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This is about a boy with Bipolar disorder, and what he goes through.

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Bipolar disorder is a confusing condition, especially for someone viewing it from the outside. If you have a friend or relative living with bipolar, this person may be reluctant to share how they feel. Because this can make it hard to know how the illness affects them, reading first-hand accounts of other people living with bipolar can help you understand the condition from their perspective.

Healthline talked to a 30-year-old man from California about what it's like to live with bipolar disorder. He explained he doesn't take medications, but prefers exercise, therapy, and nutritional supplements to help manage his condition.

Here, in his own words, is what it feels like to live with bipolar disorder. At his request, we've withheld his name. It should also be noted that this represents one person's experience. Other people with the same disorder may have vastly different experiences.

Bipolar mania

To outsiders looking in, bipolar mania comes in many forms. During these emotional highs, your friend or relative may become full of energy and overly excited about life. Mania can be mild, moderate, or severe, so you may not always link their happiness and elation with a mood disorder. Sometimes, all you see is a fun, optimistic, and upbeat person - the life of the party. But other times, you may notice erratic behaviors with their joyful mood.

This person may become more talkative, to the point where others can't get a word in. They may also speak fast, or come off as impulsive and easily distracted. While this may be confusing for you, this can be a great time for people living with bipolar.

Here is how this young man describes his mania episodes...

The mania part is awesome. I have tons of energy and don't want to stop.

The best part of mania is that I'm so optimistic about everything. You could crash a car through my house and I'd reply, "What a great time to build something new!" I'm my most creative during this process, so I'm doing as much as possible to capitalize on it. Artistic or constructive, I'm up for anything.

I have the most fun running around and entertaining people, making them laugh, and acting like a big clown. I get a lot of satisfaction from the laughs and smiles I can get out of people. It makes me feel invincible.

Every morning I wake up ready to go, even if I didn't get much sleep the night before. I don't really need that much sleep, so I just go and go and do so much. I see all my friends, have a blast, get everything done on my to-do list, and more.

And do I talk. I'm all over the place, dominating every conversation. I've been told I talk too fast and switch topics so quickly that it's hard for others to keep up with me. Sometimes I can't keep up with myself.

Unfortunately, this is when I go out more, spend all my money, and drink too much. I've been in a few fistfights during my mania, but it's not because I was really angry. Getting into a fight at a bar with some dude twice my size is exhilarating. I know it's destructive, but it's the greatest form of entertainment because it's raw, tough, and totally dangerous. I've yet to be seriously hurt in one of these fights, so I keep escalating each time. It's like a game to me.

An upside to the mania is that my sex drive goes haywire. I crave a lot more sex during this period and sometimes it's a bit much for my girlfriend.

During my mania, I feel like a god. I feel like I can do anything, so my self-worth skyrockets. I can't explain it, but when the mania burns out I've got nothing left. Without the highs of mania, I wouldn't be able to tolerate the lows of depression.

Bipolar depression

Mania isn't the only symptom of bipolar. People living with this disorder also have periods of depression and alternate between extreme highs and extreme lows. You may be all too familiar with these extremes and unpredictable moods.

Your relative could be laughing and having a great time one day. And then the next day, they disconnect from the family and isolate themselves for no apparent reason. They may have little to say, become easily irritated, or lose motivation, which can be a difficult time for everyone. Your relative may also simply revert to a normal amount of energy without symptoms of depression. They can remain like this until the next manic episode occurs.

Here is how this young man describes his bipolar depression...

When I'm depressed, I want to be left alone. It's not that I want to be by myself; I want everyone to disappear. I don't want to go anywhere, see anyone, or do anything. It's like no matter what I do, people are telling me I'm doing something wrong. So, the easiest way to feel better is to hide.

Seeing all those people carrying on, living their happy little lives is an annoying reminder of my bipolar disorder and how I'll never have that kind of stability. What's worse is hearing all the people I "entertain" while in my mania talk about how quiet I am and that I'm not entertaining. Do they try to cheer me up, or do something to make me laugh? No. They just want their clown back. It's annoying.

No matter what it is - work, hanging out with friends, exercise - I don't enjoy things because the smallest details annoy me. If friends invite me out, I imagine waiting for the bus, being crammed against angry people, waiting in lines, and all the other negative things. I think of every possible downside of something, which leaves me dreading the idea of doing anything.

I turn into this grumpy old man. I've contemplated suicide and have attempted it once before.

But the more I understand the problem, the more I know that the depression is temporary and I don't always think clearly during it. That self-reminder helps me from doing anything stupid.

When I think about the future, I don't like what I see. I can only envision more troubles, endless work, and an endless string of letdowns.

Here is how this young man describes 'the middle'...

This is what I imagine it's like for everyone else - you know, normal people. I wake up in the morning and I feel fine. I don't dread going about my day. I go to work, get things done, and have plenty of energy throughout the day.

I can roll with the punches the average day gives me. I'm not freaking out over small problems, I enjoy the little things, and I'm not loathing the future.

I feel normal and it's how I see myself. I'm not some lunatic running around or some mopey, lazy slug.

I honestly wish I could stay in this mindset all the time, but I know that won't happen. I've accepted that my moods will change on their own, so I enjoy the calm more when it's there.

Bipolar disorder in children

Keep in mind that bipolar symptoms in children differ from symptoms in adults. Symptoms in children may include:

periods of restlessness

aggression

irritability

trouble concentrating

hyperactivity

a change in sleep pattern

These behaviors don't always point to bipolar, but you should see a doctor if your child's moods become episodic and frequently shift between happiness and sadness.

Coping when a loved one has bipolar

Bipolar is unpredictable. Take it one day at a time. Healing doesn't happen overnight, and it's completely normal to worry about your relative during their mania and depressive episodes. You may fear them making reckless or irresponsible decisions, and harming themselves during an emotional low.

Bipolar can be a lifelong struggle. The more you learn about the condition, the easier it'll be to offer support. People with bipolar cannot control their emotions or moods. Remember, bipolar isn't a sign of weakness. It is a mental illness. Avoid insensitive or negative comments like "snap out of it," or "get a grip."

Let them know you're there to help in any way you can. Offering practical assistance can reduce their stress level and help keep their emotions under control. For example, help out around their house or offer to research local support groups for them.

Takeaway

Bipolar is a real disease that can have a huge impact on friends and loved ones. Treatment may help control symptoms. These include mood stabilizers, and for some people, antidepressants, anti-anxiety medication, exercise, and nutrition. Some people also benefit from counseling and support groups.

If you have bipolar, talk with your doctor to discuss a treatment plan.

