Bipolar Disorder

In 1854 French psychiatrists Jules Baillarger and Jean-Pierre Falret made separate, independent presentations to the French Imperial Academy of Medicine in which they described a mental illness characterized by periodic shifts between mania and depression. Baillarger referred to this illness as “dual-form insanity” while Falret labeled it “circular insanity”. This marked the first appearance of bipolar disorder in the psychiatric and medical literature. In 1899 the German psychiatrist Emil Kraepelin, expanding on Baillarger and Falret’s earlier work, distinguished between two different forms of psychosis, manic-depressive psychosis (bipolar disorder) and dementia praecox (which would later become schizophrenia). The term manic-depressive illness was used to describe the disorder until 1980 and the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) which introduced the term bipolar disorder. In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), bipolar and related disorders are placed between the schizophrenia spectrum and other psychotic disorders and depressive disorders and serve as a bridge between these two diagnostic categories in terms of both symptoms and presentation.



Characteristic Symptoms

The bipolar disorders are characterized by cycling mood changes. The affected individual alternates between severe highs (manic or hypomanic episodes) and severe lows (major depressive episodes), often with periods of normal mood in between. The mood changes can be rapid but most often occur gradually.

A manic episode is a distinct period of increased energy and abnormally elated, irritable, or euphoric mood that is present for most of the day, nearly every day, for at least one week. During the episode, three or more of the following symptoms must also be present: higher than usual self-esteem, significantly reduced need for sleep, an increase in talkativeness, racing thoughts, distractibility, an increase in goal-directed behavior (either socially, at work or school, or sexually), psychomotor agitation, and excessive involvement in pleasurable activities that are risky or self-destructive (e.g., excessive spending, sexual promiscuity). Mania, left untreated, may worsen to a psychotic state.

A hypomanic episode is less intense and of shorter duration (at least 4 consecutive days) than a full manic episode. The most important differences between mania and hypomania are that the latter is not severe enough to cause marked impairment in daily functioning, or to require hospitalization, and no psychotic features are present.

A major depressive episode is characterized by either a persistent depressed mood or loss of interest or pleasure in daily activities over at least a two week period. Four or more of the following symptoms must also be present: significant weight change or change in appetite, sleeping too much or not being able to sleep at all, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, an inability to concentrate or indecisiveness, and recurrent suicidal thoughts.

Types of Bipolar Disorders

Bipolar I Disorder 

Bipolar I Disorder is characterized by a manic episode that lasts at least seven days is severe enough to cause marked impairment in the individual’s daily functioning or leads to  hospitalization to prevent harm to self or others, or the presence of psychotic symptoms. Major depressive episodes may occur as well but are not required to make the diagnosis for Bipolar I.

Bipolar II Disorder 

Bipolar II Disorder is characterized by a pattern of hypomanic and major depressive episodes, but the criteria for a full manic episode are not met. The hypomanic episode is associated with a clear change in daily functioning that is uncharacteristic of the individual.

Cyclothymic Disorder

Cyclothymic Disorder (Cyclothymia) is a milder form of bipolar disorder. Cyclothymic disorder is characterized by at least 2 years of periodic hypomanic and depressive symptoms. However, the symptoms do not meet the diagnostic criteria for any other type of bipolar disorder.


Prevalence and Age of Onset

The lifetime prevalence of the bipolar disorders in the United States is estimated to be 1.0% for bipolar I disorder, 1.1% for bipolar II disorder and 2.4% for cyclothymic disorder. Bipolar I disorder and cyclothymia affect men and women equally, while bipolar II disorder is more common in women. The age of onset for the first manic, hypomanic, or major depressive episode is usually late adolescence / early adulthood although it can occur at any age. The first episode in men tends to be mania or hypomania while the first episode in women is most often depression. Some individuals experience rapid-cycling between manic and depressive states, meaning they experience four or more episodes of major depression, mania, or hypomania within a year. Rapid-cycling is more common in women than men.



Treatment & Support

The bipolar disorders are chronic, biologically driven problems that require medication for effective symptom management. In addition, several forms of psychotherapy (talk therapy) have been shown to be effective in the treatment of Bipolar disorders.

Lithium

Unlike other psychiatric medications used to treat mental disorders, lithium carbonate (e.g., Eskalith, Lithobid) is a salt, and consequently, it does not have a specific receptor to which it binds in the brain. Rather, after administration lithium is widely distributed throughout the central nervous system where it is transported into the brain’s cells (neurons) through sodium channels in the cell membranes. Lithium appears to have a neuroprotective action by reestablishing chemical balance (homeostasis) in the neurons and decreasing their susceptibility to damage from both internal and external stimuli. It has been shown to promote neurogenesis (the growth of new brain cells). This medication, while highly effective, has a number of serious side effects, and the range between an effective dose and a toxic dose is quite small.

Anticonvulsants

A number of medications originally developed for treating seizure disorders have also been found to have mood-stabilizing affects. These include Valproic acid or divalproex sodium (Depakote), lamotrigine (Lamictal), gabapentin (Neurontin), topiramate (Topamax), oxcarbazepine (Trileptal) and carbamazepine (Tegretol). These medications appear to exert their mood-stabilizing affects through a neuroprotective action similar to lithium. Anticonvulsant medications are most often used in combination with lithium, antidepressants or atypical antipsychotics in the treatment of bipolar spectrum disorders.

