Bipolar disorder

Bipolar disorder is a mood disorder, wherein the affected person experiences extreme changes in mood, energy, concentration, activity levels and the ability to perform their daily tasks. The mood changes range from periods of depression (feelings of hopelessness, sadness or indifference) to mania (energised, irritable or elated behaviour). The condition can occur in adults as well as in children and adolescents. However, the average age of onset is estimated to be about 25 years. Mood fluctuations in individuals with bipolar disorder can affect their relationship with loved ones, friends and colleagues. Early identification of the condition, following the prescribed treatment plan and maintaining a healthy lifestyle can help individuals with bipolar disorder lead a normal life. Bipolar disorder is also known by other names, such as, bipolar affective disorder, bipolar mood disorder, manic-depressive illness, manic-depressive disorder and manic depression.

Types

There are four types of bipolar disorders, namely:

• Bipolar I: This is the most severe form of bipolar disorder. The characteristic symptoms of this type include:
  • Episodes of mania (lasting for at least one week) and episodes of depression (lasting for at least two weeks)
  • Symptoms during manic episodes may be severe enough to warrant hospitalisation
  • Symptoms of mania and depression may occur together
• Bipolar II: Although a person with this type of bipolar disorder experiences episodes of depression and mania similar to those with bipolar I, the intensity of manic episodes is less severe (hypomanic episodes).
• Cyclothymic disorder (cyclothymia): This is a milder type of bipolar disorder and is characterised by episodes of depression and hypomania that persist for a minimum of two years in adults and one year in children and adolescents. However, the symptoms are not severe enough to be diagnosed as depressive or hypomanic episodes.
• Unspecified or other bipolar disorder: Individuals who experience significantly abnormal mood changes but whose symptoms do not match any of the above types of bipolar disorders are characterised as having unspecified or other bipolar disorder.

Symptoms

Symptoms that may occur during manic episodes include:

• Increased energy
• Elevated mood
• Increased physical and mental activity
• Racing thoughts and speech
• Poor judgement
• Decreased need for sleep
• Erratic driving and increased recklessness
• An exaggerated feeling of self-importance

  Symptoms that may occur during depressive episodes include:

• Decreased energy and fatigue
• Irritable mood or sadness
• Feelings of anxiety and anger
• Difficulty concentrating
• Excessive sleepiness or difficulty sleeping
• Overeating or loss of appetite
• Poor concentration
• Feelings of worthlessness
• Suicidal tendency
• Loss of interest in activities that formerly bought joy or pleasure

Individuals may experience manic and depressive episodes in the following patterns:

• Occasional periods of normal mood between manic and depressive episodes
• Multiple episodes of mood swings from mania to depression without having a period of normal mood between them (rapid cycling) may be experienced by some individuals.
• Concurrent symptoms of mania and depression, for example, overactivity with feelings of hopelessness or worthlessness (mixed state).

Causes And Risk Factors

Causes Researchers have not been able to identify a single specific cause that contributes to the development of bipolar disorder. Risk Factors Factors that may contribute to the development of bipolar disorder include:

• Family history: The risk of developing bipolar disorder is high in individuals who have a family member (parents or siblings) of the condition. Studies have found that about 80-90% of the individuals suffering from bipolar disorder have a relative with depression or bipolar disorder.
• Environmental factors: The inability to deal with traumatic or stressful events such as the following can trigger bipolar disorder: 
  • Difficult relationship
  • Divorce
  • Death in the family
  • Severe illness
  • Financial problems
• Brain structure and function: Variations in brain size or imbalances in certain brain chemicals may also trigger the condition.

Prevention

There are no guaranteed preventive measures for bipolar disorder. However, the following strategies can help identify early signs and prevent relapses or episodes of the condition:

• Educating the individual regarding the early signs of bipolar disorder, especially if they have a family history of bipolar disorder
• Getting enough sleep
• Learning stress management techniques
• Avoiding recreational drugs (ecstasy, cocaine, etc.) or excessive amounts of caffeine

Diagnosis

The doctor will conduct an interview to assess the symptoms. In addition, they will also conduct a physical examination, blood tests or body scan to rule out other illnesses (e.g., conditions of the thyroid gland) that can present with similar symptoms. A medical history, family history and a list of ongoing medications will also be assessed by the doctor. Some doctors may even talk with family members or friends of the individual with permission to better understand the symptoms. If the doctor suspects bipolar disorder, the individual will be recommended to a mental health care professional. These professionals usually assess the pattern and intensity of the symptoms to identify the type of bipolar disorder.  Due to similarities in symptoms, individuals with bipolar disorder are sometimes wrongly diagnosed as borderline personality disorder or schizophrenia.

