Introduction:

Bipolar disorder, also known as bipolar affective disorder, manic-depressive disorder, or manic depression, is a mental illness classified by psychiatry as a mood disorder. Individuals with bipolar disorder experience episodes of an elevated or agitated mood known as mania alternating with episodes of depression.
Those with bipolar disorder often describe their experience as being on an emotional roller coaster. Cycling up and down between strong emotions can keep a person from having anything approaching a “normal” life. The emotions, thoughts and behavior of a person with bipolar disorder are often experienced as beyond one’s control. Friends, co-workers and family may sometimes intervene to try and help protect their interests and health. This makes the condition exhausting not only for the sufferer, but for those in contact with her or him as well.

Prevalence:
About 4% of people suffer from bipolar disorder. Prevalence is similar in men and women and, broadly, across different cultures and ethnic groups

SIGNS AND SYMPTOMS OF BIPOLAR DISORDER
In bipolar disorder, people experience abnormally elevated (manic or hypomanic) mood states which interfere with the functions of ordinary life. Many people with bipolar disorder also experience periods of depressed mood, but this is not universal. There is no simple physiological test to confirm the disorder. Diagnosing bipolar disorder is often difficult, even for mental health professionals

Manic Episodes:
Mania is the defining feature of bipolar disorder. Mania is a distinct period of elevated or irritable mood, which can take the form of euphoria, and lasts for at least a week (less if hospitalization is required). People with mania commonly experience an increase in energy and a decreased need for sleep, with many often getting as little as three or four hours of sleep per night. Some can go days without sleeping. A manic person may exhibit pressured speech, with thoughts experienced as racing. Attention span is low, and a person in a manic state may be easily distracted. Judgment may be impaired, and sufferers may go on spending sprees or engage in risky behavior that is not normal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive, intolerant, or intrusive. They may feel out of control or unstoppable, or as if they have been "chosen" and are "on a special mission", or have other grandiose or delusional ideas. Sexual drive may increase. At more extreme levels, a person in a manic state can experience psychosis or a break with reality, where thinking is affected along with mood. This can occasionally lead to violent behaviors. The severity of manic symptoms can be measured by rating scales such as the Altman Self-Rating Mania Scale and clinician-based Young Mania Rating Scale.

Hypomanic Episodes:
Hypomania is a mild to moderate level of elevated mood, characterized by optimism, pressure of speech and activity, and decreased need for sleep. Generally, hypomania does not inhibit functioning as mania does. Many people with hypomania are actually more productive than usual, while manic individuals have difficulty completing tasks due to a shortened attention span. Some hypomanic people show increased creativity, although others demonstrate poor judgment and irritability. Many experience hyper sexuality. Hypomanic people generally have increased energy and increased activity levels. They do not, however, have delusions or hallucinations.
Hypomania may feel good to the person who experiences it. Thus, even when family and friends recognize mood swings, the individual often will deny that anything is wrong. What might be called a "hypomanic event", if not accompanied by depressive episodes, is often not deemed as problematic, unless the mood changes are uncontrollable, volatile or mercurial. If left untreated, an episode of hypomania can last anywhere from a few days to several years. Most commonly, symptoms continue for a few weeks to a few months.

Depressive Episodes:
Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal thoughts. In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.

Mixed Episodes:
A mixed state, also known as dysphoric mania, agitated depression, or a mixed episode, is a condition during which features of mania and depression, such as agitation, anxiety, fatigue, guilt, impulsiveness, irritability, morbid or suicidal ideation, panic, paranoia, pressured speech and rage, occur simultaneously.
Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. One may also feel incredibly frustrated or be prone to fits of rage in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states are often the most problematic period of mood disorders, during which susceptibility to substance abuse, panic disorder, commission of violence, suicide attempts, and other complications increase greatly.
A mixed state must meet the criteria for a major depressive episode and a manic episode nearly every day for at least one week. However, mixed episodes rarely conform to these qualifications; they may be described more practically as any combination of depressive and manic symptoms.

BIPOLAR I DISORDER

Bipolar I disorder (pronounced "bipolar one" and also known as manic-depressive disorder or manic depression) is a form of mental illness. A person affected by bipolar I disorder has had at least one manic episode in his or her life.Most people are in their teens or early 20s when symptoms of bipolar disorder first appear. Nearly everyone with bipolar I disorder develops it before age 50. People with an immediate family member who has bipolar are at higher risk.Many people with bipolar I disorder experience long periods without symptoms in between episodes. A minority has rapid-cycling symptoms of mania and depression, in which they may have distinct periods of mania or depression four or more times within a year. People can also have mixed episodes, in which manic and depressive symptoms occur simultaneously, or may alternate from one pole to the other within the same day.

