

Although many of the indicators of manic episodes appear to be pleasant, they are actually so exaggerated as to be inappropriate and leave one, feeling out of control and even desperate. In addition to typical bipolar disorder symptoms, hallucinations or delusions may accompany severe episodes.

The Highs: In bipolar disorder, a manic episode is indicated by an elevated mood or an irritable mood accompanied by restlessness - high energy and activity levels, racing thoughts and rapid talking, decreased need for sleep, euphoria, distractibility, agitation, grandiosity - inflated self-esteem, recklessness and increased interest in goal-oriented activities. The severity of these symptoms or conditions may vary from person to person. Although most people would have experienced most of these symptoms at one time or another, someone having manic depression is likely to experience a number of these symptoms over a significant period of time and with significant intensity. (David Guiness, 1998)

The Lows: The occurrence of a depressed mood or a loss of interest or pleasure indicates a depressive episode. This is accompanied by symptoms of hopelessness or pessimism, guilt, worthlessness, helplessness, fatigue, insomnia or hypersomnia (inability to stay awake), decreased concentration levels, restlessness and irritability, loss of appetite and weight or weight gain, chronic pain not caused by physical disease (hypochondria) and recurring thoughts of death and suicide. All these symptoms, as in the case of the highs, are not indicative of manic depression but occur with persistence and severity in people having manic depression. (David Guiness, 1998); (Ronald R. Fieve, 1997)

Hypomania: Hypomania literally means "low/mild mania." It is often one of the first bipolar disorder symptoms and has all the characteristics of mania, but is usually not so problematic or severe as to interfere with a person's work or social life. Because hypomania instills positive feelings, individuals often insist that they are fine when family and friends recognize the mood swings. Many bipolars often go off medication in an attempt to induce a hypomanic episode. Unfortunately this often results in severe mania or can swing into depression. (David Guiness, 1998)

Bipolar Adolescents (Mitzi Walsh, 2000)

Bipolar disorder is more likely to affect the children of parents who have the disorder. When one parent has bipolar disorder, the risk to each child is estimated to be 15-30%. When both parents have bipolar disorder, the risk increases to 50-75%. Bipolar illness is usually diagnosed in children over the age of twelve. Unfortunately, for bipolar children under age twelve, behaviors that should be associated with manic depression are often confused with attention deficit hyperactivity disorder (ADHD). In many cases, the child may suffer from both ADHD as well as bipolar disorder resulting in the latter going undiagnosed.

Bipolar children usually have uninterrupted, rapidly cycling and severe mood disturbance producing a chronic irritability with few periods of wellness. They are also given to irrational thought processes called as "thought errors." When manic, children and adolescents, in contrast to adults, are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. When depressed, there may be complaints of headaches, stomach aches, tiredness, poor performance in school, poor communication and extreme sensitivity to rejection or failure. (Durand & Barlow, 2000)

The onset of puberty is when the symptoms of adolescent bipolar disorder often manifest. Symptoms typically mirror those of adults with manic depression. For some, adolescent bipolar disorder may initially be triggered by a traumatic event, such as the loss of a loved one, or severe stress. Later episodes may occur even in the absence of stress, or may worsen with stress. (Davis & Palladino, 2000)

Hormones may also trigger adolescent bipolar disorder in girls just starting to menstruate and they may notice that their symptoms vary in severity with their cycle.

Because a majority of teens with adolescent bipolar disorder abuse drugs or alcohol, their manic depression behavior is often masked by the substance abuse. The treatment of bipolar disorder in children is based on experience in treating adults with the illness, since very few studies have been done of the effectiveness and safety of the medications in children and adolescents. In all cases, an early bipolar disorder diagnosis and start of treatment is vital to establishing mood stability and mental wellness.

Diagnosis of Bipolar Disorder

Bipolar disorder usually sets in at adolescence or early childhood, although it can sometimes start as late as the 40s or 50s. Bipolar disorder symptoms occurring late in life is generally triggered by factors such as excessive stress or substance abuse.

Manic depression behavior typically follows a pattern that cycles - sometimes rapidly - from depression to euphoria or irritability. One person's symptoms may include more mania (excitability) then depression; another person may suffer primarily from depression with mania occurring infrequently. Symptoms of mania and depression may be mixed together in any combination, but the person's mood swings from intense lows to extreme highs.

Without a professional diagnosis, symptoms of bipolar I or bipolar II disorder can be difficult to track and may be invisible except to those who know the person very well. In the early stages of the disorder, manic depression behavior may actually appear as a different problem such as substance abuse, changes in sleep patterns, strained relationships, or poor performance at work or school. (American Psychiatric Association, 1994)

Cyclothymic disorder is characterized by chronic, frequent swings between hypomania and depression that occur over a period of at least two years (or in children and adolescents, at least one year). The periods of hypomania are never severe enough to qualify as full manic episodes, and the depressive periods are too mild to qualify as major depressive episodes. A person with cyclothymia is never symptom-free for longer than two months.

