Bipolar disorder

Bipolar disorder, formerly called manic depression, causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts in the other direction, you may feel euphoric and full of energy. Mood shifts may occur only a few times a year or as often as several times a week.

Although bipolar disorder is a disruptive, long-term condition, you can keep your moods in check by following a treatment plan. In most cases, bipolar disorder can be controlled with medications and psychological counseling (psychotherapy).

There are several types of bipolar and related disorders. For each type, the exact symptoms of bipolar disorder can vary from person to person. Bipolar I and bipolar II disorders also have additional specific features that can be added to the diagnosis based on your particular signs and symptoms.

Criteria for bipolar disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing bipolar and related disorders. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Diagnostic criteria for bipolar and related disorders are based on the specific type of disorder:

• Bipolar I disorder. You’ve had at least one manic episode. The manic episode may be preceded by or followed by hypomanic or major depressive episodes. Mania symptoms cause significant impairment in your life and may require hospitalization or trigger a break from reality (psychosis).
• Bipolar II disorder. You’ve had at least one major depressive episode lasting at least two weeks and at least one hypomanic episode lasting at least four days, but you’ve never had a manic episode. Major depressive episodes or the unpredictable changes in mood and behavior can cause distress or difficulty in areas of your life.
• Cyclothymic disorder. You’ve had at least two years — or one year in children and teenagers — of numerous periods of hypomania symptoms (less severe than a hypomanic episode) and periods of depressive symptoms (less severe than a major depressive episode). During that time, symptoms occur at least half the time and never go away for more than two months. Symptoms cause significant distress in important areas of your life.
• Other types. These include, for example, bipolar and related disorder due to another medical condition, such as Cushing’s disease, multiple sclerosis or stroke. Another type is called substance and medication-induced bipolar and related disorder.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II disorder can be depressed for longer periods, which can cause significant impairment.

Criteria for a manic or hypomanic episode

The DSM-5 has specific criteria for the diagnosis of manic and hypomanic episodes:

• A manic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). The episode includes persistently increased goal-directed activity or energy.
• A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive or irritable mood that lasts at least four consecutive days.

For both a manic and a hypomanic episode, during the period of disturbed mood and increased energy, three or more of the following symptoms (four if the mood is only irritable) must be present and represent a noticeable change from your usual behavior:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (for example, you feel rested after only three hours of sleep)
• Unusual talkativeness
• Racing thoughts
• Distractibility
• Increased goal-directed activity (either socially, at work or school, or sexually) or agitation
• Doing things that are unusual and that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

To be considered a manic episode:

• The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in social activities or relationships; or to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
• Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

To be considered a hypomanic episode:

• The episode is a distinct change in mood and functioning that is not characteristic of you when the symptoms are not present, and enough of a change that other people notice.
• The episode isn’t severe enough to cause significant difficulty at work, at school or in social activities or relationships, and it doesn’t require hospitalization or trigger a break from reality.
• Symptoms are not due to the direct effects of something else, such as alcohol or drug use; a medication; or a medical condition.

Criteria for a major depressive episode

The DSM-5 also lists criteria for diagnosis of a major depressive episode:

• Five or more of the symptoms below over a two-week period that represent a change from previous mood and functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure.
• Symptoms can be based on your own feelings or on the observations of someone else.

Signs and symptoms include:

• Depressed mood most of the day, nearly every day, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)
• Markedly reduced interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
• Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
• Either insomnia or sleeping excessively nearly every day
• Either restlessness or slowed behavior that can be observed by others
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt, such as believing things that are not true, nearly every day
• Decreased ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death or suicide, or suicide planning or attempt

To be considered a major depressive episode:

• Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships
• Symptoms are not due to the direct effects of something else, such as alcohol or drug use, a medication or a medical condition
• Symptoms are not caused by grieving, such as after the loss of a loved one

Other signs and symptoms of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorders may include additional features.

