Brief overview
- Symptoms: Alternation between depressive phases and manic phases (= phases with conspicuously elevated, expansive or irritable mood, increased drive, urge to talk, etc.).
- Causes & risk factors: Presumably several factors are involved in the development of the disease, among them mainly genetic factors, but also others such as a disturbed neurotransmitter balance in the brain, stress, certain medications.
- Diagnosis: doctor-patient interview, clinical questionnaires; physical examinations to rule out organic diseases
- Treatment: mainly medication in combination with psychotherapy; if necessary, other therapies such as awake therapy and electroconvulsive therapy; supportive e.g. relaxation methods, exercise programs, ergotherapy, music therapy, meetings with self-help groups, etc.
Bipolar Disorder: Description
Bipolar disorder, like depression, belongs to the so-called affective disorders. This means that it affects the feelings of the affected person. Patients experience strong mood swings for which there is usually no external trigger. Manic phases with great euphoria, energy and self-overestimation or irritability and distrust alternate with depressive phases in which the affected person is depressed and listless. Bipolar disorder is therefore often still colloquially referred to as manic depression.
Bipolar disorder is estimated to affect one to three percent of the population.
Bipolar disorder: the different forms
- Bipolar I disorder: Depression and mania alternate. A depressive episode lasts at least two weeks, a manic episode at least seven days. The latter is severe (difference to Bipolar II disorder).
- Bipolar-II disorder: Here there are depressive episodes and at least one hypomanic episode. The latter differs from manic episodes in the minimum duration (at least four days) and in the presence of certain symptoms (e.g., increased difficulty concentrating instead of racing thoughts or flight of ideas; less overconfidence and foolhardy behavior, etc.).
- Rapid cycling: This special form is characterized by a particularly rapid change between depressive and manic episodes (at least four distinct episodes within twelve months). It affects up to 20 percent of all patients with bipolar disorder, and mainly women.
Bipolar Disorder: Symptoms
There are four different types of episodes in Bipolar Disorder. In addition to the “classic” depressive and manic episodes, they also include hypomanic and mixed episodes. Sometimes a manic phase is followed by a depressive episode – either directly as an “aftershock” or later (after a period of “normal” mood) as a separate episode. In other cases, it works the other way around: it starts with a depressive phase, followed by a manic phase – again either as an “aftershock” or occurring in isolation. Very rarely, a patient suffers only from manic phases.
Symptoms of the depressive episode
In the depressive phases, the clinical picture resembles depression. The main symptoms then include:
- depressed mood
- loss of interest and joy
- listlessness
- Sleep disturbances, especially sleeping through the night in the second half of the night
- Concentration and thinking disorders
- Feelings of guilt
- Suicidal Thoughts
Facial expressions tend to be rigid and expressionless during a depressive episode. Sufferers tend to speak softly and their responses are delayed.
Physical symptoms may also occur during the depressive episode. Appetite decreases, and many sufferers lose significant weight. Some experience pain in different parts of the body. Common complaints include shortness of breath, heart problems, stomach and intestinal problems, and dizziness, headaches, and erectile dysfunction.
Symptoms of the manic episode
In phases of mania, everything is exaggerated – emotional arousal, thinking, speaking, acting: The patient is full of energy (while needing little sleep) and either noticeably elevated in mood or very irritable. He has a strong urge to talk, is erratic and unfocused, also very in need of contact, overactive and impulsive.
During a manic episode, patients are also very creative. It is now believed that Vincent van Gogh and George Frideric Handel, among others, were manic-depressive.
In more than two thirds of all patients with mania, psychotic symptoms also occur. These include increased self-overestimation, hallucinations, persecutory delusions and delusional thoughts.
Symptoms of the hypomanic episode
In some cases of bipolar disorder, the manic symptoms are expressed in a weakened form. This is called hypomania. Affected persons suffer, for example, from concentration difficulties rather than flight of ideas and racing thoughts. Particularly conspicuous mania symptoms such as loss of social inhibitions, strong overconfidence and foolhardy behavior are also absent or hardly present.