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What Does It Feel Like to Have Bipolar Disorder? A Personal Story

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Bipolar disorder is a confusing condition, especially for someone viewing it from the outside. If you have a friend or relative living with bipolar, this person may be reluctant to share how they feel. Because this can make it hard to know how the illness affects them, reading first-hand accounts of other people living with bipolar can help you understand the condition from their perspective.

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This piece of art apparently shows how people with bipolar disorder feel. They feel as if they are trapped, they can be scared too.

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Countries With Bipolar Disorder (picture 5)

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Countries With Bipolar Disorder (picture 5)

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This graph shows that not many other countries have people with bipolar disorder, and America has most people with bipolar disorder, which is followed by New Zealand and Columbia.

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This photo shows what bipolar disorder is, where it comes from, and what branch it's in, in science of course.

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This chart shows more ways about how people with bipolar disorder may feel, and the symptoms that show with this disorder.

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This image shows how bipolar people's moods can vary, and change very quickly.

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This photo goes over the disorder, and tells others how people with bipolar disorder work.

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This article gives a basic summary of the disorder that most people know.

This disorder usually lasts a lifetime, which is pretty depressing. This disorder can be caused by abnormal brain structure, and function might have a role in that too.

If bipolar disorder is not treated, the patient could have damaged relationships, a poor school or job performance, and suicide.

A way to treat this disorder is medication and talk therapy. Both are a great combination that SHOULD treat x´s bipolar disorder.

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What is bipolar disorder?

Bipolar disorder is a mood disorder that can cause intense mood swings:

Sometimes you may feel extremely "up," elated, irritable, or energized. This is called a manic episode.

Other times you may feel "down," sad, indifferent, or hopeless. This is called a depressive episode.

You may have both manic and depressive symptoms together. This is called a mixed episode.

Along with mood swings, bipolar disorder causes changes in behavior, energy levels, and activity levels.

Bipolar disorder used to be called other names, including manic depression and manic-depressive disorder.

What are the types of bipolar disorder?

There are three main types of bipolar disorder:

Bipolar I disorder involves manic episodes that last at least 7 days or manic symptoms so severe that you need immediate hospital care. Depressive episodes are also common. Those often last at least two weeks. This type of bipolar disorder can also involve mixed episodes.

Bipolar II disorder involves depressive episodes. But instead of full-blown manic episodes, there are episodes of hypomania. Hypomania is a less severe version of mania.

Cyclothymic disorder, or cyclothymia, also involves hypomanic and depressive symptoms. But they are not as intense or as long-lasting as hypomanic or depressive episodes. The symptoms usually last for at least two years in adults and for one year in children and teenagers.

With any of these types, having four or more episodes of mania or depression in a year is called "rapid cycling."

What causes bipolar disorder?

The exact cause of bipolar disorder is unknown. Several factors likely play a role in the disorder. They include genetics, brain structure and function, and your environment.

Who is at risk for bipolar disorder?

You are at higher risk for bipolar disorder if you have a close relative who has it. Going through trauma or stressful life events may raise this risk even more.

What are the symptoms of bipolar disorder?

The symptoms of bipolar disorder can vary. But they involve mood swings known as mood episodes:

The symptoms of a manic episode can include

Feeling very up, high, or elated

Feeling jumpy or wired, more active than usual

Having a very short temper or seeming extremely irritable

Having racing thoughts and talking very fast

Needing less sleep

Feeling like you are unusually important, talented, or powerful

Do risky things that show poor judgment, such as eating and drinking too much, spending or giving away a lot of money, or having reckless sex

The symptoms of a depressive episode can include

Feeling very sad, hopeless, or worthless

Feeling lonely or isolating yourself from others

Talking very slowly, feeling like you have nothing to say, or forgetting a lot

Having little energy

Sleeping too much

Eating too much or too little

Lack of interest in your usual activities and being unable to do even simple things

Thinking about death or suicide

The symptoms of a mixed episode include both manic and depressive symptoms together. For example, you may feel very sad, empty, or hopeless, while at the same time feeling extremely energized.

Some people with bipolar disorder may have milder symptoms. For example, you may have hypomania instead of mania. With hypomania, you may feel very good and find that you can get a lot done. You may not feel like anything is wrong. But your family and friends may notice your mood swings and changes in activity levels. They may realize that your behavior is unusual for you. After the hypomania, you might have severe depression.

Your mood episodes may last a week or two or sometimes longer. During an episode, symptoms usually occur every day for most of the day.

How is bipolar disorder diagnosed?

To diagnose bipolar disorder, your health care provider may use many tools:

A physical exam

A medical history, which will include asking about your symptoms, lifetime history, experiences, and family history

Medical tests to rule out other conditions

A mental health evaluation. Your provider may do the evaluation or may refer you to a mental health specialist to get one.

What are the treatments for bipolar disorder?

Treatment can help many people, including those with the most severe forms of bipolar disorder. The main treatments for bipolar disorder include medicines, psychotherapy, or both:

Medicines can help control the symptoms of bipolar disorder. You may need to try several different medicines to find which one works best for you. Some people need to take more than one medicine. It's important to take your medicine consistently. Don't stop taking it without first talking with your provider. Contact your provider if you have any concerns about side effects from the medicines.

Psychotherapy (talk therapy) can help you recognize and change troubling emotions, thoughts, and behaviors. It can give you and your family support, education, skills, and coping strategies. There are several different types of psychotherapy that may help with bipolar disorder.

Other treatment options include:

Electroconvulsive therapy (ECT), a brain stimulation procedure that can help relieve symptoms. It uses a mild electric current and is done while you are under general anesthesia. ECT is most often used for severe bipolar disorder that is not getting better with other treatments. It may also be used when someone needs a treatment that will work more quickly than medicines. This might be when a person has a high risk of suicide or is catatonic (unresponsive).

Repetitive transcranial magnetic stimulation (rTMS), a brain stimulation procedure that uses magnetic waves to relieve depression. It is not as powerful as ECT, but with rTMS, you don't need general anesthesia. It also has a low risk of negative effects on your memory and thinking.

Light therapy has been shown to be effective for seasonal affective disorder (SAD). Many people with bipolar disorder also find that their depression gets worse during certain seasons, usually in the fall and winter. Light therapy may help with their symptoms.

Healthy lifestyle changes, such as getting regular exercise, having a consistent sleep schedule, and keeping a mood journal, can also help with your symptoms.

Bipolar disorder is a lifelong illness. But long-term, ongoing treatment can help manage your symptoms and enable you to live a healthy, successful life.

NIH: National Institute of Mental Health

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Bipolar disorder is a mood disorder that can cause intense mood swings. It's also called manic depression. Learn about the types, symptoms, treatment, and more.

