Bipolar Disorder / Anxiety

This article is one of a series of articles about bipolar disorder by the American Psychiatric
Association (APA).

What Is Bipolar Disorder?

People who have bipolar disorder, also commonly called manic depression, have extreme mood
swings that can alternate between intense, high periods (mania) and subsequent low periods
(depression). The manic episodes are characterized by increased energy, feeling euphoric or
irritable, and having poor judgment and impulsive behavior.

People with bipolar disorder may experience a range of manic and depressive emotions on their
way to a manic peak or a depressive low. There can be long periods of "feeling normal" between
episodes. The duration and timing of episodes can be unpredictable and will vary from person to
person. In general, however, manic episodes usually are shorter than depressive episodes. Manic
episodes can last days or weeks, sometimes longer, whereas depressive episodes can last months
or longer, especially if untreated.

Although no two people with bipolar disorder experience the same pattern of episodes, research
shows that the first episode of bipolar disorder in men is likely to be manic. In women, the first
episode usually is depressive. After the onset of this first episode, an average of five years passes
until the second episode. The time between subsequent episodes usually is shorter, which means
more frequent episodes of illness.

The pattern described above is only a generalization. Many people with bipolar disorder have a
different pattern. Also, a small percentage of people with bipolar disorder experience what is called
"rapid cycling." These people can alternate between depression and mania four or more times per
year. Some people may experience both manic and depressive symptoms at the same time, and this
is referred to as mixed state bipolar disorder.


What Are the Symptoms of Bipolar Disorder?

A person must have experienced at least one manic episode to be diagnosed with bipolar disorder.
Even if depression has not yet occurred or has not been diagnosed, one episode of mania is
enough to diagnose bipolar disorder. Symptoms of mania include:


Extreme irritability
Intense feelings of euphoria
Increased energy, activity and restlessness
Decreased need for sleep or insomnia
Racing thoughts
Rapid talking
Increased sexual drive
Drug or alcohol abuse
The depression that alternates with mania also has recognizable symptoms. They include:


Ongoing sad, anxious or empty feelings
A loss of interest in normally pleasurable activities, including sex
Appetite and weight changes (either loss or gain)
Sleep problems (insomnia, early morning wakening or oversleeping)
Irritability
A loss of energy and a sense of fatigue, or being "slowed down"
Feelings of guilt, worthlessness, helplessness
Feelings of hopelessness, pessimism
Difficulty in concentrating, remembering, making decisions
Thoughts of death or suicide, or suicide attempts
Ongoing body aches and pains or problems with digestion that are not caused by another medical
condition.

Who Gets Bipolar Disorder?

Approximately 1 percent of people in the United States have bipolar disorder. People of any age or
race can develop the condition, and men and women are equally likely to develop it. Men tend to
develop bipolar disorder with a mixture of highs and lows, whereas women tend to have more
cycles of depression than mania. Most people develop bipolar disorder in their 20s, but some show
symptoms of the disorder during childhood or adolescence, and some develop the illness much
later in life.

Researchers have found that people with parents, brothers or sisters who have bipolar disorder or
another mood disorder are more likely than others to develop bipolar disorder or major depression.


What Causes Bipolar Disorder?

Genetics plays a role in predisposing people to bipolar disorder. What causes the actual onset of
bipolar disorder in these people, however, is not well understood.

For example, research has shown that manic and depressive episodes may be triggered by major
life changes, emotional trauma or the loss of a relationship. Sometimes physical illnesses, hormonal
changes or medications – such as steroids, stimulants or certain antidepressant medications – can
trigger the onset of an episode. Alcohol or drug abuse, as well as lack of sleep, also may trigger the
illness. In other cases, however, episodes occur for no clear or major reason, especially after the
first episode.


How Is Bipolar Disorder Diagnosed?

In the depressive phase of bipolar disorder, most people, especially women, tend to seek medical
help on their own. During the manic phase of the illness, however, people often are brought to
medical attention by others, or they may seek medical help in the aftermath of the manic episode.

Occasionally, a person first gets help for bipolar depression at a hospital during a manic episode, or
during a severe or suicidal episode of depression. Usually, a psychiatrist will diagnose the
condition and oversee the treatment of bipolar disorder. Some people are treated by a family or
primary care physician, who might consult regularly with a psychiatrist. The psychiatrist or treating
physician may recommend a physical examination or laboratory tests as part of the medical
evaluation.

When first evaluating the person, the psychiatrist will ask many specific questions about the
person's symptoms, moods and feelings. The psychiatrist also may ask how the person's symptoms
affect his family, social life and work or school activities. The evaluation includes general questions
about the person's overall physical and mental health and family history, as well as questions to
help determine if the person has another mental health condition, such as an anxiety disorder or a
substance abuse problem, which often accompany bipolar disorder.


How Is Bipolar Disorder Treated?

Although some people only have one episode of the illness, for most, bipolar disorder is usually a
persistent and life-long condition. It is important for people to understand their illness and follow
their treatment plan carefully to manage the condition over time. Bipolar disorder can severely
impair personal relationships, the ability to work or go to school, and the ability to function in social
situations. With the right treatment, however, many people improve and lead successful and
gratifying lives.

Treatment of bipolar disorder involves taking medication, which requires careful monitoring and
occasional dosage adjustments to respond to side effects or changes in a person's condition.