Symptoms of the mixed episode
Bipolar disorder is associated with great suffering and an increased risk of suicide. In this regard, suicide attempts and suicides almost always occur during or immediately after a depressive or mixed episode.
Bipolar disorder: causes and risk factors.
Bipolar disorder is caused by both biological and psychosocial factors. Previous research suggests that a complicated interaction of several genes with various environmental factors promotes the disease.
Bipolar disorder: genetic causes.
Family and twin studies have shown that genetic factors are involved in the development of bipolar disorder. For example, children of an ill parent are ten percent more likely to also become manic-depressive. If both parents have bipolar disorder, the probability of developing the disease increases to as much as 50 percent.
Bipolar Disorder: Influence of Neurotransmitters
There is much evidence to suggest that in Bipolar Disorder the distribution and regulation of important messenger substances in the brain (neurotransmitters) is disturbed. Neurotransmitters are endogenous substances that cause certain reactions in the body and brain. Examples are serotonin, noradrenaline and dopamine.
Depressed people have been found to be deficient in norepinephrine and serotonin. In manic phases, on the other hand, the concentration of dopamine and norepinephrine is increased. Thus, in bipolar disorder, the imbalance of the various neurotransmitters may play an important role. Drug therapy for bipolar disorder is therefore aimed at achieving a controlled release of these signal substances.
Bipolar disorder: psychosocial causes
Serious illnesses, bullying, bad experiences in childhood, separations due to divorce or death mean stress just as much as some developmental phases (e.g. puberty). How stress is felt and handled depends on the individual. Some people have developed good strategies for dealing with stress, while others are quickly overwhelmed. Thus, stress-inducing factors can increase the likelihood of developing bipolar disorder.
Bipolar disorder: Medication causes
Some medications can alter mood and, in extreme cases, even trigger Bipolar Disorder. These include cortisone-containing preparations, methylphenidate, certain antiparkinsonian and epilepsy medications, and also drugs such as alcohol, LSD, marijuana, and cocaine.
There are also isolated case reports of bipolar disorder occurring after brain injury.
Bipolar disorder: examinations and diagnosis
Bipolar II disorder and cyclothymia in particular are difficult to recognize, as the symptoms here are less pronounced than in bipolar I disorder. It is therefore particularly important to describe experiences, moods and feelings in detail to the doctor or therapist.
The right contact person
If Bipolar Disorder is suspected, the primary care physician may be contacted first. However, due to the difficult diagnosis and the increased risk of suicide, it is advisable to immediately contact a clinic or consult a psychiatric specialist. Often, however, those affected do not see the need for medical help – especially during their manic phase.
Extensive questioning
To clarify a possible bipolar disorder, the doctor will first talk to the patient in detail to obtain a medical history (anamnesis). The doctor or therapist might ask the following questions during this process:
- Did you have difficulty getting up in the morning?
- Did you have difficulty sleeping through the night?
- Did you have a good appetite?
- What are your thoughts at the moment? What is on your mind?
- Do you sometimes have thoughts of death or taking your own life?
- Have you been unusually hyper in the last few weeks?
- Have you had the feeling that you are under power?
- Did you feel like you were talking more and faster than usual?
- Was your need for sleep reduced?
- Were you very active, getting many things done in a short period of time?
- Has your mood been changeable lately?
- Are there any known cases of manic-depressive illness in your family?
Clinical questionnaires are also used in the diagnosis of bipolar disorder. Some are used to assess manic symptoms, others to assess depressive symptoms. In addition, such questionnaires are available for self-assessment as well as for external assessment (e.g. by the partner).
Differential diagnoses
When making a diagnosis, the physician must pay particular attention to the distinction between mania and schizophrenia, which is not always easy. Other mental illnesses may also be responsible for the patient’s symptoms instead of bipolar disorder. These differential diagnoses include borderline personality disorder and ADHD, for example.
Concomitant diseases
When a physician diagnoses bipolar disorder, he or she must also carefully record any accompanying illnesses (comorbidities). These are not uncommon in bipolar disorder and can influence its course and prognosis. The physician must take this into account when planning therapy.
Many people with bipolar disorder also suffer from other mental illnesses. Among the most common are anxiety and obsessive-compulsive disorders, alcohol or drug addiction, ADHD, eating disorders and personality disorders.