DSM-IV- TR Criteria for Bipolar I Disorder, Single Manic Episode

A. Presence of only one Manic Episode and no past Major Depressive Episodes.
Note: Recurrence is defined as either a change in polarity from depression or an interval of at least 2 months without manic symptoms.
B. The Manic Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
DSM-IV- TRCriteria for Bipolar I Disorder, Most Recent Episode Hypomanic
A. Currently (or most recently) in a Hypomanic Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

DSM-IV- TR Criteria for Bipolar I Disorder, Most Recent Episode Manic

A. Currently (or most recently) in a Manic Episode.
B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
DSM-IV-TRCriteria for Bipolar I Disorder, Most Recent Episode Mixed
A. Currently (or most recently) in a Mixed Episode.
B. There has previously been at least one Major Depressive Episode, Manic Episode, or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

DSM-IV- TR Criteria for Bipolar I Disorder, Most Recent Episode Depressed

A. Currently (or most recently) in a Major Depressive Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

DSM-IV -TR Criteria for Bipolar I Disorder, Most Recent Episode Unspecified

A. Criteria, except for duration, are currently (or most recently) met for a Manic, a Hypomanic, a Mixed, or a Major Depressive Episode.
B. There has previously been at least one Manic Episode or Mixed Episode.
C. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
E. The mood symptoms in Criteria A and B 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).

BIPOLAR II DISORDER
Bipolar II disorder is a bipolar spectrum disorder characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for bipolar II disorder requires that the individual must never have experienced a full manic episode (one manic episode meets the criteria for bipolar I disorder. The course of bipolar II disorder is more chronic and consists of more frequent cycling than the course of bipolar I disorder. Bipolar II is associated with a greater risk of suicidal thoughts and behaviors than bipolar I or unipolar depression. Although bipolar II is commonly perceived to be a milder form of Type I, this is not the case. Types I and II present equally severe burdens. Bipolar II is difficult to diagnose. Patients usually seek help when they are in a depressed state. Because the symptoms of hypomania are often mistaken for high functioning behavior or simply attributed to personality, patients are typically not aware of their hippomanic symptoms.
As a result, they are unable to provide their doctor with all the information needed for an accurate assessment; these individuals are often misdiagnosed with unipolar depression. Of all individuals initially diagnosed with major depressive disorder, between 40% and 50% will later be diagnosed with either BP-I or BP-II. Despite the difficulties, it is important that BP-II individuals are correctly assessed so that they can receive the proper treatment.

DSM-IV- TRCriteria for Bipolar II Disorder

A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode.
C. There has never been a Manic Episode or a Mixed Episode.
D. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Cyclothymic Disorder:
Cyclothymia or cyclothymic disorder is a relatively mild mood disorder. In cyclothymic disorder, moods swing between short periods of mild depression and hypomania, an elevated mood. The low and high mood swings never reach the severity of major depression or mania.In cyclothymia, moods fluctuate from mild depression to hypomania and back again. In most people, the pattern is irregular and unpredictable. Hypomania or depression can last for days or weeks. In between up and down moods, a person might have normal moods for more than a month -- or may cycle continuously from hypomanic to depressed, with no normal period in between.

DSM-IV- TR Criteria for Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms (see p. 338) 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.
B. 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.
C. 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).
D. The symptoms in Criterion 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.
E. 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).
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

ETIOLOGY OF BIPOLAR DISORDERS:

The current thinking is that this is a predominantly biological disorder that occurs in a specific part of the brain and is due to a malfunction of the neurotransmitters (chemical messengers in the brain). As a biological disorder, it may lie dormant and be activated spontaneously or it may be triggered by stressors in life.
Although, no one is quite sure about the exact causes of bipolar disorder, researchers have found these important clues:
Genetic factors in Bipolar Disorder:
• Bipolar disorder tends to be familial, meaning that it “runs in families.” About half the people with bipolar disorder have a family member with a mood disorder, such as depression.
• A person who has one parent with bipolar disorder has a 15 to 25 percent chance of having the condition.
• A person who has a non-identical twin with the illness has a 25 percent chance of illness, the same risk as if both parents have bipolar disorder.
• A person who has an identical twin (having exactly the same genetic material) with bipolar disorder has an even greater risk of developing the illness about an eightfold greater risk than a nonidentical twin.
• Studies of adopted twins (where a child whose biological parent had the illness is raised in an adoptive family untouched by the illness) has helped researchers learn more about the genetic causes vs. environmental and life events causes.
Environmental Factors in Bipolar Disorder:
• A life event may trigger a mood episode in a person with a genetic disposition for bipolar disorder.
• Even without clear genetic factors, altered health habits, alcohol or drug abuse or hormonal problems can trigger an episode.
• Among those at risk for the illness, bipolar disorder is appearing at increasingly early ages. This apparent increase in earlier occurrences may be due to underdiagnosis of the disorder in the past. This change in the age of onset may be a result of social and environmental factors that are not yet understood.