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Bipolar Disorder, a Medical Student´s Point of View

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Bipolar Disorder, a Medical Student´s Point of View

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This medical student talks about bipolar disorder, of course. He talks about all the key events that happen with this disorder. those events consist of mood swings, manic or depressive episodes, really sad days, but then they can be euphoric in the matter of days or weeks, etc.

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Bipolar Disorder | Clinical Presentation

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This article overviews the signs of the disorder, the main things about the disorder, the risks of bipolar disorder, and lastly... treatments and therapies for bipolar disorder.

Sometimes, if a person has either severe episodes of mania, depression, or both; this can be a form of psychosis.

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National Institute of Mental Health (NIMH)

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Overview

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.

There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely "up," elated, irritable, or energized behavior (known as manic episodes) to very "down," sad, indifferent, or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

Bipolar I Disorder- defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depressive symptoms and manic symptoms at the same time) are also possible.

Bipolar II Disorder- defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder.

Cyclothymic Disorder (also called Cyclothymia)- defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

Sometimes a person might experience symptoms of bipolar disorder that do not match the three categories listed above, which is referred to as "other specified and unspecified bipolar and related disorders."

Bipolar disorder is typically diagnosed during late adolescence (teen years) or early adulthood. Occasionally, bipolar symptoms can appear in children. Bipolar disorder can also first appear during a woman's pregnancy or following childbirth. Although the symptoms may vary over time, bipolar disorder usually requires lifelong treatment. Following a prescribed treatment plan can help people manage their symptoms and improve their quality of life.

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

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Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels.

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Mental Hospital Experience (person has bipolar disorder)

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Mental Hospital Experience (person has bipolar disorder)

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This boy named Ryan has bipolar disorder and talks about his experience with this disorder and his psych ward journey. He says that the other patients were really sweet, but he was going through an episode whilst a boy turned him down, and did not want to date him. Which led to Ryan cutting himself, and engraving the word ¨Worthless¨ in his thigh.

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This article is all about how bipolar 1 and bipolar 2 are not real, and try their best to show their viewpoints, aka their "facts and proof" about how this disorder is just a hoax.

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This post was edited and updated on June 24, 2013, to address comments received from readers. I thank them for their input.

. . . . . . . . . . . . . . . .

DSM-IV's criteria for a manic episode are given below:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode

D. The mood disturbance is sufficiently severe to cause marked impairment in
occupational functioning or in usual social activities or relationships with others, or
to necessitate hospitalization to prevent harm to self or others, or there are psychotic
features.

E. The symptoms 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).

: Manic-like episodes that are clearly caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count
toward a diagnosis of Bipolar I Disorder.

The manic episode is an important part of the DSM system because it acts as the basis for a diagnosis of Bipolar Disorder. DSM lists several variations of Bipolar Disorder, each with its own specific criteria, but in general, if a person has had a manic or hypomanic episode, he has bipolar disorder.

Let's take a look at criterion A. This criterion calls for a distinct period of abnormally and persistently elevated expansive or irritable mood, lasting at least a week... The DSM defines elevated mood as: an exaggerated feeling of well-being or euphoria or elation. Expansive mood is defined as a lack of restraint in expressing one's feelings, frequently with an over-evaluation of one's significance or importance. Finally irritable mood is defined as being easily annoyed and provoked to anger.

So the very basis for a diagnosis of Bipolar Disorder is either feeling particularly good about everything or feeling particularly grumpy and angry. How can the same illness manifest itself in such completely different ways? And bear in mind that these are not relatively trivial, incidental aspects of the so-called illness. These are the defining features. The very essence of bipolar disorder - according to DSM - is an episode of profound happiness or an episode of profound grumpiness and irritability. This is indeed a strange illness.

But let's move on to criterion B. This provides a list of seven specific "symptoms," three of which must be present for a positive diagnosis. (Incidentally, if the mood problem in criterion A is "only irritable," then four items are needed from the list.)

This practice of providing a list of symptoms and specifying how many must be present in order to provide a diagnosis is very common in DSM and raises obvious difficulties. First is the arbitrariness of the number chosen. Why three? Why not two or four? The answer, of course, is because the APA says so. The second objection is that different groupings of three will generate very different presentations. For instance, a person meeting criteria 1, 3 and 4 will be grandiose, overly talkative, and somewhat scattered in his choice of topics. Whereas a person who meets criteria 2, 5, and 7 will be sleeping very little, very distractible, and will be maxing out his credit cards in unrestrained buying sprees. The notion that these two presentations are in fact manifestations of the same illness is untenable. This is particularly so in that the only justification for this position is that the APA say so.

A more important difficulty stems from the question: Why should these problems be considered indications of illness? Let's look at each of the so-called symptoms in turn.

1. inflated self-esteem or grandiosity.
In this context it is worth noting that one of the "symptoms" of a major depressive episode is "feelings of worthlessness..." So if you haven't got enough self-esteem, you're depressed, but if you have too much, you're manic. This raises the question: how much self-esteem is OK, and how much (or how little) is pathological? Who decides? In practice, of course, intake workers at mental health centers and hospitals make the decision, and the decision-making is intrinsically subjective and unreliable. In an informal way, we have all encountered individuals who are "full of themselves" to an obnoxious degree. Intuitively we attribute this kind of behavior either to an attempt to mask a marked sense of inferiority or to poor socialization training during childhood. The notion that this character trait is really a symptom of an illness is an extreme position for which the APA offers no proof. Indeed there isn't even an argument. The APA simply says so.

2. decreased need for sleep...
This is a complex subject. A great deal has been learned about sleep but much remains unknown. Sleeplessness might well be an indication of some neurological damage or illness, but might on the other hand be simply a reflection of individual differences. There are numerous reports in history of prominent individuals who managed perfectly well on four or five hours sleep each night. Others need eight or nine. It would require a neurological examination to determine if a particular sleep pattern were pathological or a variation of normal. But even if a pathological condition were established, this would indicate a neurological condition, not a so-called mental illness. It is also worth noting that a "decreased need for sleep" very often is nothing more than excessive intake of caffeine or other stimulant drugs.

3. more talkative than usual or pressure to keep talking
We've all encountered individuals who talk too much - who hog the conversation. This phenomenon is best conceptualized as rudeness, i.e. a disregard for the normal conventions that direct social intercourse. This particular form of rudeness is usually the result of poor training during childhood. Small children sometimes talk excessively and try to dominate social relationships in this way. If steps are not taken to train them towards a more give-and-take approach to conversation, they often carry this trait into adult life.

4. flight of ideas or subjective experience that thoughts are racing
DSM defines flight of ideas as: "A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When severe, speech may be disorganized and incoherent."