Treatment

Although there is no definitive cure for bipolar disorder, the following treatment options help to manage and control the symptoms:

• Medications: The doctor will prescribe certain medicines to control the symptoms. The following classes of drugs may be prescribed:
  • Antipsychotics (control the symptoms)
  • Mood stabilisers (reduce the symptoms and prevent relapse)
  • Antidepressants (rarely used due to their tendency to trigger manic episodes or rapid cycling)
  • Anti-anxiety medicines (decrease the agitation occurring with manic episodes and instil a feeling of calmness)

However, these medicines are associated with certain side effects or disadvantages, such as:

• Risk of bipolar depression (associated with intake of antidepressants)
• Weight gain (increased risk in women than in men)
• Longer waiting period (some medicines need to be taken for weeks to months before its effects can be seen)

• Psychotherapy (talk therapy): This treatment aims to identify the troubling thoughts, behaviour and emotions and change them by providing appropriate guidance, education and support to the affected person and their family members. The various treatments under psychotherapy include:
  • Psychoeducation (a therapy that aims to educate and provide more information on bipolar disorder)
  • Cognitive behavioural therapy (a therapy that aims to manage the problems by changing the way a person thinks and behaves)
  • Family-focused therapy (a therapy that encourages family members to work collectively to improve the mental health of the person)
  • Interpersonal and social rhythm therapy
• Electroconvulsive therapy (ECT): This procedure is performed under general anaesthesia to stimulate certain areas in the brain using low-level electric current. This treatment is employed to treat severe episodes of mania and depression, especially when medicines and psychotherapy prove to be ineffective. It is also effective in individuals at a high risk of suicide. 
• Hospitalisation: It is recommended in individuals with long, severe episodes of mania or depression, especially if they have psychosis or suicidal tendencies.

If you have a suspicion that you or any of your family members suffer from bipolar disorder, seek medical help immediately as the disorder usually worsens when left untreated.

Lifestyle / Management

Apart from the prescribed treatment plan, the following changes in lifestyle may help to better manage and control the condition:

• Exercise regularly: Aerobic exercises (brisk walking, jogging, cycling, swimming, etc.) promote better sleep, better health, and help with depression. Certain studies suggest that pilates, yoga, weightlifting and other anaerobic exercises can also be helpful. 
• Maintain a healthy diet: Combine regular exercises with a healthy diet to control weight gain, a common side effect of the medicines used for bipolar disorder.
• Maintain a journal: Keeping a journal to record sleep patterns, changes in mood and other symptoms can help the doctor keep track of the condition and recommend an appropriate course of treatment. 
• Avoid alcohol and drugs: Alcohol and illegal drugs have harmful physical and social effects and should not be used as a substitute for medicines or treatments.
• Other recommendations: Get more sleep and participate in enjoyable activities that give a sense of accomplishment.

Prognosis And Complications

Prognosis Although the course of treatment for bipolar disorder varies from person to person, it is essential to follow the prescribed treatment plan as the condition can worsen if not treated and with age. Finding the right treatment plan requires perseverance; however, once identified, it can prove to be very effective in diminishing and sometimes even eliminating many of the symptoms, which can help the individual lead a normal and productive life.   Complications The complications of bipolar disorder are as follows:

• If left untreated, manic episodes and depressive episodes in individuals with bipolar disorder can last up to four and six months, respectively. 
• Individuals with bipolar disorder are at an increased risk of:

• Unhealthy weight gain
• Diabetes
• Substance abuse
• Cardiovascular and heart conditions
• Anxiety
• Suicidal thoughts

• Individuals with bipolar disorder may also have coexisting conditions such as post-traumatic stress disorder and attention-deficit hyperactivity disorder (ADHD).
• The presence of coexisting conditions and misdiagnosis can make the treatment of bipolar disorder difficult; for example, stimulants and antidepressants prescribed for the treatment of ADHD and obsessive-compulsive disorder, respectively, can trigger manic episodes and worsen the symptoms of bipolar disorder.

Alternative Treatments

Few alternative treatments for bipolar disorder that are under research include:

• Transcranial magnetic stimulation (TMS): It is a procedure that employs magnetic waves to stimulate certain areas of the brain. 
• Vagus nerve stimulation (VNS): In this procedure, a pacemaker-like device is implanted under the skin near the left collarbone. The device sends small electrical signals to the area of the brain responsible for seizures.

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