To make a bipolar disorder diagnosis, the psychiatrist uses the criteria established by the American Psychiatric Association in the Diagnostic and Statistic Manual of Mental Disorders. The mental health professional takes a detailed family history and a history of manic depression behavior over the patient's lifetime, including age at onset and current symptoms (described in the symptoms of bipolar disorder). While cyclothymia is considered a form of manic depression, many practitioners who do not specialize in mental health often fail to arrive at a bipolar disorder diagnosis. (American Psychiatric Association, 1994)

Diagnostic Criteria for Major Depressive Episodes:

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 due to a general medical condition, or mood-incongruent delusions or hallucinations.

A depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful) Note: In children and adolescents, can be irritable mood.

A 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 made by others) 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 gains.

A insomnia or hypersomnia nearly every day psychomotor agitation or retardation nearly every day) observable by others, not merely subjective feelings of restlessness of being slowed down) fatigue or loss of energy nearly every day feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 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.

The symptoms do not meet criteria for a Mixed Episode.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. (Extracted from American Psychiatric Association, 1994)

Diagnostic Criteria for Manic Episodes:

distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

inflated self-esteem or grandiosity decreased need for sleep (e.g., feels rested after only 3 hours of sleep) more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying spree, sexual indiscretions, or foolish business investments)

The symptoms do not meet criteria for a Mixed Episode.

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder. (Extracted from American Psychiatric Association, 1994)

Diagnostic Criteria for Mixed Episode:

The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.

The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder. (Extracted from American Psychiatric Association, 1994)

Diagnostic Criteria for Hypomania:

distinct period of persistently elevated, expansive; or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

inflated self-esteem or grandiosity decreased need for sleep (e.g., feels rested after only 3 hours of sleep) more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

The disturbance in mood and the change in functioning are observable by others.

The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder. (Extracted from American Psychiatric Association, 1994)

Diagnostic Criteria for Cyclothymic Disorder:

For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In children and adolescents, the duration must be at least 1 year.

During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.

No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic, or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

The symptoms in Criteria A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

The symptoms are not due to the direct physiological effects of a substance (e.g, a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (Extracted from American Psychiatric Association, 1994)

Treatment of Bipolar Disorder

Bipolar disorder treatment focuses on taking regular and proper medication along with changes in lifestyle so as to reduce the risk of episodes. In most cases, symptoms can be managed with the right combination of medication, psychotherapy and social/emotional support. If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression whose results can even be fatal. Once bipolar medication is started, some individuals may live many years free of symptoms while others continue to have mild but troubling depression or mood swings. (Bernstein et al., 2000)

Most people with bipolar disorder -- "even those with the most severe forms -- "can be helped by bipolar medication. Because antidepressants alone can actually encourage episodes of mania or set off more frequent cycles, they are not the medication of choice in most cases of bipolar disorder. They are however prescribed in conjunction with another bipolar medication, typically a mood stabilizer, to help manage depressive episodes alone. Common antidepressants include certain types of selective serotonin reuptake inhibitors (Zoloft®, Paxil®, Prozac®) and monocyclic aminoketones (Wellbutrin®). Because they both have a low incidence of causing manic episodes, first choice antidepressants are Zoloft (especially in teens) and Wellbutrin. While Paxil is in the same class of drugs as Zoloft and Prozac, it also has anti-anxiety effects.

Lithium is a popular mood stabilizing medication and is usually very effective in controlling mania and preventing the occurrence of both manic and depressive episodes. Exactly how lithium works is unknown. Lithium should not be used in cases of severe cardiovascular disease, renal disease, or brain damage, or when evidence of severe debilitation, dehydration or sodium depletion exists. A mood stabilizer combined with an antipsychotic or anticonvulsant is typically prescribed as part of the bipolar disorder treatment plan. (American Psychiatric Association, 1994)

The anticonvulsants dicalproex (commonly known as Depakote®) and valproate are becoming more frequently used in bipolar treatment, and have shown to be especially useful in hard to treat cases. Zyprexa® is a commonly prescribed antipsychotic medication for the short-term control of bipolar disorder. Zyprexa reduces the symptoms of mania by correcting elements of chemical imbalance that causes manic episodes.

Electroconvulsive therapy (ECT), also known as electroshock therapy, was first used to treat schizophrenia in the 1940s. Doctors soon found that ECT was also helpful in relieving the symptoms of mood disorders, including bipolar disorder. Electroconvulsive therapy is usually given every other day during the first few weeks. Treatments are then reduced to weekly, then every other week, and finally monthly. While the typical three to twelve ECT treatments may take place over a few months, patients often experience a relief in symptoms within the first couple of weeks. Interestingly, ECT is most effective in severe cases of manic depression. (Goodwin and Jamison, 1990)

Compliance Problem person on medication for bipolar disorder may suddenly stop taking his or her medication. This is because the manic highs and depressive lows of manic depression contribute to some degree of passion to one's personality. While bipolar artists do their best painting and writers produce their best poetry during high or low episodes, they find that medication may leave them feeling quite flat and relatively lacking in emotion. When they get to a point where they fear the loss of their talent, and even their very livelihood, they may decide to stop taking medication in favor of regaining the extremes of emotion that they prefer. (Kay Redfield Jamison, 1996)