Bipolar Disorder – Signs, Prognosis, and Treatment

Dr. Alexander Sidawi

Dr. Sidawi is an Orlando based, UF trained physician who is happy to be serving the community he grew up in by offering a combination of psychiatric medication management and psychodynamic psychotherapy.

Bipolar Spectrum Disorders

Bipolar disorder, a multifaceted mental health condition, often faces misinterpretation and incorrect diagnosis. This blog post aims to provide a clearer understanding of Bipolar Disorder by discussing its signs, symptoms, diagnostic criteria as per the DSM-5, prevalence, gender distribution, and the various factors that can influence its manifestation and prognosis.

Bipolar Disorder is primarily distinguished by its unique mood episodes, which oscillate between periods of elevated or expansive mood (mania or hypomania) and periods of depression. These mood fluctuations are not just ordinary mood swings; they are intense and can significantly disrupt a person’s life, affecting emotions, behavior, and daily activities. While the majority of individuals with Bipolar Disorder experience depressive episodes, it’s crucial to note that these are not mandatory for a diagnosis. Manic episodes in Bipolar I and hypomanic episodes in Bipolar II are key for diagnosis, often accompanied by depressive episodes.

The severity of these episodes can vary greatly among individuals. During manic phases, one might experience heightened energy, reduced need for sleep, grandiosity, and impulsive behavior. Hypomanic episodes are similar but less intense and without significant functional impairment. Conversely, depressive episodes can lead to feelings of deep sadness, hopelessness, changes in appetite and sleep, and in severe cases, thoughts of self-harm.

Bipolar I Disorder: DSM-5 Criteria for a Manic Episode

The DSM-5 criteria for Bipolar 1 disorder are as follows:

A. There must be a distinct period of abnormally and persistently elevated, expansive, or irritable mood AND abnormally and persistently increased activity or energy, lasting nearly every day for at least 1 week, termed a manic episode

B. During the period of mood disturbance and increased energy and activity, at least 3 of the following symptoms have persisted (4 symptoms if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:

Distractibility (easily distractable), as reported or observed.
Indiscretion, characterized by excessive involvement in activities that have a high potential for painful consequences (e.g. – unrestrained spending sprees, sexual behaviors, or foolish business investments).
Grandiosity or inflated self-esteem.
Flight of ideas (rapidly going from topic to topic) or subjective experience that thoughts are racing.
Activity (goal-directed) increase (ex: socially, at work or school, or sexually) or psychomotor agitation.
Sleep decreased (ex: feels rested after only a few hours of sleep).
Talkative (more than usual, feels pressured)

B. The mood disturbance in the manic episode causes significant impairment in social, occupational, or other important areas of functioning, or requires hospitalization to prevent harm to self or others, or there are psychotic features.

C. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication, other treatment) or another medical condition (e.g., hyperthyroidism).

D. The occurrence of the manic episode is not better explained by a Schizoaffective Disorder, Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or other specified or unspecified Schizophrenia Spectrum and Other Psychotic Disorder.

Bipolar II Disorder: DSM-5 Criteria for a Hypomanic Episode

For a diagnosis of Bipolar 2 Disorder, one must only meet criteria for a hypomanic episode, rather than a full manic episode. The other diagnostic criteria are similar to Bipolar I.
A hypomanic episode involves all the same criteria as a manic episode with a few exceptions:
- The episode can be shorter (4 days rather than 7),
- There is no marked social or occupational impairment (ex: doesn’t have to call out of work or miss school for multiple days in a row)
- There are no psychiatric hospitalization.
- There are no psychotic symptoms.

Bipolar II Disorder: DSM-5 Criteria for a Hypomanic Episode

For a diagnosis of Bipolar 2 Disorder, one must only meet criteria for a hypomanic episode, rather than a full manic episode. The other diagnostic criteria are similar to Bipolar I.
A hypomanic episode involves all the same criteria as a manic episode with a few exceptions:
- The episode can be shorter (4 days rather than 7),
- There is no marked social or occupational impairment (ex: doesn’t have to call out of work or miss school for multiple days in a row)
- There are no psychiatric hospitalization.
- There are no psychotic symptoms.

Prevalence and Factors

Bipolar Disorder is estimated to affect around 1% of the American population, with its global prevalence slightly lower at approximately 0.6%. Notably, the disorder is more commonly diagnosed in wealthier countries, which might reflect differences in healthcare access or diagnostic practices. When it comes to gender distribution, Bipolar Disorder impacts men and women equally, showing no gender-specific prevalence.

There’s an observed higher incidence of Bipolar Disorder among individuals who are divorced or widowed. This observation suggests a potential link between significant life stressors, such as major relationship changes, and the onset or exacerbation of the disorder. However, it’s important to consider that these factors may contribute to the disorder’s visibility rather than being direct causes.

