Bipolar Disorder

What is bipolar disorder?

Bipolar disorder is a chronic mental health condition marked by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).

• Mania: A state of excessively elevated mood, energy, and activity.

• Depression: A state of low mood, energy, and interest in daily life.

• Study Pointer:
  Understand that the hallmark of bipolar disorder is episodic mood fluctuation — patients move between distinctly different states over time, not just moodiness.

Types of Bipolar Disorders

1. Bipolar I Disorder

   • Requires at least one manic episode, which may be preceded or followed by depressive episodes.

   • May include psychotic symptoms (e.g., delusions).

   • Mood shifts can occur with mixed features (mania + depression) or rapid cycling (frequent shifts).

2. Bipolar II Disorder

   • Involves episodes of hypomania (milder than mania) and major depressive episodes.

   • No full-blown manic episodes.

   • Can progress to Bipolar I.

3. Cyclothymic Disorder (Cyclothymia)

   • Fluctuations between mild hypomanic and mild depressive symptoms for at least 2 years (1 year in children).

   • Symptoms don’t meet criteria for full episodes.

4. Study Pointer:
   Differentiate types based on severity and duration of episodes. Mania = Bipolar I, Hypomania + Depression = Bipolar II, Subthreshold symptoms = Cyclothymia.

• Common symptoms: Grandiosity, flight of ideas, impulsivity, risky behaviors, euphoria or irritability.

  Study Pointer:
  Learn the diagnostic criteria. Mania often requires medical attention; hypomania might be overlooked due to increased productivity and creativity.

Associated Features of Manic Episodes

• Lack of Insight: Denial of illness, resisting treatment.

• Sensory Enhancement: Heightened smell, hearing, vision.

• Risky Behavior: Gambling, sexual promiscuity, excessive spending.

• Mood Shifts: Rapid transitions to anger or depression.

• Consequences: Hospitalization, legal trouble, financial loss.

• Mixed Features: Depressive symptoms during mania (linked to suicide risk).

Study Pointer:
Be able to recognize behavioral changes as diagnostic clues and understand the high risk for harm during manic states.

Differential Diagnosis

Bipolar disorder can mimic or be confused with several other disorders:

• Major Depressive Disorder (MDD): Lacks manic/hypomanic episodes.

• Generalized Anxiety Disorder (GAD): Racing thoughts may resemble mania.

• PTSD: May show mood swings and hyperactivity.

• Schizoaffective Disorder: Includes psychotic symptoms independent of mood episodes.

• ADHD: Chronic, not episodic like bipolar disorder.

• Borderline Personality Disorder: Chronic instability vs. episodic in bipolar.

• DMDD (in children): Persistent irritability, no distinct manic episodes.

Study Pointer:
Master how bipolar is episodic, in contrast to more constant symptoms in other disorders.

Comorbidities

Often co-occurs with:

• Anxiety disorders

• Substance use disorders

• ADHD

• Personality disorders (e.g., borderline, antisocial)

Study Pointer:
Remember comorbid conditions can complicate diagnosis and treatment; this is why a comprehensive assessment is critical.

Epidemiology

• Lifetime prevalence: ~3.9% (U.S. adults), 2.1% (adolescents).

• Equal rates in men and women (Bipolar I and Cyclothymia).

• Onset: Adolescence to early adulthood.

• Cyclothymia affects 0.4–2.5% of the population.

• High risk of progression: Bipolar II → Bipolar I.

Study Pointer:
Know the age of onset and prevalence patterns. Early diagnosis can improve outcomes.

Stigma

• Misunderstandings and negative stereotypes hinder treatment.

• Education is key to reducing stigma.

Study Pointer:
Reflect on how stigma impacts care-seeking behavior and treatment adherence.

Causes of Bipolar Disorder

Biological Risk Factors

1. Genetics:

   • First-degree relatives have 7–10× higher risk.

   • Heritability estimates: 79–93%.

   • Polygenic influences across chromosomes (e.g., 1, 5, 11, X).

2. Brain Structure/Function:

   • Overactivity in anterior cingulate and putamen linked to mania.

   • Reduced white and gray matter.

   • Affected circuits: limbic-thalamic-cortical pathway.

3. Neurochemical & Hormonal Factors:

   • Elevated dopamine → mania.

   • High glutamate → excitation and mania.

   • Low thyroid activity → rapid cycling.

   • Cortisol elevation via HPA axis → emotional instability.

4. Sleep and Circadian Rhythms:

   • Disruption in REM and slow-wave sleep.

   • Sleep deprivation can trigger mania.

Study Pointer:
Understand the interplay between genetics, neurotransmitters, and brain circuits. Know how circadian disruption links to mood instability.

Environmental Risk Factors

• Stressful Events: Interact with biological vulnerability (diathesis-stress model).

• Cognitive Distortions: Unrealistic beliefs, denial of illness.

• Family Dynamics: Low warmth, poor parenting, instability.

Study Pointer:
Use the diathesis-stress model to understand how internal vulnerabilities and external stressors combine.

Treatment of Bipolar Disorder

Biological Treatments

• Lithium: Gold-standard mood stabilizer; reduces dopamine/glutamate.

  • Side effects: Nausea, thyroid issues, tremors.

  • Requires blood monitoring (toxicity risk).

• Divalproex (Anticonvulsant): Increases GABA, sedative.

  • Effective for mixed or rapid-cycling forms.

• Carbamazepine: Used for severe or refractory cases.

• Other Interventions:

  • Electroconvulsive Therapy (ECT)

  • Repetitive Transcranial Magnetic Stimulation (rTMS)

  • Light Therapy

Study Pointer:
Focus on Lithium’s effectiveness and side effects. Know why monitoring is critical.

Psychological Treatments

• Cognitive Behavioral Therapy (CBT):

  • Targets faulty thinking patterns.

  • Teaches problem-solving, early warning signs, and adherence.

• Behavioral Activation:

  • Increases positive behaviors and routines.

• Family/Marital Therapy:

  • Enhances communication and support.

• Interpersonal Therapy (IPT):

  • Focuses on roles, sleep routines, social functioning.

• Mindfulness-Based Strategies

Study Pointer:
Emphasize that psychological therapy enhances medication adherence and daily functioning.

Final Study Advice:

• Know the distinctions between Bipolar I, II, and Cyclothymia.

• Learn symptom criteria for manic and hypomanic episodes.

• Understand the biopsychosocial model (biological, psychological, social causes).

• Recognize the importance of medication adherence.

• Be familiar with treatment combinations (medication + therapy).

• Practice differential diagnosis with overlapping conditions like ADHD or BPD.