In addition, bipolars often have one or more organic illnesses, including most notably cardiovascular disease, metabolic syndrome, diabetes mellitus, migraines, and musculoskeletal disorders.
Bipolar disorder: treatment
Basically, a distinction is made between acute treatment and phase prophylaxis in the therapy of bipolar disorder:
- Acute treatment: This is provided during an acute phase of the illness and aims to reduce current depressive or (hypo)manic symptoms in the short term.
- Phase prophylaxis: Here, the long-term goal is to avoid or at least reduce further affective episodes. Often this cannot be fully achieved immediately. Then one tries to approach the long-term goal with “stage victories.” For example, one strives to make the episodes of illness shorter and/or less frequent.
Bipolar disorder: therapy components
Both in acute treatment and in phase prophylaxis, a combination of medication and psychotherapeutic measures is generally used:
- Psychotherapeutic treatment can have a positive influence on the course of bipolar disorder. Above all, however, it is decisive for the patient’s understanding of the illness and his or her will to be treated. Bipolars often lack this so-called compliance, as they feel particularly good during the manic phases and are reluctant to give them up.
Medication and psychotherapeutic treatment can be usefully supplemented by other measures. These can be, for example, awake therapy or electroconvulsive therapy in acute treatment or creative and action-oriented methods (e.g. music therapy) in phase prophylaxis.
Manic-depressives usually have to be treated for life, as this is the only way to keep their mood stable. If patients discontinue treatment, there is a high risk of relapse.
Bipolar disorder: drug treatment
Bipolar disorder is mainly treated with antidepressants, mood stabilizers and atypical neuroleptics. If the patient also suffers from agitation, aggressive impulses or anxiety disorders, the doctor may also temporarily prescribe a sedative such as diazepam.
- Antidepressants: They can relieve depressive symptoms. There are about 30 antidepressant agents available, for example tricyclic antidepressants (such as amitriptyline, imipramine, doxepin) and selective serotonin reuptake inhibitors (SSRIs such as fluoxetine, citalopram, paroxetine).
- Atypical neuroleptics: These are medications approved for the treatment of psychotic (primarily schizophrenic) disorders and, in some cases, for the treatment of bipolar disorder. For example, quetiapine, amisulpride, aripiprazole, olanzapine and risperidone are used in bipolar patients.
The individual case determines which active ingredients in which combination and in which dosage the treating physician prescribes to the patient. Decisive factors include the type and phase of the bipolar disorder, the tolerability of individual active ingredients and any concomitant diseases.
The effect of these drugs often only sets in after a few weeks. Patients must therefore be patient until the improvement is noticeable.
Bipolar Disorder: Psychotherapeutic Treatment
There are several psychotherapeutic procedures used to treat Bipolar Disorder. Some procedures have been particularly effective in preventing further episodes of illness:
Psychoeducational therapy
In psychoeducational therapy, the patient and his or her relatives are informed and educated about bipolar disorder, its causes, its course, and treatment options. This can take place to varying degrees – for example, in a time-limited informational discussion in an individual or group setting (“simple psychoeducation”) or as detailed and interactive psychoeducation.
The latter includes, for example, instructions for self-observation: the patient should pay attention to his moods, activities, sleep-wake rhythm and everyday experiences in order to identify a possible connection to his mood swings.
In behavioral therapy, for example, the patient learns to recognize early warning signs and potential triggers of depressive or manic phases. He or she should learn to use medication conscientiously and develop strategies for dealing with manic and depressive symptoms.
In addition, individual problems and interpersonal conflicts are dealt with in behavioral therapy. This is intended to reduce the patient’s stress level – stress, after all, plays a crucial role in the flare-up of bipolar episodes.
Family-focused therapy (FFT).
Family-focused therapy is used primarily with younger patients. It is a cognitive-behavioral oriented family therapy – so important attachment figures of the patient (e.g. family, partner) are included in the therapy here.