Heritability and Manifestation

Bipolar Disorder has a substantial genetic component, with heritability estimates at around 80%. This high percentage underscores the role of family history in the risk of developing the disorder. Individuals with close relatives who have Bipolar Disorder are at a heightened risk, highlighting the importance of genetic factors.

A characteristic pattern of Bipolar Disorder is the sequence of manic episodes often followed by depressive episodes. This alternating pattern can lead to dramatic and unpredictable shifts in mood, energy, and behavior, which are central to the disorder’s impact on an individual’s life.

Prognostic Factors

Several factors significantly influence the prognosis of Bipolar Disorder:

Treatment Adherence: Consistently following prescribed treatment plans, which may include medication, therapy, or a combination of both, is crucial for managing symptoms and improving long-term outcomes.
Childhood Adversity: A history devoid of significant early childhood adversity is sometimes associated with a more favorable prognosis, although this is not universally true for all cases.
Age of Onset: Generally, a later age at onset is linked with better outcomes, although early intervention and treatment can significantly improve prognosis in younger individuals.
Social Support: Robust social networks and support systems can greatly aid in managing the disorder, providing emotional and practical support that contributes to better outcomes.
Rapid Cycling: The presence of rapid cycling, defined as experiencing four or more mood episodes in a year, is a complicating factor in treatment and management, often indicating a more severe form of the disorder.
Co-occurring Personality Disorders: The presence of additional personality disorders can complicate the clinical picture and may pose challenges in treatment, often leading to a more complex and challenging prognosis.
Substance Abuse: The co-occurrence of substance abuse can significantly worsen the prognosis of Bipolar Disorder. Substance use can exacerbate symptoms, interfere with treatment adherence, and increase the risk of adverse outcomes such as hospitalization or suicidal behavior.

Treatment Options for Bipolar Disorder

Managing Bipolar Disorder effectively requires a multifaceted approach, combining various therapies and medications to address the unique needs of each individual:

Differentiating From Other Psychiatric Illnesses: First and foremost, it is important to make sure this diagnosis is correct, as treatment for Bipolar disorder can vastly differ from treatment of other psychiatric diagnoses. Major Depressive Disorder (MDD) for example, is often treated with antidepressants, however these medications can potentially exacerbate cycling between mania in depression in those with Bipolar disorder. As another example, the rapid ups and downs in mood associated with Borderline Personality Disorder (BPD) are often misdiagnosed as Bipolar disorder.
Mood Stabilizers: These are cornerstone medications for Bipolar Disorder, with lithium being one of the most renown. Mood stabilizers work by evening out the highs (mania) and lows (depression) in mood associated with the disorder. They are crucial in reducing the frequency and severity of episodes.
Antiepileptic Medications: Originally developed for seizures, medications like valproic acid (Depakote), lamotrigine (Lamictal), and carbamazepine (Tegretol) have mood-stabilizing properties. They are particularly effective in managing mood swings, helping to prevent the extreme variations in mood characteristic of Bipolar Disorder.
Antipsychotic Medications: Atypical antipsychotics, such as aripiprazole, olanzapine, and quetiapine, play a pivotal role in managing both manic and depressive episodes. These medications can be used alone or in combination with mood stabilizers to control symptoms.
Psychotherapy: Cognitive Behavioral Therapy (CBT) and social rhythm therapy are vital components of a comprehensive treatment plan. CBT helps individuals identify and change harmful thought patterns and behaviors, while social rhythm therapy focuses on establishing regular daily routines to reduce the likelihood of mood episode triggers.
Supportive Therapies: Incorporating family-focused therapy and psychoeducation involves family members in the treatment process. This approach not only supports the individual with Bipolar Disorder but also educates family members about the condition, helping create a supportive and understanding home environment.

Living with Bipolar Disorder

Recognizing the complexities of Bipolar Disorder is crucial for empathetic and effective management. Understanding its signs, prevalence, risk factors, and elements influencing prognosis is essential. With appropriate treatment, including mood stabilizers, antipsychotics, therapy, and supportive care, individuals with Bipolar Disorder can effectively manage their symptoms. This comprehensive approach offers a path toward stability and improved quality of life, empowering individuals to navigate the challenges of Bipolar Disorder with hope and resilience.

Bipolar Disorder – Signs, Prognosis, and Treatment

Dr. Alexander Sidawi

Bipolar Spectrum Disorders

Bipolar I Disorder: DSM-5 Criteria for a Manic Episode

Bipolar II Disorder: DSM-5 Criteria for a Hypomanic Episode

Bipolar II Disorder: DSM-5 Criteria for a Hypomanic Episode

Prevalence and Factors

Heritability and Manifestation

Prognostic Factors

Treatment Options for Bipolar Disorder

Living with Bipolar Disorder

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