• Anxious distress — having anxiety, such as feeling keyed up, tense or restless, having trouble concentrating because of worry, fearing something awful may happen, or feeling you may not be able to control yourself
• Mixed features — meeting the criteria for a manic or hypomanic episode, but also having some or all symptoms of major depressive episode at the same time
• Melancholic features — having a loss of pleasure in all or most activities and not feeling significantly better, even when something good happens
• Atypical features — experiencing symptoms that are not typical of a major depressive episode, such as having a significantly improved mood when something good happens
• Catatonia — not reacting to your environment, holding your body in an unusual position, not speaking, or mimicking another person’s speech or movement
• Peripartum onset — bipolar disorder symptoms that occur during pregnancy or in the four weeks after delivery
• Seasonal pattern — a lifetime pattern of manic, hypomanic or major depressive episodes that change with the seasons
• Rapid cycling — having four or more mood swing episodes within a single year, with full or partial remission of symptoms in between manic, hypomanic or major depressive episodes
• Psychosis — severe episode of either mania or depression (but not hypomania) that results in a detachment from reality and includes symptoms of false but strongly held beliefs (delusions) and hearing or seeing things that aren’t there (hallucinations)

Symptoms in children and teens

The same DSM-5 criteria used to diagnose bipolar disorder in adults are used to diagnose children and teenagers. Children and teens may have distinct major depressive, manic or hypomanic episodes, between which they return to their usual behavior, but that’s not always the case. And moods can rapidly shift during acute episodes.

Symptoms of bipolar disorder can be difficult to identify in children and teens. It’s often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. And children who have bipolar disorder are frequently also diagnosed with other mental health conditions.

The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual mood swings.

When to see a doctor

If you have any symptoms of depression or mania, see your doctor or mental health provider. Bipolar disorder doesn’t get better on its own. Getting treatment from a mental health provider with experience in bipolar disorder can help you get your symptoms under control.

Many people with bipolar disorder don’t get the treatment they need. Despite the mood extremes, people with bipolar disorder often don’t recognize how much their emotional instability disrupts their lives and the lives of their loved ones.

And if you’re like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out — and perhaps in financial, legal or relationship trouble.

If you’re reluctant to seek treatment, confide in a friend or loved one, a health care professional, a faith leader or someone else you trust. He or she may be able to help you take the first steps to successful treatment.

When to get emergency help

Suicidal thoughts and behavior are common among people with bipolar disorder. If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately.

Also consider these options:

• Reach out to a close friend or loved one.
• Contact a minister, spiritual leader or someone in your faith community.
• Call a suicide hotline number — in the United States, call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor. Use that same number and press 1 to reach the Veterans Crisis Line.
• Make an appointment with your doctor, mental health provider or other health care provider.

If you have a loved one who is in danger of committing suicide or has made a suicide attempt, make sure someone stays with that person. Call 911 or your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

The exact cause of bipolar disorder is unknown, but several factors may be involved, such as:

• Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
• Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a significant role in bipolar disorder and other mood disorders.
• Inherited traits. Bipolar disorder is more common in people who have a first-degree relative, such as a sibling or parent, with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.

Factors that may increase the risk of developing bipolar disorder or act as a trigger for the first episode include:

• Having a first-degree relative, such as a parent or sibling, with bipolar disorder
• Periods of high stress
• Drug or alcohol abuse
• Major life changes, such as the death of a loved one or other traumatic experiences

Conditions that commonly occur with bipolar disorder

If you have bipolar disorder, you may also have another health condition that’s diagnosed before or after your diagnosis of bipolar disorder. Such conditions need to be diagnosed and treated because they may worsen existing bipolar disorder or make treatment less successful. They include:

• Anxiety disorders. Examples include social anxiety disorder and generalized anxiety disorder.
• Post-traumatic stress disorder (PTSD). Some people with PTSD, a trauma- and stressor-related disorder, also have bipolar disorder.
• Attention-deficit/hyperactivity disorder (ADHD). ADHD has symptoms that overlap with bipolar disorder. For this reason, bipolar disorder can be difficult to differentiate from ADHD. Sometimes one is mistaken for the other. In some cases, a person may be diagnosed with both conditions.
• Addiction or substance abuse. Many people with bipolar disorder also have alcohol, tobacco or drug problems. Drugs or alcohol may seem to ease symptoms, but they can actually trigger, prolong or worsen depression or mania.
• Physical health problems. People diagnosed with bipolar disorder are more likely to have certain other health problems, such as heart disease, thyroid problems or obesity.

