WHAT IS BIPOLAR DISORDER?
From the National Institute of Mental Health
Bipolar disorder, also known as manic-depressive illness, is a brain
disorder that causes unusual shifts in a person's mood, energy, and
ability to function. Different from the normal ups and downs that everyone
goes through, the symptoms of bipolar disorder are severe. They can
result in damaged relationships, poor job or school performance, and
even suicide. But there is good news: bipolar disorder can be treated,
and people with this illness can lead full and productive lives.
More than 2 million American adults, or about 1 percent of the population
age 18 and older in any given year, have bipolar disorder. Bipolar disorder
typically develops in late adolescence or early adulthood. However,
some people have their first symptoms during childhood, and some develop
them late in life. It is often not recognized as an illness, and people
may suffer for years before it is properly diagnosed and treated. Like
diabetes or heart disease, bipolar disorder is a long-term illness that
must be carefully managed throughout a person's life.
What Are the Symptoms of Bipolar Disorder?
Bipolar disorder causes dramatic mood swings-from overly "high" and/or
irritable to sad and hopeless, and then back again, often with periods
of normal mood in between. Severe changes in energy and behavior go
along with these changes in mood. The periods of highs and lows are
called episodes of mania and depression.
Signs and symptoms of mania (or a manic episode) include:
* Increased energy, activity, and restlessness
* Excessively "high," overly good, euphoric mood
* Extreme irritability
* Racing thoughts and talking very fast, jumping from one idea to another
* Distractibility, can't concentrate well
* Little sleep needed
* Unrealistic beliefs in one's abilities and powers
* Poor judgment
* Spending sprees
* A lasting period of behavior that is different from usual
* Increased sexual drive
* Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
* Provocative, intrusive, or aggressive behavior
* Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with 3 or more
of the other symptoms most of the day, nearly every day, for 1 week
or longer. If the mood is irritable, 4 additional symptoms must be present.
Signs and symptoms of depression (or a depressive episode) include:
* Lasting sad, anxious, or empty mood
* Feelings of hopelessness or pessimism
* Feelings of guilt, worthlessness, or helplessness
* Loss of interest or pleasure in activities once enjoyed, including
* Decreased energy, a feeling of fatigue or of being "slowed down"
* Difficulty concentrating, remembering, making decisions
* Restlessness or irritability
* Sleeping too much, or can't sleep
* Change in appetite and/or unintended weight loss or gain
* Chronic pain or other persistent bodily symptoms that are not caused
by physical illness or injury
* Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if 5 or more of these symptoms last
most of the day, nearly every day, for a period of 2 weeks or longer.
A mild to moderate level of mania is called hypomania. Hypomania may
feel good to the person who experiences it and may even be associated
with good functioning and enhanced productivity. Thus even when family
and friends learn to recognize the mood swings as possible bipolar disorder,
the person may deny that anything is wrong. Without proper treatment,
however, hypomania can become severe mania in some people or can switch
Sometimes, severe episodes of mania or depression include symptoms of
psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations
(hearing, seeing, or otherwise sensing the presence of things not actually
there) and delusions (false, strongly held beliefs not influenced by
logical reasoning or explained by a person's usual cultural concepts).
Psychotic symptoms in bipolar disorder tend to reflect the extreme mood
state at the time. For example, delusions of grandiosity, such as believing
one is the President or has special powers or wealth, may occur during
mania; delusions of guilt or worthlessness, such as believing that one
is ruined and penniless or has committed some terrible crime, may appear
during depression. People with bipolar disorder who have these symptoms
are sometimes incorrectly diagnosed as having schizophrenia, another
severe mental illness.
It may be helpful to think of the various mood states in bipolar disorder
as a spectrum or continuous range. At one end is severe depression,
above which is moderate depression and then mild low mood, which many
people call "the blues" when it is short-lived but is termed "dysthymia"
when it is chronic. Then there is normal or balanced mood, above which
comes hypomania (mild to moderate mania), and then severe mania.
In some people, however, symptoms of mania and depression may occur
together in what is called a mixed bipolar state. Symptoms of a mixed
state often include agitation, trouble sleeping, significant change
in appetite, psychosis, and suicidal thinking. A person may have a very
sad, hopeless mood while at the same time feeling extremely energized.
Bipolar disorder may appear to be a problem other than mental illness-for
instance, alcohol or drug abuse, poor school or work performance, or
strained interpersonal relationships. Such problems in fact may be signs
of an underlying mood disorder.
Diagnosis of Bipolar Disorder
Like other mental illnesses, bipolar disorder cannot yet be identified
physiologically-for example, through a blood test or a brain scan. Therefore,
a diagnosis of bipolar disorder is made on the basis of symptoms, course
of illness, and, when available, family history. The diagnostic criteria
for bipolar disorder are described in the Diagnostic and Statistical
Manual for Mental Disorders, fourth edition (DSM-IV).
Descriptions offered by people with bipolar disorder give valuable
insights into the various mood states associated with the illness:
Depression: I doubt completely my ability to do anything well. It
seems as though my mind has slowed down and burned out to the point
of being virtually useless. [I am] haunt[ed] with the total, the desperate
hopelessness of it all. Others say, "It's only temporary, it will pass,
you will get over it," but of course they haven't any idea of how I
feel, although they are certain they do. If I can't feel, move, think
or care, then what on earth is the point?
Hypomania: At first when I'm high, it's tremendous ideas are fast
like shooting stars you follow until brighter ones appear. All shyness
disappears, the right words and gestures are suddenly there uninteresting
people, things become intensely interesting. Sensuality is pervasive,
the desire to seduce and be seduced is irresistible. Your marrow is
infused with unbelievable feelings of ease, power, well-being, omnipotence,
euphoria, you can do anything, but, somewhere this changes.