It's clear from this definition that the real issue here is not so much flight of ideas as flight of speech. Most people in fact experience flight of ideas on a fairly regular basis. It's called stream of consciousness, and it flows like a babbling brook, swishing and eddying around twists and turns, over rocks and sand banks, endlessly changing and shifting. Even as I write these words, for instance, my thoughts have flitted to actual streams and rivers I have known. The problem is not that the person experiences a bewildering array of successive ideas, but rather that he puts these ideas into words. Most of us learn to censor stream of consciousness material at an early age and to confine our speech to items that have meaning and relevance for our listeners. A small number of poets and song-writers have managed to make a good living by dispensing with this kind of censorship, but most of us confine our verbal utterances to those ideas that have cogency and relevance for others. We call it discipline or self-control. Once again, it is lacking in small children whose early speech does indeed reflect stream of consciousness material. Proud parents are usually delighted with this initially, because it represents a major developmental breakthrough. Most parents, however, fairly soon begin the process of training and coaching that results in what we would call normal speech. If this training does not occur or is thwarted or frustrated for whatever reason, then the individual grows up without acquiring this skill. As with many skills normally acquired in childhood, it can be extremely difficult to learn in later life.

This facet of the manic presentation then is best conceptualized as a deficit in training and socialization, rather than a symptom of a medical condition.

5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
This is essentially the same thing as the flight of ideas discussed above. The effect of splitting this phenomenon into two separate "symptoms" is to increase the likelihood of a positive "diagnosis." Remember, it takes three (or more) symptoms for a diagnosis. If a person displays flight of ideas, he will almost certainly also meet the criteria for distractibility. So you get two hits for the price of one. The primary purpose of DSM is to generate business for psychiatrists.

6. increase in goal-directed activity (either socially, at work, or school, or sexually )or
psychomotor agitation
Most people would probably see an increase in goal-directed activity as a good thing. Painting the garage or mowing the yard is better than vegetating in front of the television. But this is not quite what the APA has in mind by "goal-directed activity." Elsewhere in the text they describe goal-directed activity that is "excessive" and as examples they mention: " taking on multiple new business ventures...without regard for the apparent risks...," "...calling friends or even strangers at all hours of the day or night...;"
"...writing a torrent of letters on many different topics to friends, public figures, or the media."

It is clear that the real issue here is not goal-directed activity as such but rather irresponsible and inconsiderate activity. Once again, responsibility and consideration for others are attributes that we acquire during childhood through the normal methods of parental discipline, coaching, role modeling, etc.. When we see a person displaying a marked deficit in these areas the most parsimonious assumption is that his/her training and discipline in these areas was for some reason neglected or deficient. The notion that the person is ill is certainly not obvious. The APA offers no proof or even arguments for this position.

7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Once again, what's involved here is what most people would call irresponsibility: the kind of behavior we try to discourage in our children through the normal time-honored methods of discipline and example. The notion that these kinds of irresponsible and self-indulgent behaviors are in fact caused by a diagnosable illness is quite a reach. Bipolar disorder, like most of the other DSM diagnoses, is not something a person has, but is rather something that a person does. It is constantly presented by the APA, and by practitioners in the field, however, as something a person has (like diabetes) and something that is best treated with drugs.

I realize that many people reading this post will say that I've got it all wrong - that I've misrepresented the reality of the condition called bipolar disorder. They might say that people with this "diagnosis" are "crazy" - not just irresponsible or self-indulgent. And there is a measure of truth in this. Some of the individuals who are assigned this label do sometimes behave in a "crazy" fashion. But it's important to note that in the DSM, this aspect of the matter - "psychotic features" - is included almost as an afterthought. It is not one of the defining features of a manic episode. Rather, it is something that may be present.

What the APA is doing here is trying to have their cake and eat it too. By including the possibility of psychotic features, they create the impression that this is a very serious matter; but by not making psychotic features a requirement, they manage to extend the diagnostic net to include people with relatively mild problems.

I will discuss psychotic features in later posts on the topic of "schizophrenia."

The fact that lithium has a calming affect on individuals who behave in this manner is often cited as proof that the behavior in question really does stem from an illness. The logic is untenable. A couple of beers can be very effective in helping shy people overcome their inhibitions. Very few rational people would conclude from this that shyness is an illness and alcohol a "medication." In addition, lithium has a calming effect on all people - not just those who carry a diagnosis of bipolar disorder.

Lithium carbonate is a salt - found widely in nature - and until 1949 was sold openly in the United States as a substitute for table salt. Besides having a salty taste, lithium salt has a calming effect on people's behavior. With regards to the latter, the mechanism of action is unknown. There have been numerous proposed theories, but none has produced conclusive evidence or gathered much support.

In some respects the shyness/alcohol analogy mentioned earlier is even more apt. The chronically shy person can acknowledge his problem and take corrective action using the normal time-honored methods of effecting personal change. Or he can simply drink a couple of beers before every social situation. Either solution to the problem will work. Similarly the manically irresponsible person can acknowledge his problem behaviors and tackle them in the normal way - or he can take lithium carbonate. The latter is often quite effective in dampening the behavioral excesses, but like the alcohol, it also has some long-term side effects.

The central point of this and my earlier posts is that there are no mental illnesses. There are problems of living - problems that human beings encounter, sometimes resolve, sometimes live with. The so-called mental illnesses are an attempt to explain or understand these phenomena, but as explanations they are spurious, unhelpful, and indeed, counter-productive. They are merely labels.

A perfect analogy to the mental illness explanation of human problems is the phlogiston explanation of fire or the witchcraft theories of illness and crop destruction. The popularity of a concept is often independent of its validity. The phlogiston theory of fire is a good example. This theory, which held sway among scientists during the 1600's and most of the 1700's, maintained that combustible objects contain an element called phlogiston which was released when the object was burned. Non-flammable objects simply didn't have this substance. Towards the end of the 1700's evidence was gradually amassed to debunk the theory in favor of the oxygen-combination ideas of today. Many scientists, however, including Joseph Priestley (the discoverer of oxygen!), tried to cling to the older theory. Similarly, in former years, sickness and crop failures were often attributed to witchcraft. Here again, we have a spurious theory, i.e. that sickness and crop failures are caused by the actions of these so-called witches. Such thinking - back in the days - was very widespread, and witch-burnings were popular events. But the concept was nonsense, and today, thanks to science, we have a better understanding of the causes of illnesses and crop failures. Popularity is a very unreliable barometer for conceptual validity. Phlogiston doesn't exist. There's no such thing as witchcraft. And there are no mental illnesses. Fire, however, does exist. Crop failures and illness are realities. And human problems of living are real. People are complex and diverse and the problems we encounter on our journey through life are also complex and diverse. Some of the problems we meet are relatively minor and easy to deal with. Others can be truly overwhelming. Some are indeed medical problems and require medical help. Others do not.