Left untreated, bipolar disorder can result in serious problems that affect every area of your life. These may include:

• Problems related to drug and alcohol use
• Suicide or suicide attempts
• Legal problems
• Financial problems
• Relationship troubles
• Isolation and loneliness
• Poor work or school performance
• Frequent absences from work or school

You may start by seeing your primary care doctor or you may choose to see a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist).

What you can do

Before your appointment, make a list of:

• Any symptoms you’ve had, including any that may seem unrelated to the reason for the appointment
• Key personal information, including any major stresses or recent life changes
• All medications, vitamins or other supplements that you’re taking, and their dose
• Questions to ask your doctor

Take a family member or friend along, if possible. That person may provide more information or remember something that you missed or forgot.

Some basic questions to ask your doctor include:

• Do I have bipolar disorder?
• Are there any other possible causes for my symptoms?
• What kinds of tests will I need?
• What treatments are available? Which do you recommend for me?
• What side effects are possible with that treatment?
• What are the alternatives to the primary approach that you’re suggesting?
• I have these other health conditions. How can I best manage these conditions together?
• Should I see a psychiatrist or other mental health provider?
• Is there a generic alternative to the medicine you’re prescribing?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don’t hesitate to ask questions at any time during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you or your loved ones first begin noticing your symptoms of depression, mania or hypomania?
• How frequently do your moods change?
• Do you ever have suicidal thoughts when you’re feeling down?
• Do your symptoms interfere with your daily life or relationships?
• Do you have any blood relatives with bipolar disorder or depression?
• What other mental or physical health conditions do you have?
• Do you drink alcohol, smoke cigarettes or use street drugs?
• How much do you sleep at night? Does it change over time?
• Do you go through periods when you take risks that you wouldn’t normally take, such as unsafe sex or unwise, spontaneous financial decisions?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

When doctors suspect someone has bipolar disorder, they typically do a number of tests and exams. These can help rule out other problems, pinpoint a diagnosis and also check for any related complications. These may include:

• Physical exam. A physical exam and lab tests may be done to help identify any medical problems that could be causing your symptoms.
• Psychological evaluation. Your doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms and possible episodes of mania or depression.
• Mood charting. To identify exactly what’s going on, your doctor may have you keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.
• Signs and symptoms. Your doctor or mental health professional typically will compare your symptoms with the criteria for bipolar and related disorders in the Diagnostic and Statistical Manual of Mental Disorders to determine a diagnosis.

Diagnosis in children

Although bipolar disorder can occur in young children, typically it’s diagnosed in the teenage years or early 20s.  It’s often hard to tell whether a child’s emotional ups and downs are normal for his or her age, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder.

Bipolar symptoms in children and teens often have different patterns than they do in adults and may not fit neatly into the categories used for diagnosis. And children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems.

Your child’s doctor can help you learn the symptoms of bipolar disorder and how they differ from behavior related to your child’s developmental age, the situation and appropriate cultural behavior.

Treatment is best guided by a psychiatrist skilled in treating bipolar and related disorders. You may have a treatment team that also includes a psychologist, social worker and psychiatric nurse.