Interpersonal and Social Rhythm Therapy (IPSRT)
Interpersonal and Social Rhythm Therapy attempts to prevent manic-depressive episodes through three mechanisms. These mechanisms are:
- responsible use of medication
- Stabilization of social rhythms or a regular daily routine (e.g., daily structure, sleep-wake rhythm, social stimulation)
- @ reduction of individual and interpersonal difficulties
Bipolar disorder: awake therapy
Wake therapy or sleep deprivation therapy helps during depressive episodes: In 40 to 60 percent of bipolar patients, reduced sleep significantly improves depressive symptoms, but only for a short time. Therefore, awake therapy is only suitable as an adjunct to other therapies (such as medications).
The treatment protocol of a waking therapy includes two to three waking periods within a week.
- In partial awake therapy, one sleeps during the first half of the night (e.g., from 9 p.m. to 1 a.m.) and then stays awake for the second half of the night and the following day (until evening).
Both variants show the same antidepressant effect and can be carried out both as an outpatient and as an inpatient.
In certain cases, awake therapy should not be used, such as in patients with a known seizure disorder (sleep deprivation increases the risk of epileptic seizures).
Bipolar disorder: electroconvulsive therapy.
Acute treatment with electroconvulsive therapy (ECT) is very effective for severe depressive and manic episodes. It proceeds as follows:
In total, a treatment series of electroconvulsive therapy usually comprises six to twelve sessions. The response rate is usually significantly higher than with drug treatment – electroconvulsive therapy is therefore effective in more patients than acute treatment with drugs. In addition, the effect of electroconvulsive therapy is felt more quickly than with medication, which usually takes several weeks to take effect.
Nevertheless, after successful application of electroconvulsive therapy, patients must, if possible, receive medication to prevent new episodes of the disease (in combination with psychotherapy). Otherwise, relapse may occur quickly.
To be on the safe side, various physical and psychiatric examinations are performed before electroconvulsive therapy. This is because it must not be used in certain cases, such as increased intracranial pressure or severe hypertension. Advanced age and pregnancy also “forbid” ECT.
Comprehensive therapy concepts, such as those used for bipolar disorder, usually also include supportive procedures. For example, relaxation procedures can help against specific symptoms such as restlessness, sleep disturbances and anxiety.
Sports and exercise therapy can distract from negative stimuli and improve mood through interaction with other people.
Occupational therapy can be used to help people with bipolar disorder continue or resume participation in important areas of life, such as household management, employment, education, or recreation.
Various artistic therapies (music therapy, dance therapy, art therapy) can support or restore patients’ mental health.
Living with the disease
Bipolar disorder: course of the disease and prognosis
Is bipolar disorder curable? This is a question asked by many sufferers and their relatives. The answer: At present, science does not know of any proven methods or ways to cure bipolar disorder. There are patients in whom the manic-depressive episodes become weaker with age, occur only very rarely or even do not occur at all. However, the vast majority of patients suffer from the disorder for the rest of their lives.
Course
However, this does not mean that sufferers with Bipolar II Disorder or Cyclothymia have a lower level of suffering. This is because in these forms of bipolar disorder, the manic or depressive episodes often occur more frequently than in bipolar I disorder.
Number and duration of episodes
Most patients with bipolar disorder experience only a few episodes of illness. Only one in ten patients experiences more than ten episodes in their lifetime. Rapid cycling, with its very rapid change between episodes of illness, is a particularly severe form of illness.
Risk factors for a severe course
Bipolar disorder usually first becomes apparent between the ages of 15 and 25. The earlier the onset of bipolar disorder, the less favorable its course. According to studies, young patients have a higher suicidal tendency and often develop other mental disorders.
Experts estimate the rate of suicides in bipolar patients at around 15 percent.
In addition to a young age at first onset, there are other risk factors for a severe course of bipolar disorder, i.e. for frequently recurring episodes. These include female gender, major life events, mixed episodes, psychotic symptoms (such as hallucinations), and inadequate response to phase prophylactic therapy. Very frequent recurrent episodes of illness are also present in rapid cycling disorder.
Early diagnosis important
Unfortunately, even then relapses cannot be ruled out. However, the symptoms of bipolar disorder and thus the level of suffering can be significantly reduced by medication (and other treatment measures).