The so-called mental illnesses are problems that do not require medical help. The medicalization of all human problems of living is as spurious as the phlogiston and witchcraft theories mentioned earlier. It is also counter-productive. Drugs are not an effective solution to life's problems any more than the burning of so-called witches was a solution to crop failures or illness.

The medicalization of all human problems is about turf. The American Psychiatric Association is the psychiatrists' trade union, and has as its primary agenda the promotion of its members' interests. There's nothing intrinsically wrong with this - all trade associations do the same. That's why they exist. The problem with the APA, however, is that they have been so successful. At the present time one would be hard pressed to identify any problem of human living that is not covered by a DSM "diagnosis." The purpose of these diagnoses is to legitimize psychiatric intervention and the prescription of drugs in any and every human problem.

At the risk of repetition, I am not saying that people should not use drugs. It is not for me to tell people what they should or should not ingest. These are decisions that people have to make for themselves. What I do object to, though, are the spurious notions that these pharmaceutical products are medicines, and that they are being prescribed to combat illnesses.

Next Post: Adjustment Disorder: Everyone can have a mental illness

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This post was edited and updated on June 24, 2013, to address comments received from readers. I thank them for their input. . . . . . . . . . . . . . . . . DSM-IV's criteria for a manic episode are given below: A.

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This article is about how bipolar disorder functions, the symptoms, the experience, and the treatment for this particular disorder.

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Ursula McCormick, MSN, RN, PMHCNS‐BC, (Clinical Nurse Specialist), 1 Bethany Murray, PhD, RN, PMHCNS‐BC, (Clinical Assistant Professor), 2 and Brittany McNew, MSN, RN, PMHNP‐BC, (Nurse Practitioner) 1

Purpose

This review article provides an overview of the frequency, burden of illness, diagnosis, and treatment of bipolar disorder (BD) from the perspective of the advanced practice nurses (APNs).

Data sources

PubMed searches were conducted using the following keywords: "bipolar disorder and primary care," restricted to dates 2000 to present; "bipolar disorder and nurse practitioner"; and "bipolar disorder and clinical nurse specialist." Selected articles were relevant to adult outpatient care in the United States, with a prioritization of articles written by APNs or published in nursing journals.

Conclusions

BD has a substantial lifetime prevalence in the population at 4%. Because the manic or depressive symptoms of BD tend to be severe and recurrent over a patient's lifetime, the condition is associated with significant burden to the individual, caregivers, and society. Clinician awareness that BD may be present increases the likelihood of successful recognition and appropriate treatment. A number of pharmacological and nonpharmacological treatments are available for acute and maintenance treatments, with the prospect of achieving reduced symptom burden and increased functioning for many patients.

Implications for practice

Awareness of the disease burden, diagnostic issues, and management choices in BD has the potential to enhance outcome in substantial proportions of patients.

Keywords: Primary care, bipolar disorder, managed care, mental health, nurse practitioners

Definitions in BD

Patients with BD experience recurrent episodes of pathologic mood states, characterized by manic or depressive symptoms, which are interspersed by periods of relatively normal mood (euthymia; Figure ; Vieta & Goikolea, 2005). Formal definitions of manic and depressive symptoms are included in the recently updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM‐5; American Psychiatric Association, 2013). Notably, the depressive episodes of BD are defined by the same criteria as MDD in the DSM‐5, so that distinguishing BD from MDD frequently depends on identifying a history of manic or hypomanic symptoms (Table ).

Table 1

▪ At least one lifetime manic episode is required for a diagnosis of BD I

▪ Period of abnormally and persistently elevated, expansive, or irritable mood and increased energy and activity lasting at least 1 week

▪ Three or more of following symptoms (four symptoms if the mood is irritable):

* Low self‐esteem

* Decreased sleep

* Pressured speech

* Racing thoughts

* Activity at heightened levels

* Goal agitation

* Risk‐taking behaviors

▪ Symptoms severe enough to cause marked impairment

▪ At least one past or current hypomanic episode and a past or current major depressive episode are required for diagnosis of BD II

▪ Period of abnormally and persistently elevated, expansive, or irritable mood and increased energy and activity lasting at least 4 days

▪ Same symptoms as for a manic episode

▪ Mood disturbance observable by others

▪ Symptoms not severe enough to cause marked impairment

▪ At least one past or current hypomanic episode and a past or current major depressive episode are required for diagnosis of BD II

▪ Criteria are same for MDD and for depressive episodes of BD

▪ Five or more of the following symptoms over a 2‐week period (depressed mood or loss of interest or pleasure present, nearly every day)

* Depressed mood

* Loss of interest or pleasure

* Weight loss/gain

* Insomnia/hypersomnia

* Agitation

* Fatigue

* Worthlessness

* Lack of focus

* Suicidal ideation

▪ Significant distress or impairment

Rapid cycling

Four or more episodes of manic, hypomanic, or major depressive episodes

during a 12‐month period

Anxious distress

At least two of the following symptoms (on most days during the most recent mood episode):

▪ Keyed up or tense

▪ Unusually restless

▪ Difficulty concentrating

▪ Fear something awful may happen

▪ Feeling individual might lose control

▪ Manic or hypomanic episode, with mixed features

▪ Depressive episode, with mixed features

Criteria for a manic or hypomanic episode, with at least three depressive symptoms

Criteria for a depressive episode, with at least three manic/hypomanic symptoms

There are two major types of BD. Bipolar I disorder (BD I) is defined by the presence of at least one episode of mania, whereas bipolar II disorder (BD II) is characterized by at least one episode of hypomania and depression. The main distinction between mania and hypomania is the severity of the manic symptoms: mania results in severe functional impairment, it may manifest as psychotic symptoms, and often requires hospitalization; hypomania does not meet these criteria (American Psychiatric Association, 2013).

The duration of mood episodes is highly variable, both between patients and in an individual patient over time, but, in general, a hypomanic episode may last days to weeks, a manic episode lasts weeks to months, and a depressive episode may last months to years (Benazzi, 2007; Manning, 2010; Valente & Kennedy, 2010). Although a history of depressive episodes is not required to make a diagnosis of BD I by the DSM‐5 criteria, in practice most patients do experience depressive episodes; however, depressive episodes are required for a diagnosis of BD II. Long‐term studies show that patients with BD, regardless of the subtype, experience symptomatic episodes of depression more frequently and for longer durations than manic or hypomanic episodes (Baldessarini et al., 2010; Geddes & Miklowitz, 2013; Judd et al., 2003; Valente & Kennedy, 2010).