Treatment also may involve psychiatric management and psychotherapy. Psychiatric management is
discussed below. Psychotherapy is a series of private talks with a psychiatrist where a person
discusses the feelings, thoughts and behavior that cause difficulty. A psychiatrist also can
recognize other mental and medical problems. The goal of psychotherapy is to help people
understand and master their problems so they can function better. It is critical that people with
bipolar disorder and their families find a psychiatrist they are comfortable working with and can
come to trust.

Getting Treated: Medications

The goals of treating bipolar disorder are to reduce the frequency and severity of manic and
depressive episodes, prevent their recurrence, improve functioning between episodes, and
support the person and the family as they adapt to changes caused by the condition.

Mood-Stabilizing Medications

Medication usually is necessary for controlling bipolar disorder. Lithium, a mood stabilizer, is the
most commonly used and studied medication for treating the condition. It is an effective treatment
for manic episodes, and it can help bipolar depression. Lithium also helps prevent future episodes,
so it is often prescribed for long periods of time, even in between episodes. Studies show that
approximately 50 percent to 80 percent of people with bipolar disorder who are treated with lithium
have some response to the medication.


In addition to lithium, several other mood-stabilizing medicines (chemical names: valproate,
olanzapine, risperidone, carbamazepine, lamotrigine and gabapentin) may be used alone or in
combination with lithium to treat bipolar disorder. These medicines have not been as extensively
studied as lithium, but they also have been shown to reduce the symptoms of manic episodes.


Mood-stabilizing medications can have bothersome side effects. Many people who take lithium gain
weight or have memory problems, poor concentration, tremors, sedation, impaired coordination,
nausea, diarrhea, hair loss, acne or altered white blood cell counts. Many of these side effects,
however, can be reduced or eliminated by adjusting the dosage or changing when the medication
is taken. The psychiatrist can work closely with the person who has bipolar disorder to minimize
side effects.


Because of these side effects, getting people with bipolar disorder to keep taking their medication
can be difficult. It can take some time and patience to find the right medication and dosage.
Treatment is complicated by the fact that many people with the condition deny they have the illness,
especially when they are having an episode. The intoxicating feelings of increased energy and
confidence that accompany a manic episode may cause the person with bipolar disorder to minimize
or deny the destructive behavior and damage to relationships and work that mania causes or the
hopelessness that comes with subsequent episodes of depression.


People with bipolar disorder who quit taking their mood-stabilizing medications often become ill
again. For this reason, family and spouses should encourage people with bipolar disorder to stick
to their treatment plan. Ongoing support is essential, but at times the family will need to come
together to insist that treatment occurs.


Other Medications

Other medications used to treat the manic phase of bipolar disorder include neuroleptics (such as
haloperidol, perphenazine, olanzapine and risperidone) and benzodiazepines (such as
clonazepam). Sometimes these are used alone or in combination with lithium or another mood-
stabilizing medication.


Antidepressant medication also may be prescribed, many times in combination with mood-
stabilizers, to treat or prevent the depressive phase of bipolar disorder. Because some preliminary
research shows that some antidepressants taken alone may increase the likelihood of having a
manic episode, the psychiatrist may prescribe both an antidepressant and a mood-stabilizer to help
prevent the problem or select an antidepressant thought to be less likely to provoke mania.
Antidepressant medications usually are prescribed for as short a time as possible.


For severe manic or depressive episodes, electroconvulsive therapy (ECT) can be safe and
effective. The psychiatrist may consider ECT for people with bipolar disorder who cannot tolerate or
do not respond to medications, or if the illness has become life-threatening. The treatment is safe
and highly effective, and it is administered in a medical setting under comfortable conditions.


Getting Treated: Psychiatric Management

Psychiatric management forms the foundation for all psychiatric treatment and begins the
psychotherapy process. People with bipolar disorder, especially when in the unstable phase of
their illness, will require psychiatric management. Psychiatric management generally involves some
or all of the following basic components.

Getting Educated
People with bipolar disorder (and their families) often benefit from learning about the disorder,
especially its symptoms, early signs of an episode, and types of treatment.

Developing a Relationship
It is important for the psychiatrist and the person with bipolar disorder to develop a good
relationship. They will have to work together and be patient trying to find the right medications and
dosages. People with bipolar disorder will need to work with a psychiatrist they trust to overcome
the symptoms of depression and manic episodes.

Establishing Routines
The psychiatrist may recommend establishing regular sleep, eating and activity patterns. Having
regular routines and taking care of their health appears to help people with bipolar disorder control
their moods.


Identifying Symptoms
The early warning signs of an approaching episode vary from person to person, but the psychiatrist
can help people with bipolar disorder and their families learn to identify what behavior changes can
signal the onset of an episode. (For some people it may be insomnia; for others it may be something
as apparently unrelated as going on shopping sprees or becoming suddenly and intensely involved
in religion.)

Adapting
The psychiatrist can help the person with bipolar disorder avoid the embarrassing behavior during
manic episodes that often causes a great deal of shame when the episode is over. They also can
help people set realistic goals for treatment, prepare for future episodes, and manage fear about
having another episode. Understanding the types of stress that can cause episodes and the
lifestyle changes that can reduce stress are important for adapting to the illness and getting
satisfaction from life.

Review

Bipolar disorder can become a debilitating illness if untreated. In most cases, however, treatment
can go a long way towards preventing bipolar episodes or reducing their frequency and intensity. It
can take time and patience to find the right treatment and then it may take some more time to see
results. Following the right treatment, however, can help people with bipolar disorder lead a
healthy, active and satisfying life.

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