Depending on your needs, treatment may include:

• Initial treatment. Often, you’ll need to start taking medications to balance your moods right away. Once your symptoms are under control, you’ll work with your doctor to find the best long-term treatment.
• Continued treatment. Bipolar disorder requires lifelong treatment, even during periods when you feel better. Maintenance treatment is used to manage bipolar disorder on a long-term basis. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
• Day treatment programs. Your doctor may recommend a day treatment program. These programs provide the support and counseling you need while you get symptoms under control.
• Substance abuse treatment. If you have problems with alcohol or drugs, you’ll also need substance abuse treatment. Otherwise, it can be very difficult to manage bipolar disorder.
• Hospitalization. Your doctor may recommend hospitalization if you’re behaving dangerously, you feel suicidal or you become detached from reality (psychotic). Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you’re having a manic or major depressive episode.

The primary treatments for bipolar disorder include medications and psychological counseling (psychotherapy), and may include education and support groups.

Medications

A number of medications are used to treat bipolar disorder. The types and doses of medications prescribed are based on your particular symptoms.

Medications may include:

• Mood stabilizers. Whether you have bipolar I or II disorder, you’ll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).
• Antipsychotics. If symptoms of depression or mania persist in spite of treatment with other medications, adding an antipsychotic medication such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may help. Your doctor may prescribe some of these medications alone or along with a mood stabilizer.
• Antidepressants. Your doctor may add an antidepressant to help manage depression. Because an antidepressant can sometimes trigger a manic episode, it’s usually prescribed along with a mood stabilizer or antipsychotic.
• Antidepressant-antipsychotic. The medication Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer. Symbyax is approved by the Food and Drug Administration specifically for the treatment of depressive episodes associated with bipolar I disorder.
• Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep. Benzodiazepines are generally used for relieving anxiety only on a short-term basis.

Side effects

Talk to your doctor or mental health provider about side effects. If side effects seem intolerable, you may be tempted to stop taking your medication or to reduce your dose on your own. Don’t do it. You may experience withdrawal effects or your symptoms may return.

Side effects often improve as you find the right medications and doses that work for you, and your body adjusts to the medications.

Finding the right medication

Finding the right medication or medications for you will likely take some trial and error. If one doesn’t work well for you, there are several others to try.

This process requires patience, as some medications need weeks to months to take full effect. Generally only one medication is changed at a time so that your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. Medications also may need to be adjusted as your symptoms change.

Medications and pregnancy

A number of medications for bipolar disorder can be associated with birth defects. Discuss these issues with your doctor:

• Birth control options, as birth control medications may lose effectiveness when taken along with certain bipolar disorder medications
• Treatment options if you plan to become pregnant
• Breast-feeding, as some bipolar medications can pass through breast milk to your infant

Psychotherapy

Psychotherapy is a vital part of bipolar disorder treatment and can be provided in individual, family or group settings. Several types of therapy may be helpful. These include:

• Cognitive behavioral therapy. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. It can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
• Psychoeducation. Counseling to help you learn about bipolar disorder (psychoeducation) can help you and your loved ones understand bipolar disorder. Knowing what’s going on can help you get the best support and treatment, and help you and your loved ones recognize warning signs of mood swings.
• Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on the stabilization of daily rhythms, such as sleep, wake and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise.
• Other therapies. Other therapies have been studied with some evidence of success. Ask your doctor if any other options may be appropriate for you.

Other treatment options

Depending on your needs, other treatments may be added to your depression therapy, such as:

• Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don’t work. Physical side effects, such as headache, are tolerable. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don’t get better with medications, can’t take antidepressants for health reasons or are at high risk of suicide. ECT may be an option if you have mania or severe depression when you’re pregnant and cannot take your regular medications.
• Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven’t responded to antidepressants. During TMS, you sit in a reclining chair with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you’ll have five treatments each week for up to six weeks.

Treatment in children and teenagers

Treatments for children and teenagers are generally decided on a case-by-case basis, depending on symptoms, medication side effects and other factors.