Mania: The fast ideas become too fast and there are far too many overwhelming confusion replaces clarity you stop keeping up with it-memory
goes. Infectious humor ceases to amuse. Your friends become frightened. Everything is now against the grain you are irritable, angry, frightened,
uncontrollable, and trapped.
Some people with bipolar disorder become suicidal. Anyone who is thinking
about committing suicide needs immediate attention, preferably from
a mental health professional or a physician. Anyone who talks about
suicide should be taken seriously. Risk for suicide appears to be higher
earlier in the course of the illness. Therefore, recognizing bipolar
disorder early and learning how best to manage it may decrease the risk
of death by suicide.
Signs and symptoms that may accompany suicidal feelings include:
* talking about feeling suicidal or wanting to die
* feeling hopeless, that nothing will ever change or get better
* feeling helpless, that nothing one does makes any difference
* abusing alcohol or drugs
* feeling like a burden to family and friends
* putting affairs in order (e.g., organizing finances or giving away
possessions to *prepare for one's death)
* writing a suicide note
* putting oneself in harm's way, or in situations where there is a danger
of being killed
What Is the Course of Bipolar Disorder?
Episodes of mania and depression typically recur across the life span.
Between episodes, most people with bipolar disorder are free of symptoms,
but as many as one-third of people have some residual symptoms. A small
percentage of people experience chronic unremitting symptoms despite
The classic form of the illness, which involves recurrent episodes of
mania and depression, is called bipolar I disorder. Some people, however,
never develop severe mania but instead experience milder episodes of
hypomania that alternate with depression; this form of the illness is
called bipolar II disorder. When 4 or more episodes of illness occur
within a 12-month period, a person is said to have rapid-cycling bipolar
disorder. Some people experience multiple episodes within a single week,
or even within a single day. Rapid cycling tends to develop later in
the course of illness and is more common among women than among men.
People with bipolar disorder can lead healthy and productive lives when
the illness is effectively treated. Without treatment, however, the
natural course of bipolar disorder tends to worsen. Over time a person
may suffer more frequent (more rapid-cycling) and more severe manic
and depressive episodes than those experienced when the illness first
appeared. But in most cases, proper treatment can help reduce the frequency
and severity of episodes and can help people with bipolar disorder maintain
good quality of life.
What Causes Bipolar Disorder?
Scientists are learning about the possible causes of bipolar disorder
through several kinds of studies. Most scientists now agree that there
is no single cause for bipolar disorder-rather, many factors act together
to produce the illness.
Because bipolar disorder tends to run in families, researchers have
been searching for specific genes-the microscopic "building blocks"
of DNA inside all cells that influence how the body and mind work and
grow-passed down through generations that may increase a person's chance
of developing the illness. But genes are not the whole story. Studies
of identical twins, who share all the same genes, indicate that both
genes and other factors play a role in bipolar disorder. If bipolar
disorder were caused entirely by genes, then the identical twin of someone
with the illness would always develop the illness, and research has
shown that this is not the case. But if one twin has bipolar disorder,
the other twin is more likely to develop the illness than is another
In addition, findings from gene research suggest that bipolar disorder,
like other mental illnesses, does not occur because of a single gene.
It appears likely that many different genes act together, and in combination
with other factors of the person or the person's environment, to cause
bipolar disorder. Finding these genes, each of which contributes only
a small amount toward the vulnerability to bipolar disorder, has been
extremely difficult. But scientists expect that the advanced research
tools now being used will lead to these discoveries and to new and better
treatments for bipolar disorder.
Brain-imaging studies are helping scientists learn what goes wrong in
the brain to produce bipolar disorder and other mental illnesses. ,
New brain-imaging techniques allow researchers to take pictures of the
living brain at work, to examine its structure and activity, without
the need for surgery or other invasive procedures. These techniques
include magnetic resonance imaging (MRI), positron emission tomography
(PET), and functional magnetic resonance imaging (fMRI). There is evidence
from imaging studies that the brains of people with bipolar disorder
may differ from the brains of healthy individuals. As the differences
are more clearly identified and defined through research, scientists
will gain a better understanding of the underlying causes of the illness,
and eventually may be able to predict which types of treatment will
work most effectively.
How Is Bipolar Disorder Treated?
Most people with bipolar disorder-even those with the most severe forms-can
achieve substantial stabilization of their mood swings and related symptoms
with proper treatment. Because bipolar disorder is a recurrent illness,
long-term preventive treatment is strongly recommended and almost always
indicated. A strategy that combines medication and psychosocial treatment
is optimal for managing the disorder over time.
In most cases, bipolar disorder is much better controlled if treatment
is continuous than if it is on and off. But even when there are no breaks
in treatment, mood changes can occur and should be reported immediately
to your doctor. The doctor may be able to prevent a full-blown episode
by making adjustments to the treatment plan. Working closely with the
doctor and communicating openly about treatment concerns and options
can make a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms, treatments, sleep
patterns, and life events may help people with bipolar disorder and
their families to better understand the illness. This chart also can
help the doctor track and treat the illness most effectively.
This publication, written by Melissa Spearing of NIMH, is a revision
and update of an earlier version by Mary Lynn Hendrix. Scientific information
and review were provided by NIMH Director Steven E. Hyman, M.D., and
other NIMH staff members Matthew V. Rudorfer, M.D., and Jane L. Pearson,
Ph.D. Editorial assistance was provided by Clarissa K. Wittenberg, Margaret
Strock, and Lisa D. Alberts of NIMH.
NIH Publication No. 02-3679
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