Atypical Antipsychotics

Atypical antipsychotics modify the functioning of both dopamine and serotonin in the brain. These medications have been shown to have mood-stabilizing affects and are particularly useful for treating acute mania with or without psychotic symptoms. Atypical antipsychotics commonly used to in the treatment of bipolar spectrum disorders include olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon).

Psychotherapy

In psychotherapy, or what some would call “talking” therapy, a patient receives assistance from another individual in understanding and resolving problems that may be contributing to his or her disorder. The therapy sessions may focus on a number of issues, including helping the patient unlearn behavioral patterns that contribute to or result from his or her disorder, mend disrupted personal relationships, change negative thinking styles, and/or resolve conflicted feelings and emotions. Four psychotherapeutic approaches have been shown to be effective in treating bipolar spectrum disorders.

The major aim of cognitive-behavioral therapy (CBT) is to help the client eliminate negative beliefs and/or behaviors and replace them with positive ones. Symptom reduction is seen as an end in itself. Family-focused therapy (FFT) includes family members. This approach helps enhance family coping strategies, improves communication and teaches effective problem-solving skills. Interpersonal and social rhythm therapy (IPSRT) helps people with bipolar disorder identify and maintain the regular routines of everyday life. Regular daily routines and sleep schedules help protect against the onset of difficult symptoms. Interpersonal issues and problems that may arise which directly impact the person’s routines are also part of the therapy. The principal goal of psychoeducation (PE) is to provide accurate and reliable information about the disorder including ways of dealing with mental illness and its effects. Helping individuals become more knowledgeable and aware of their disorder gives them more control over their condition. This can help reduce the frequency and severity of symptoms.

 

A Spiritual Perspective

The bipolar disorders are destructive. Not only do they destroy the mind of the one who is afflicted, but they also destroy his or her relationships and family. Watching a loved one suffer with bipolar disorder makes it difficult to believe in God, let alone trust Him. How could a loving God allow such misery, such pain?

As finite beings, we are limited in our ability to grasp the broader meanings and purposes of trials and suffering in our lives. What we can rest in, however, is that God does understand them and that He is fully in control. God is both sovereign and good. We know that God is sovereign because He created and sustains all things (Deuteronomy 4:39; Daniel 4:34–35; Colossians 1:16–17). Without Him there is nothing, and nothing occurs apart from His divine will. We know He is good because He sent His beloved Son to die for us so that we might have new life (1 John 4:9). Recognizing God’s sovereignty and goodness helps us navigate through the difficult times, as we cry out with the psalmist: “But as for me, I trust in You, O Lord, I say, ‘You are my God.’ My times are in Your hand” (Psalm 31:14–15). We may never understand why our loved one is suffering, but we can be assured that God is in control and ready to provide sustaining grace to all those who seek Him (2 Corinthians 12:9).


Finding Care

Mental Health Care Providers

When assisting an individual it is important to help them find the right type of mental health care provider. These links will assist you in beginning your provider search. Knowing and building relationships with providers in your area can prove invaluable. Both in aiding the individual in getting an appointment, as well as, being able to better support them once they begin receiving professional treatment.

An individual struggling with a bipolar disorder needs to see both a clinical psychologist or therapist for psychotherapy (talk therapy) and a psychiatrist for medication.

By providing your zip code the following search engines will give you information about local mental health care providers.

Clinical Psychologists / Therapists Psychiatrists


Treatment Facilities

In some people, bipolar disorders can become so severe that hospitalization is needed. This may be necessary if the individuals seeking your care can’t take care of themselves properly or are in immediate danger of harming themselves or someone else. Psychiatric treatment at a hospital can help keep them calm and safe until their mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

By providing your zip code the following search engine will give you information about mental health treatment facilities in your area.

Substance Abuse and Mental Health Services Administration American Residential Treatment Association


Support Groups

Recognizing that community is one of the factors necessary for successful recovery, attending support groups can be a powerful and meaningful way to connect with others facing similar challenges. Support group experiences allow people affected by mental health difficulties and disorders to connect in a safe and supportive environment. Support groups are led by trained facilitators and teach coping skills, help reduce anxiety, build resiliency and provide a place for people to share common concerns and receive emotional support.

These links will give you information on support groups for bipolar disorders in your area.

Depression and  Bipolar Support Alliance National Alliance on Mental Illness Grace Alliance  Fresh Hope for Mental Health


Supporting the Family

Many times the family caring for an individual with a mental illness is overlooked. They are often the front line support for the individual. The responsibility of care can take a physical and psychological toll on caregivers. Many times the caregiver needs as much support as the individual that has the illness. Caregiver support groups are available for the families of those struggling with bipolar disorders.

These links will give you information on caregiver (family) support groups in your area.

National Alliance on Mental Illness – Family Support Group National Alliance on Mental Illness – Family to Family Support Group Grace Alliance  Fresh Hope for Mental Health




Educational Resources

Here are some links to aid you in learning more about bipolar disorders. The more knowledge you have, the better you are able to help those seeking your guidance.

National Institute of Mental Health Mental Health America


Downloadable Resources 

First Step – What to do once a diagnosis has been made.

Daily Steps – Developing a holistic mental health care plan.

Difficult Steps – Navigating destructive behavior and legal issues.