While a mood episode may consist solely of manic or depressive symptoms, it may also include a combination of these symptoms. Such episodes are newly defined in DSM‐5 as either a manic or hypomanic episode with mixed features or a depressive episode with mixed features, depending on which symptoms are predominant (American Psychiatric Association, 2013; Table ).

Rapid cycling is a term describing the occurrence of at least four mood episodes within 1 year. Identification of rapid cycling is important, because these patients are less responsive to treatment. Rapid cycling should be considered a "red flag" that indicates the need for referral to specialist care.

Table 2

The Mood Disorder Questionnaire bipolar screening tool

Please answer each question to the best of your ability.

1. Has there ever been a period of time when you were not your usual self and ...

3. How much of a problem did any of these cause you-like being unable to work; having family, money, or legal troubles; getting into arguments or fights?
Please circle one response only.

▪ No problem

▪ Minor problem

▪ Moderate problem

▪ Serious problem

For a positive screen, 7 of the 13 items in no. 1 must be Yes, no. 2 must be Yes, and no. 3 must be moderate or serious.

Pharmacotherapy

Pharmacological treatment is fundamental for successfully managing patients with BD. For acute episodes, the objective is symptom reduction, with the ultimate goal of full remission. For maintenance treatment, the goal is to prevent the recurrences of mood episodes. Medications used in the treatment of BD include mood stabilizers (e.g., lithium, valproate, lamotrigine, and carbamazepine), atypical antipsychotics, and conventional antidepressants (Geddes & Miklowitz, 2013; Hirschfeld, Bowden, & Gitlin, 2002). Table lists the medications that are approved by the U.S. Food and Drug Administration (FDA) in treating the different phases of BD.

Table 3

Mood stabilizers

Lithium was the first agent to be used in the treatment of BD. Although it has many limitations, including a delayed onset of action in the treatment of acute mania, limited efficacy in the treatment of bipolar depression, and a narrow therapeutic window, lithium still has an important role today (Geddes, Burgess, Hawton, Jamison, & Goodwin, 2004; Hirschfeld et al., 2002). In particular, lithium has shown efficacy in preventing recurrence of manic episodes and it is the only medication correlated with a reduced risk of suicide in BD. A study that reduced the lithium dosage (to increase its tolerability) reported no benefit from using lithium plus optimized personalized treatment when compared to optimized personalized treatment alone (Nierenberg et al., 2013).

Sodium valproate is the most commonly used mood stabilizer. It has a more rapid onset of action than lithium for the acute treatment of mania, and was superior to placebo as an acute therapy in the largest study performed to date (Bowden et al., 1994), but the evidence for its efficacy as a maintenance treatment for mania is not so robust (Geddes et al., 2010; Kessing, Hellmund, Geddes, Goodwin, & Andersen, 2011). Placebo‐controlled studies of carbamazepine describe significant efficacy in acute mania (Weisler, Kalali, & Ketter, 2004; Weisler et al., 2005). In the absence of long‐term controlled studies, a naturalistic study over an average of 10 years reported that carbamazepine is efficacious in most patients (Chen & Lin, 2012). Lamotrigine, in contrast to the other mood stabilizers, is more effective for preventing the recurrence of depressive than manic episodes of BD (Vieta & Valenti, 2013). Lamotrigine has also been investigated for the treatment of acute bipolar depression, but the evidence for efficacy is less convincing (Geddes, Calabrese, & Goodwin, 2009). A study of lamotrigine in acute mania reported no significant difference from placebo (Frye et al., 2000).

There are a number of safety and tolerability concerns with mood stabilizers that impact their long‐term use. Lithium requires regular monitoring of blood levels, because the therapeutic window is narrow. Lithium can cause progressive renal insufficiency and thyroid toxicity. After initial assessment of renal and thyroid functions, repeat monitoring of renal and thyroid functions every 6 months is recommended to ensure normal functioning (Price & Heninger, 1994). The most common adverse events associated with lithium include tremors as well as gastrointestinal problems such as nausea, vomiting, and diarrhea. Hepatotoxicity is the most common serious adverse event associated with valproate (risk: 1/20,000); other adverse effects include nausea, dizziness, somnolence, lethargy, infection, tinnitus, and cognitive impairment. Monitoring is required for hematologic abnormalities including low platelet count, low white blood count, and, in some cases, bone marrow suppression during valproate therapy (Martinez, Russell, & Hirschfeld, 1998). Carbamazepine is associated with reduced tolerability during rapid dose titration and its potential for interaction with other psychiatric and nonpsychiatric medications further limits its use (Grunze et al., 2009). Carbamazepine has an FDA boxed warning for agranulocytosis and aplastic anemia and is associated in approximately 10% of patients with the formation of a benign rash. Lamotrigine, which is overall the best‐tolerated medication in this class, can cause a rash like the Stevens-Johnson rash. Lamotrigine has been studied specifically in relation to fetal cleft palate formation; however, the evidence remains unconvincing. Fetal exposure to valproate, carbamazepine, and lithium can be teratogenic (Connolly & Thase, 2011; Dodd & Berk, 2004; Geddes & Miklowitz, 2013; Hirschfeld et al., 2002; Tatum, 2006).

Atypical antipsychotics

The atypical antipsychotics were developed in the modern era of psychopharmacology; all agents in this class have been studied by randomized controlled trials in the treatment of BD (Derry & Moore, 2007; Yatham et al., 2013). For the treatment of acute bipolar mania, all approved atypical antipsychotics (also called "second‐generation" antipsychotics) demonstrate efficacy and acceptable safety. For acute bipolar depression, however, few atypical antipsychotics have demonstrated efficacy. Only quetiapine (immediate‐release [IR] and extended‐release [XR] formulations) has proven efficacy as monotherapy for treating acute depressive episodes of BD I or BD II (Table ; Calabrese et al., 2005; Suppes et al., 2010; Thase et al., 2006). A fixed‐dose combination of olanzapine and fluoxetine has demonstrated efficacy for treating acute depressive episodes of BD I (Tohen et al., 2003) and lurasidone has recently received FDA approval as monotherapy or adjunctive therapy (with either lithium or valproate) in BD I but not BD II (Loebel et al., 2014a, 2014b).

For the maintenance treatment of BD I, FDA‐approved atypical antipsychotics include aripiprazole, olanzapine, quetiapine (IR and XR), risperidone long‐acting injection (LAI), and ziprasidone; these agents are approved either as monotherapy or as adjunctive therapy in combination with a mood stabilizer. A recent meta‐analysis of trials of the atypical antipsychotics in maintenance treatment concluded that aripiprazole, olanzapine, quetiapine (IR or XR), and risperidone LAI monotherapy were statistically superior to placebo for treating manic or mixed episodes, while quetiapine alone was also significantly effective against recurrence of depressive episodes (Vieta et al., 2011).