Physiological Factors in Bipolar Disorder:

Although the abnormalities in the brain due to bipolar disorder are still unknown, the structural abnormalities believed to be linked to bipolar disorder are amygdala, basal ganglia, and the prefrontal cortex. Research is currently being conducted to find more definite information on the definite causes and changes in the brain of bipolar disorder.



Recently using MRI, hyperintense (bright white) spots have been found in bipolar patients. Hyperintensities have previously been associated with a change in water content in the brain tissue, but the causes of these are not known.
Amygdala volumes have been shown to be reduced in unmediated patients and increased in medicated patients. This is seen in the chart below.

In this figure, normal brain scans are at the top, hypomanic is in the middle row and depressed are at the bottom. You can see the reduced activity in the depressed brain, by the presence of more dark blue and can see the over activity in the manic brain by the presence of more green, yellow and red in the brain scan.


BD patients and healthy control subjects

Abnormalities in the structure and/or function of certain brain circuits could underlie bipolar. Meta-analyses of structural MRI studies in bipolar disorder report an increase in the volume of the lateral ventricles, globuspallidus and increase in the rates of deep white matter hyper intensities. Functional MRI findings suggest that abnormal modulation between ventral prefrontal and limbic regions, especially the amygdale, likely contribute to poor emotional regulation and mood symptoms.

TREATMENT OF BIPOLAR DISORDER

Psychological Treatment:
Medication is a necessary part of treatment for bipolar disorder but psychological treatment can supplement medication.

Psychoeducational Approaches:
Psychoeducational approaches typically help people learn about the symptoms of the disorder, the expected time course of symptoms, the biological and psychological triggers for symptoms and treatment strategies. Studies confirm that careful education about bipolar disorder can help people adhere to treatment with medications such as lithium.

Family Focused Treatment:
Family focused treatment (FFT) aims to educate the family about the illness, enhance family communication and develop problem solving skills. FFT leads to lower rates of relapse when added to medication.

Medications for Bipolar Disorder:
Lithium (brand names Eskalith, Lithobid) is the most widely used and studied medication for treating bipolar disorder. Lithium helps reduce the severity and frequency of mania. It may also help relieve bipolar depression.
Studies show that lithium can significantly reduce suicide risk. Lithium also helps prevent future manic and depressive episodes. As a result, it may be prescribed for long periods of time (even between episodes) as maintenance therapy.
Lithium acts on a person's central nervous system (brain and spinal cord). It is thought to help strengthen nerve cell connections in brain regions that are involved in regulating mood, thinking and behavior.
The dose of lithium varies among individuals and as phases of their illness change. Although bipolar disorder is often treated with more than one drug, some people can control their condition with lithium alone.

Benzodiazepines:
Benzodiazepines rapidly help control certain manic symptoms in bipolar disorder until mood-stabilizing drugs can take effect. They are usually taken for a brief time, up to two weeks or so, with other mood-stabilizing drugs. They may also help restore normal sleep patterns in people with bipolar disorder.
Benzodiazepines slow the activity of the brain. In doing so, they can help treat mania, anxiety, panic disorder, insomnia, and seizures.

Benzodiazepines prescribed for bipolar disorder include (among others):

Ativan (lorazepam)
Klonopin (clonazepam)
Valium (diazepam)
Xanax (alprazolam)

Electroconvulsive Therapy:
Electroconvulsive therapy, also known as ECT or electroshock therapy, is a short-term treatment for severe manic or depressive episodes, particularly when symptoms involve serious suicidal or psychotic symptoms, or when medicines seem to be ineffective. It can be effective in nearly 75% of patients.

PROGNOSIS
For many individuals with bipolar disorder a good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder can have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar disorder can be a severely disabling medical condition. However, many individuals with bipolar disorder can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with bipolar disorder may have periods of normal or near normal functioning between episodes.