• Medications. Children and teens with bipolar disorder are often prescribed the same types of medications as those used in adults. There’s less research on the safety and effectiveness of bipolar medications in children than in adults, so treatment decisions are often based on adult research.
• Psychotherapy. Most children diagnosed with bipolar disorder require counseling as part of initial treatment and to keep symptoms from returning. Psychotherapy can help children develop coping skills, address learning difficulties, resolve social problems, and help strengthen family bonds and communication. And, if needed, it can help treat substance abuse problems, common in older children with bipolar disorder.
• Support. Working with teachers and school counselors and encouraging support from family and friends can help identify services and encourage success.

You’ll probably need to make lifestyle changes to stop cycles of behavior that worsen your bipolar disorder. Here are some steps to take:

• Quit drinking or using illegal drugs. One of the biggest concerns with bipolar disorder is the negative consequences of risk-taking behavior and drug or alcohol abuse. Get help if you have trouble quitting on your own.
• Steer clear of unhealthy relationships. Surround yourself with people who are a positive influence and won’t encourage unhealthy behavior or attitudes that can worsen your bipolar disorder.
• Get regular physical activity and exercise. Moderate, regular physical activity and exercise can help steady your mood. Working out releases brain chemicals that make you feel good (endorphins), can help you sleep and has a number of other benefits. Check with your doctor before starting any exercise program, especially if you’re taking lithium, to make sure exercise won’t interfere with your medication.
• Get plenty of sleep. Don’t stay up all night. Instead, get plenty of sleep. Sleeping enough is an important part of managing your mood. If you have trouble sleeping, talk to your doctor or mental health provider about what you can do.

Alternative medicine is the use of a nonconventional approach instead of conventional medicine. Complementary medicine is a nonconventional approach used along with conventional medicine.

There isn’t much research on alternative medicine and bipolar disorder. Most of the studies on alternative or complementary medicine that do exist are on major depression, so it isn’t clear how well most of these work for bipolar disorder.

• Omega-3 fatty acids. These oils may help improve depression associated with bipolar disorder. Bipolar disorder appears to be less common in areas of the world where people regularly eat fish rich in omega-3s. Omega-3s appear to have a number of health benefits, but more studies are needed to determine just how much they help with bipolar disorder.
• Magnesium. Several small studies have suggested that magnesium supplements may lessen mania and the rapid cycling of bipolar symptoms. More research is needed to confirm these findings.
• St. John’s wort. This herb may be helpful with depression. However, it can also interact with antidepressants and other medications, and it has the potential to trigger mania in some people.
• S-adenosyl-L-methionine (SAMe). This amino acid supplement appears to help brain function related to depression. It isn’t clear yet whether it’s helpful in people with bipolar disorder. As with St. John’s wort, SAMe can trigger mania in some people.
• Herbal combinations. Herbal remedies that combine a number of different herbs, such as those used in traditional Chinese medicine, haven’t been well-studied and the contents may vary among products. Risks and benefits still aren’t clear.
• Acupuncture. This ancient Chinese practice of inserting tiny needles into the skin may relieve depression, but more studies are needed to confirm its benefits. However, acupuncture is considered safe and can be done along with other bipolar disorder treatments.

If you choose to use complementary medicine in addition to your physician-recommended treatment, take some precautions first:

• Don’t stop taking your prescribed medications or skip therapy sessions. Alternative medicine is not a substitute for regular medical care when it comes to treating bipolar disorder.
• Be honest with your doctors and mental health providers.Tell them exactly which complementary treatments you use or would like to try.
• Be aware of potential dangers. Just because it’s natural doesn’t mean it’s safe. Before using alternative or complementary medicine, find out the risks, including possible interactions with medications.

Coping with bipolar disorder can be challenging. Here are some strategies that can help:

• Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan. Help educate your family and friends about what you’re going through.
• Stay focused on your goals. Recovery from bipolar disorder can take time. Stay motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
• Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
• Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
• Learn ways to relax and manage stress. Yoga, tai chi, massage, meditation or other relaxation techniques can be helpful.

Recommend this page

Share

Tweet

Email