Conventional antidepressants

The proper use of conventional antidepressants is an area of controversy in the treatment of BD (Pacchiarotti et al., 2013). The main concern in using antidepressants as monotherapy in patients with bipolar depression is the risk of precipitating a switch to mania/hypomania, which is estimated to occur in between 3% and 15% of cases (Pacchiarotti et al., 2013; Tondo, Baldessarini, Vazquez, Lepri, & Visioli, 2013; Vazquez, Tondo, & Baldessarini, 2011). Another unresolved issue is whether maintenance treatment that includes antidepressants is effective for the prevention of recurrence (Pacchiarotti et al., 2013; Vazquez et al., 2011). If conventional antidepressants are used, it is recommended to combine them with a mood stabilizer or an atypical antipsychotic, and to taper the antidepressant dose following remission of the episode (Amit & Weizman, 2012; Connolly & Thase, 2011; Hirschfeld et al., 2002; Yatham et al., 2013). Contemporary guidelines recommend selective serotonin reuptake inhibitors (SSRIs) or bupropion rather than selective serotonin‐norepinephrine reuptake inhibitors (SNRIs) or tricyclics, as SSRIs and bupropion are less likely to cause manic switch. While full consensus is currently absent, there is wide agreement that antidepressant monotherapy should be avoided in patients with BD I and patients with BD II with two or more concomitant core manic symptoms, while antidepressants should be avoided entirely in patients with rapid cycling or those being treated for a mixed episode (Pacchiarotti et al., 2013).

Psychosocial treatments

Psychosocial treatments, including individual psychotherapies as well as educational and supportive group therapies, are increasingly considered an integral part of the treatment of BD (Connolly & Thase, 2011; Geddes & Miklowitz, 2013). Common components of psychosocial treatments are education about the disease and a focus on treatment adherence and self‐care. Interestingly, among the psychosocial treatments, the strongest evidence for effectiveness is for group psychoeducation of patients and caregivers (Colom et al., 2009; Reinares et al., 2008). Long‐term benefits of this approach include a reduction in days with symptoms and in days hospitalized (Colom et al., 2009).

Peer support

BD impacts all aspects of a person's life, causing severe disruption to relationships, employment, and education. Peer support can be very helpful in dealing with the consequences of these effects through sharing of experiences, where patients can discover that others have had similar experiences and can have hope for recovery, stability, and a satisfying life. Support groups, sponsored by national organizations, may be available locally or regionally. There is also a wealth of resources available online (Table ).

Table 4

Resource

Contact

Summary description of services

Information helpline: 1‐800‐950‐NAMI (6264)

and support to patients and families. Especially valuable for caregivers and families with special educational and support programs.

Ph: 1‐800‐969‐6642

families to find treatment, support groups, and information on issues such as medication and financial concerns around treatment.

Ph: 1‐978‐992‐0008

maintained by a psychologist, Dr. Grohol. It is not specific to BD but covers the disorder comprehensively. Special features include an "ask the therapist" facility and moderated online support groups.

Nonadherence

Nonadherence is probably the most significant factor contributing to poor treatment outcome in BD (Hassan & Lage, 2009; Lew, Chang, Rajagopalan, & Knoth, 2006), which leads to increased emergency room visits and hospitalization (Hassan & Lage, 2009; Lage & Hassan, 2009; Lew et al., 2006; Rascati et al., 2011). Investing more time and resources to work with patients during symptom‐free periods is likely to be cost saving by reducing the utilization of these high‐cost resources (Zeber et al., 2008).

Comorbid psychiatric disorders

Comorbid medical disorders

The burden of medical disorders may be increased by the adverse effects of BD treatment, by cooccurring substance misuse or by decrements in self‐care secondary to BD itself (McIntyre, 2009). For example, depression typically deprives patients of the motivation and energy to engage in treatment for chronic medical conditions. Early recognition and treatment of medical disorders in patients with BD has been shown to have a major beneficial effect on all‐cause mortality (Crump, Sundquist, Winkleby, & Sundquist, 2013).

Women of childbearing age

Women are at high risk of BD recurrence during pregnancy, especially if medications are discontinued, as well as during the postpartum period. Balancing the risk of medications against the need to prevent a mood episode requires active collaboration between the healthcare providers and the patient (McKenna et al., 2005). Teratogenicity is a potential risk with most of the mood stabilizers; lamotrigine may be an exception, but there are no well‐controlled studies in humans to confirm this. Atypical antipsychotics, with the exception of lurasidone, are rated FDA pregnancy category C, meaning that they have not been shown to be either safe or unsafe for use during pregnancy; lurasidone is classed in pregnancy category B based on current data.

Suicide

Alcohol abuse in patients with BD is associated with further elevation in the risk of suicide, particularly in the presence of concurrent drug use disorders. A study that investigated this association concluded that higher suicide attempt rates in patients with BD I and alcoholism were mostly explained by higher aggression scores, while the higher rates of attempted suicide associated with other drug use disorders appeared to be the result of higher impulsiveness, hostility, and aggression (Sublette et al., 2009). This study, similar to previous reports, found that earlier age of bipolar onset increased the likelihood that alcohol use disorder would be associated with suicide attempts. Effective clinical management of substance use disorders has the potential to reduce the risk of suicidal behavior in these patients with BD.

Table 5

Prepare

Provide psychiatric

Provide medical

Provide support

the practice

Diagnose BD

treatment

treatment

and counseling

Define level of management to be assumed by practice.

Obtain agreement of clinical staff.

Set up systems for followup, monitoring, and recall.

Contact referral and support services for mania and suicidality and pharmacologic expertise.

Develop crisis response strategies.

Prepare compendium of web resources.

Screen for BD and psychiatric comorbidities in those positive on depression screening.

Obtain family and social history.

Establish treatment goals and therapeutic alliance.

Link with psychiatric and community colleagues for referrals.

Provide education to patients and their families about the disorder and its treatments, including treatment adherence.

Initiate followup, monitoring.

Collaborate with psychiatric clinician as necessary.

Check for medical comorbidities (e.g., cardiovascular problems, lipid abnormalities, diabetes).

Treat medical comorbidities aggressively.

Monitor for psychotropic medication side effects.

Collaborate with specialists as necessary.

Instruct in self‐monitoring and response to prodromal symptoms.

Provide support through transitions.

Improve problem‐solving skills.

