Bipolar Disorder

Manic Episode

An expansive, elevated, or irritable mood state with increased activity or energy for at least 1 week during which 3 or more of the following symptoms occur (DSM-5, 2013):

• Increased self-esteem or feelings of grandiosity;
• Decreased need for sleep;
• More talkative than usual or a need to keep talking;
• Racing thoughts or pressured speech;
• Distractibility, as observed by self or others;
• Increased goal-directed activity or psychomotor agitation;
• Involvement in activities with a high potential for painful consequences (e.g., reckless spending, sexual promiscuity, or foolish investments).

This episode is severe enough to cause:

• Marked impairment in social or occupational functioning;
• The need for hospitalization to prevent harm to self or others;
• The appearance of hallucinations or delusions.

Hypomanic Episode

This episode is very similar to the Manic Episode, but it has some differences:

• Minimum duration of symptoms: 4 consecutive days;
• The severity of this episode is not sufficient to cause marked impairment in social or occupational functioning, doesn't require hospitalization, and doesn't involve hallucinations or delusions.

Major Depressive Episode

Depressive mood state or loss of interest or pleasure for at least two weeks, accompanied by five or more of the following symptoms (DSM-5, 2013):

• Depressed mood most of the day, nearly every day, as observed by self (e.g., feeling sad, empty, or hopeless) or others (e.g., noted to be tearful);
• Diminished interest or pleasure in most activities most of the day, nearly every day;
• Significant weight loss or gain or decrease or increase in appetite, nearly every day;
• Insomnia or hypersomnia nearly every day;
• Psychomotor agitation or retardation nearly every day;
• Fatigue or loss of energy nearly every day;
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day;
• Diminished ability to concentrate;
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Types of Bipolar Disorder

Bipolar I - characterized by the presence of one or more manic episodes, which may be preceded or followed by hypomanic or major depressive episodes.

Bipolar II - characterized by the presence of a major depressive episode, preceded or followed by a hypomanic episode.

Cyclothymia - A chronic and unstable mood disorder that includes periods of hypomanic and depressive symptoms that are not in number, intensity, duration, and overall sufficient to meet the criteria for a Manic Episode and Major Depressive Episode, respectively. To diagnose Cyclothymia, the individual must not be symptom-free for more than two months consecutively during a two-year period (one year for children or adolescents), and during the first two years of the disorder, no Major Depressive or Manic Episodes should occur.

Causes and Risk Factors

Various factors may be involved in the mood swings caused by the disorder, but its exact cause is still unknown.

Biological factors appear to have a significant role in its occurrence. An imbalance in the levels of one or more neurotransmitters (norepinephrine, serotonin, and dopamine) can lead to the onset of bipolar disorder.

Several studies demonstrate a genetic predisposition to bipolar disorder, which is a major risk factor. The magnitude of risk decreases with degrees of relatedness: parents, siblings, and grandparents.

Environmental factors, such as dysfunctional family contexts or stressful life events (e.g., family deaths, unemployment, accidents, abrupt life changes, etc.), seem to play a significant role in triggering the disorder.

Abuse of certain substances (cocaine or amphetamines) and/or alcohol consumption increase the risk of developing the first episode and may also increase the frequency of recurrences.

Who Is More Affected?

Bipolar Disorder affects approximately 1.5% of the population (Jones, 2004), and several studies indicate that it occurs equally in men and women.

Regarding the average age of onset: 18 years for Bipolar I Disorder, 25 years for Bipolar II Disorder, and adolescence for Cyclothymia (in the latter, there is a variable risk between 15% and 50% that the person will develop Bipolar I or II Disorder).

How Can Psychotherapy Help?

There is no treatment that can completely cure the disorder, but it is possible to manage it by reducing the number of relapses, anticipating and reducing the number of depressive or manic mood episodes and increasing mood stability. Simultaneously, psychotherapy can help with cognitive, emotional, and behavioral work to strengthen mood balance, taking into account the individual's life context.

Family Therapy (FT) aims to improve understanding of the disorder, enhance overall patient functioning, and focus on how to deal with symptoms. FT involves evaluation phases, education about the disorder, improvement of communication skills, and problem-solving abilities within the family.

Psychoeducation can provide information about the disorder and its treatment to families, caregivers, and patients, with the goal of acceptance and management. Psychoeducation is also crucial for medication adherence, avoiding substance abuse, and identifying and anticipating signs of relapse.

In this condition, pharmacological treatment prescribed by a psychiatrist is essential and should be combined with psychotherapy.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.): DSM-5. Washington: Author.

Jones, S. (2004). Psychotherapy of bipolar disorder: a review. Journal of Affective Disorders, 80, 101-114.