BIPOLAR DISORDER

Overview

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).

Symptoms

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.
• Either insomnia or sleeping excessively nearly every day.
• Either restlessness or slowed behavior that can be observed by others.
• Either restlessness or slowed behavior that can be observed by others.
• 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 is 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.

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.