Facilitate connection to support groups, online support, and so on.

American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

Connolly K. R., & Thase M. E. (2011). The clinical management of bipolar disorder: A review of evidence‐based guidelines. Primary Care Companion for CNS Disorders, 13, pii: PCC.10r01097. doi:10.4088/PCC.10r01097.

Culpepper L. (2010). The role of primary care clinicians in diagnosing and treating bipolar disorder. Primary Care Companion to the Journal of Clinical Psychiatry, 12(Suppl 1), 4-9. doi:10.4088/PCC.9064su1c.01.

Hirschfeld R. M., Bowden C. L., & Gitlin M. J. (2002). Practice guideline for the treatment of patients with bipolar disorder. American Psychiatric Association. Retrieved from http://dbsanca.org/docs/APA_Bipolar_Guidelines.1783155.pdf.

Hoyle S., Elliott L., & Comer L. (2015). Available screening tools for adults suffering from bipolar affective disorder in primary care: An integrative literature review. Journal of the American Association of Nurse Practitioners, 27, 280-289.

Manning J. S. (2010). Tools to improve differential diagnosis of bipolar disorder in primary care. Primary Care Companion to the Journal of Clinical Psychiatry, 12(Suppl 1), 17-22. doi:10.4088/PCC.9064su1c.03.

Miller K. (2006). Bipolar disorder: Etiology, diagnosis, and management. Journal of the American Association of Nurse Practitioners, 18, 368-373. 10.1111/j.1745-7599.2006.00148.x.

National Collaborating Centre for Mental Health (UK) . (2006). Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. Living with bipolar disorder: Interventions and lifestyle advice. British Psychological Society. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK55353/

The Management of Bipolar Disorder Working Group . (2010). VA/DoD clinical practice guidelines for management of bipolar disorder in adults Washington, DC: Department of Veterans Affairs, Department of Defense.

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Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses

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Ursula McCormick, MSN, RN, PMHCNS‐BC, (Clinical Nurse Specialist), 1 Bethany Murray, PhD, RN, PMHCNS‐BC, (Clinical Assistant Professor), 2 and Brittany McNew, MSN, RN, PMHNP‐BC, (Nurse Practitioner) 1 This review article provides an overview of the frequency, burden of illness, diagnosis, and treatment of bipolar disorder (BD) from the perspective of the advanced practice nurses (APNs).

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Bipolar 1 is when someone has experienced at least one manic episode, which CAN be followed by hypomanic or really bad depressive episodes.

Bipolar 2 is where one has experienced one depressive episode and one hypomanic episode too, but they don't have manic episodes like bipolar 1.

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Overview

Bipolar disorder, formerly called manic depression, is a mental health condition that 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 to mania or hypomania (less extreme than mania), you may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep, energy, activity, judgment, behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While most people will experience some emotional symptoms between episodes, some may not experience any.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other symptoms by following a treatment plan. In most cases, bipolar disorder is treated with medications and psychological counseling (psychotherapy).
Bipolar disorder care at Mayo Clinic
Symptoms

There are several types of bipolar and related disorders. They may include mania or hypomania and depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life.

Bipolar I disorder. You've had at least one manic episode that may be preceded or followed by hypomanic or major depressive episodes. In some cases, mania may trigger a break from reality (psychosis).

Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode.

Cyclothymic disorder. You've had at least two years - or one year in children and teenagers - of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression).

Other types. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

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.

Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or early 20s. Symptoms can vary from person to person, and symptoms may vary over time.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms. Mania is more severe than hypomania and causes more noticeable problems at work, school and social activities, as well as relationship difficulties. Mania may also trigger a break from reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

Abnormally upbeat, jumpy or wired

Increased activity, energy or agitation

Exaggerated sense of well-being and self-confidence (euphoria)

Decreased need for sleep

Unusual talkativeness

Racing thoughts

Distractibility

Poor decision-making - for example, going on buying sprees, taking sexual risks or making foolish investments

Major depressive episode

A major depressive episode includes symptoms that are severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships. An episode includes five or more of these symptoms:

Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens, depressed mood can appear as irritability)

Marked loss of interest or feeling no pleasure in all - or almost all - activities

Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)

Either insomnia or sleeping too much

Either restlessness or slowed behavior

Fatigue or loss of energy

Feelings of worthlessness or excessive or inappropriate guilt

Decreased ability to think or concentrate, or indecisiveness

Thinking about, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as anxious distress, melancholy, psychosis or others. The timing of symptoms may include diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during pregnancy or change with the seasons.

Symptoms in children and teens

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.

Children and teens may have distinct major depressive or manic or hypomanic episodes, but the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift during episodes. Some children may have periods without mood symptoms between episodes.

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

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 don't get the treatment they need.

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

When to get emergency help

Suicidal thoughts and behavior are common among people with bipolar disorder. If you have thoughts of hurting yourself, call 911 or your local emergency number immediately, go to an emergency room, or confide in a trusted relative or friend. Or contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat. Services are free and confidential.

If you have a loved one who is in danger of 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.

Causes

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.

Genetics. 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.

Risk factors

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, such as the death of a loved one or other traumatic event

Drug or alcohol abuse

Complications

Left untreated, bipolar disorder can result in serious problems that affect every area of your life, such as:

Problems related to drug and alcohol use

Suicide or suicide attempts

Legal or financial problems

Damaged relationships

Poor work or school performance

Co-occurring conditions

If you have bipolar disorder, you may also have another health condition that needs to be treated along with bipolar disorder. Some conditions can worsen bipolar disorder symptoms or make treatment less successful. Examples include:

Anxiety disorders

Eating disorders

Attention-deficit/hyperactivity disorder (ADHD)

Alcohol or drug problems

Physical health problems, such as heart disease, thyroid problems, headaches or obesity

Prevention

There's no sure way to prevent bipolar disorder. However, getting treatment at the earliest sign of a mental health disorder can help prevent bipolar disorder or other mental health conditions from worsening.

If you've been diagnosed with bipolar disorder, some strategies can help prevent minor symptoms from becoming full-blown episodes of mania or depression:

Pay attention to warning signs. Addressing symptoms early on can prevent episodes from getting worse. You may have identified a pattern to your bipolar episodes and what triggers them. Call your doctor if you feel you're falling into an episode of depression or mania. Involve family members or friends in watching for warning signs.

Avoid drugs and alcohol. Using alcohol or recreational drugs can worsen your symptoms and make them more likely to come back.

Take your medications exactly as directed. You may be tempted to stop treatment - but don't. Stopping your medication or reducing your dose on your own may cause withdrawal effects or your symptoms may worsen or return.

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Bipolar disorder causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression).