UNIT 2 BIPOLAR DISORDER

Structure
2.0 Introduction
2.1 Objectives
2.2 Bipolar Disorders
2.2.1 Symptoms of Bipolar Disorder
2.2.1.1 Depressive Episode
2.2.1.2 Manic Episode
2.2.1.3 Hypomanic Episode
2.2.1.4 Mixed Episode
2.2.2 Classification of Bipolar Disorder
2.2.2.1 Bipolar I Disorder
2.2.2.2 Bipolar II Disorder
2.2.2.3 Cyclothymia
2.2.2.4 Bipolar Disorder NOS
2.2.3 Causes of Bipolar Disorder
2.2.3.1 Biological Factors
2.2.3.2 Psychological Factors
2.2.4 Treatment
2.2.4.1 Medications
2.2.4.1.1 Mood Stabilising Medications
2.2.4.1.2 Atypical Antipsychotic Medications
2.2.4.1.3 Antidepressant Medications
2.2.4.2 Psychotherapy
2.2.5 Prognosis

2.3 Let Us Sum Up

2.4 Unit End Questions
2.5 Glossary
2.6 Suggested Readings

2.0 INTRODUCTION
Bipolar disorder or manic-depressive disorder, which is also referred to as bipolar
affective disorder or manic depression, is a psychiatric diagnosis that describes a
category of mood disorders defined by the presence of one or more episodes of
abnormally elevated energy levels, cognition and mood with or without one or more
depressive episodes. The elevated moods are clinically referred to as mania or, if
milder hypomania. Individuals who experience manic episodes also commonly
experience depressive episodes, or symptoms, or mixed episode in which features
of both mania and depression are present at the same time. These episodes are
usually separated by periods of “normal” mood; but in some individuals, depression
and mania may rapidly alternate, which is known as rapid cycling. In the present unit
we will first discuss the symptoms and types of bipolar disorder, after that we will
explain the causes of bipolar disorder and finally we will come across to the treatment
and prognosis of bipolar disorder.
19
Mood Disorders
2.1 OBJECTIVES
After reading this unit, you will be able to:
 Explain the nature of bipolar disorder;
 Describe the symptoms of bipolar disorder;
 Understand the different types of bipolar disorder;
 Explain the causes of bipolar disorder;
 Describe the treatment and prognosis of bipolar disorder; and
 Analyse the difference between bipolar disorder and other forms of depressive
disorder.

2.2 BIPOLAR DISORDERS

Although recurrent cycles of mania and depression were recognised as early as sixth
century, but it was Kraepelin in 1899 who first introduced the term manic-depressive
insanity and to clarify the clinical picture. Kraepelin described the disorder as a series
of attack of deletion and depression, with periods of relative normality in between,
and a general favorable prognosis. Bipolar disorder has traditionally been thought
to be much less common than depression.
Earlier it was opined that depressive disorders were four to five times more frequent
than bipolar disorder. But recent studies disagree with this view and believe that
depressive and bipolar disorder are really very similar (Bowden, 1993). The reason
is that depression has traditionally been considered to be more common, and
accordingly many individuals suffering from bipolar disorder are wrongly classified as
suffering from unipolar disorder because a manic or hypomanic episode has not yet
occurred. Sometimes, a person with severe episodes of mania or depression has
psychotic symptoms too, such as hallucinations or delusions.
The psychotic symptoms tend to reflect the person’s extreme mood. For example,
psychotic symptoms for a person having a manic episode may include believing he
or she is famous, has a lot of money, or has special powers. In the same way, a
person having a depressive episode may believe he or she is ruined and penniless,
or has committed a crime. As a result, people with bipolar disorder who have
psychotic symptoms are sometimes wrongly diagnosed as having schizophrenia, another
severe mental illness that is linked with hallucinations and delusions.

2.2.1 Symptoms of Bipolar Disorder

Bipolar disorder is distinguished from major depression by at least one episode of
mania. Any given episode is classified as depressive, manic, or mixed, according to
its predominant features. If individuals experience only one of these moods (for
example, either mania or depression), they are said to suffer only Unipolar mood
disorder. Since the experience of manic symptoms alone is extremely rare, almost all
individuals with unipolar mood disorders suffer from unipolar depression.
If the individual alternates between experiences of depression and mania he/she is
said to be suffering from a bipolar disorder. Bipolar disorder is a condition in which
people experience abnormally elevated (manic or hypomanic) and, in many cases,
abnormally depressed states for periods of time in a way that interferes with
20 functioning.
2.2.1.1 Depressive Episode Bipolar Disorder

A depressive episode has features typical of major depression, including depressed

mood, anhedonia, psychomotor retardation, and feelings of pessimism and guilt.
Sleeping and eating often increase. Delusions of guilt accompanied by self-loathings
are common in psychotic depression, and some patients have hallucinations. Signs
and symptoms of the depressive phase of bipolar disorder include persistent feelings
of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and
appetite; fatigue and loss of interest in usually enjoyable activities; problems in
concentration, loneliness, self-loathing, apathy or indifference; loss of interest in sexual
activity; shyness or social anxiety, irritability, chronic pain (with or without a known
cause); lack of motivation; and morbid suicidal ideation. In severe cases, the individual
may become psychotic – a condition also known as severe bipolar depression with
psychotic features. Features of depressive form of bipolar disorders are usually
clinically indistinguishable from those of major depression (Perris, 1992, American
Psychiatric Association, 1994), although some studies report higher rates of
psychomotor retardation, overeating, and oversleeping in the depressive phase of
bipolar disorder (Cassano, et.al., 1992; Whybrow, 1997).
2.2.1.2 Manic Episode
A manic episode is defined as one or more than one week of a persistently elevated,
expansive, or irritable mood plus three or more than three of the following additional
symptoms:
Inflated self-esteem or grandiosity, decreased need for sleep, greater talkativeness
than usual, persistent elevation of mood, flight of ideas or racing of thoughts,
distractibility, and increased goal-directed activity.
People suffering from bipolar disorder commonly experience an increase in energy
and a decreased need for sleep. A person’s speech may be pressured, with thoughts
experienced as racing. Attention span is low, and a person in a manic state may be
easily distracted. Judgment may become impaired, and sufferers may go on spending
sprees or engage in behaviour that is quite abnormal for them. They may indulge in
substance abuse, particularly alcohol or other depressants, cocaine or other stimulants,
or sleeping pills. Their behaviour may become aggressive, intolerant, or intrusive.
People may feel out of control or unstoppable. People may feel they have been
“chosen” and are “on a special mission” or have other grandiose or delusional ideas.
Sexual drive may increase.
Manic patients may inexhaustibly, excessively, and impulsively involved in various
pleasurable, high-risk activities (e.g. gambling, dangerous sports, promiscuous sexual
activity) without insight into possible harm. Symptoms are so severe that they impair
functioning. Typically, patients in a manic episode are exuberant and flamboyantly or
colorfully dressed; they have an authoritative manner with a rapid, unstoppable flow
of speech. Patients may make clang associations (new thoughts that are triggered by
word sounds rather than meaning). Easily distracted, patients may constantly shift
from one theme or endeavor to another. However, they tend to believe they are in
their best mental state. Lack of insight and an increased capacity for activity often
lead to intrusive behaviour and can be a dangerous combination. Interpersonal friction
results and may cause patients to feel that they are being unjustly treated or persecuted.
As a result, patients may become a danger to themselves or to other people.
Accelerated mental activity is experienced as racing thoughts by patients and is
observed as flights of ideas by the physician.
21
Mood Disorders 2.2.1.3 Hypomanic Episode
A hypomanic episode is a less extreme variant of mania involving a distinct episode
that lasts four or more than four days and is distinctly different from the patient’s
usual nondepressed mood. Hypomania is generally a mild to moderate level of
mania, characterised by optimism, pressure of speech and activity, and decreased
need for sleep. Generally, hypomania does not inhibit functioning like mania. Many
people with hypomania are actually in fact more productive than usual. Some people
have increased creativity while others demonstrate poor judgment and irritability.
Many people experience hypersexuality. These persons generally have increased
energy and tend to become more active than usual. They do not, however, have
delusions or hallucinations. During the hypomanic period, mood brightens, the need
for sleep decreases, and psychomotor activity accelerates. For some patients,
hypomanic periods are adaptive because they produce high energy, creativity,
confidence, and supernormal social functioning. Many do not wish to leave the
pleasurable, euphoric state. Some function quite well, and in most, functioning is not
markedly impaired. However, in some patients, hypomania manifests as distractibility,
irritability, and labile mood, which the patient and others find less attractive.
2.2.1.4 Mixed Episode
A mixed episode blends depressive and manic or hypomanic features; the criteria for
both mania and depression are met. For example, patients may momentarily switch
to tearfulness during the height of mania, or their thoughts may race during a depressive
period. Often, the switch follows circadian factors (e.g. going to bed depressed and
waking early in the morning in a hypomanic state). In at least one third of people with
bipolar disorder, the entire episode is mixed. A common presentation consists of a
dysphorically excited mood, crying, curtailed sleep, racing thoughts, grandiosity,
psychomotor restlessness, suicidal ideation, persecutory delusions, auditory
hallucinations, indecisiveness, and confusion. This presentation is called dysphoric
mania (i.e. prominent depressive symptoms superimposed on manic psychosis).

2.2.2 Classification of Bipolar Disorder

In DSM-IV-TR and ICD-10 bipolar disorder is conceptualised as a spectrum of
disorders occurring on a continuum. The DSM-IV-TR lists three specific subtypes
and one for non-specified:
 Bipolar I Disorder
 Bipolar I Disorder
 Cyclothymia
 Bipolar Disorder NOS (Not Otherwise Specified)
2.2.2.1 Bipolar I Disorder
Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least
seven days, or by manic symptoms that are so severe that the person needs immediate
hospital care. Usually, the person also has depressive episodes, typically lasting at
least two weeks. The symptoms of mania or depression must be a major change
from the person’s normal behaviour. A person with bipolar disorder experiences
episodes of mania and, usually, major depressive episodes as well. Avery small
number of people may experience one or more periods of mania without ever
experiencing depression (Goodwin and Jamison, 1990).
22
2.2.2.2 Bipolar II Disorder Bipolar Disorder

Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and

forth with hypomanic episodes, but no full-blown manic or mixed episodes. Hypomanic
episodes do not go to the full extremes of mania (i.e., do not usually cause severe
social or occupational impairment, and are without psychosis), and this can make
bipolar II more difficult to diagnose, since the hypomanic episodes may simply
appear as a period of successful high productivity and is reported less frequently than
a distressing, crippling depression. Thus bipolar II disorder differs from Bipolar I in
that – rather than experiencing one or more florid, dramatic manic episodes – the
manic behaviour is present to a lesser degree. People who experience a hypomanic
episode may not see it as pathological, although those around them may be concerned
about the erratic behaviour they see.
2.2.2.3 Cyclothymia
Cyclothymia, or Cyclothymic Disorder, is a mild form of bipolar disorder. People
who have cyclothymia have episodes of hypomania that shift back and forth with
mild depression for at least two years. However, the symptoms do not meet the
diagnostic requirements for any other type of bipolar disorder. Symptoms of
cyclothymic disorder are depressed mood for most of the day, for more days than
not, for one year, including the presence of two of the following symptoms: poor
appetite or overeating; insomnia/hypersomnia; low energy/fatigue; poor concentration;
feelings of hopelessness. Symptoms are less severe than those of a major depressive
episode but are more persistent. A history of hypomanic episodes with periods of
depression that do not meet criteria for major depressive episodes There is a low-
grade cycling of mood which appears to the observer as a personality trait, and
interferes with functioning.
2.2.2.4 Bipolar Disorder NOS (Not Otherwise Specified)
Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person
has symptoms of the illness that do not meet diagnostic criteria for either bipolar I
or II. The symptoms may not last long enough, or the person may have too few
symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly
out of the person’s normal range of behaviour. This is a catchall category, diagnosed
when the disorder does not fall within a specific subtype. Bipolar disorders NOS can
still significantly impair and adversely affect the quality of life of the patient.

2.2.3 Causes of Bipolar Disorder

Although causes of bipolar disorder likely vary between individuals. But studies
suggest that both biological and psychological factors seem to play a role in
determining whether a person will develop symptoms of bipolar disorder.
2.2.3.1 Biological Factors
Studies conducted on the families of people diagnosed with bipolar disorder show
that there is strong tendency for other family members also to have higher than
expected risk for a mood disorder of some type including bipolar disorder (Mitchell
et.al., 1993). Results of studies indicated that about nine percent of the first degree
relatives of a person with bipolar illness can also be expected to have bipolar
disorder (nine times the rate of the disorder in the general population) (Katz and
McGuffin 1993; Plomin et.al., 1997). Although family studies cannot by themselves
establish a genetic basis for the disorder, results from twin studies also point to a
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Mood Disorders genetic basis. Twin studies have been limited by relatively small sample sizes but have
indicated a substantial genetic contribution, as well as environmental influence.
The concordance rates for these disorders are much higher for identical twins than
for fraternal twins (Kallman, 1958). The study of Bertelsen, Harvald, and Hauge
(1977) estimated that monozygotic twins were three times more likely to be concordant
(67 percent) for a diagnosis of bipolar disorder than were dizygotic twins (20 percent).
About three-quarters of the affected cot-wins had the same form of disorder (bipolar),
but nearly one-quarter had unipolar disorder. This study further suggests that genes
account for over 80 percent of the variance in the tendency to develop (that is
liability for) bipolar depression. For bipolar I, the (probandwise) concordance rates
in modern studies have been consistently put at around 40% in monozygotic twins
(same genes), compared to 0 to 10% in dizygotic twins ( Kieseppa et. al., 2004).
A combination of bipolar I, II and cyclothymia produced concordance rates of 42%
vs. 11%, with a relatively lower ratio for bipolar II that likely reflects heterogeneity.
The overall heritabibility of the bipolar spectrum have been put at 0.71 (Edvardsen
et. al., 2008). There is overlap with unipolar disorder and if this is also counted in
the co-twin the concordance with bipolar disorder rises to 67% (monozygotic) and
19% (dizygotic) (McGuffin et.al., 2003) The relatively low concordance between
dizygotic twins brought up together suggests that shared family environmental effects
are limited, although the ability to detect them has been limited by small sample sizes.
Genetic studies of bipolar disorder have also used recombinant DNA technology in
an attempt to locate genetic markers. The studies have suggested many chromosomal
regions appearing to relate to the development of bipolar disorder, but the results are
not consistent and often not replicated (Kato, 2007). Although the first genetic
linkage finding for mania was in 1969 (Reich et. al., 1969), the linkage studies have
been inconsistent (Burmeister el. al., 2008). Recent meta-analyses of linkage studies
detected either no significant genome-wide findings or, using a different methodology,
only two genome-wide significant peaks, on chromosome 6 and on chromosome 11.
Studies also suggest that abnormalities in the structure and/or function of certain brain
circuits could underlie bipolar and other mood disorders. Imaging studies show how
the brains of people with bipolar disorder may differ from the brains of healthy
people or people with other mental disorders. For example, one study using MRI
found that the pattern of brain development in children with bipolar disorder was
similar to that in children with “multi-dimensional impairment,” a disorder that causes
symptoms that overlap somewhat with bipolar disorder and schizophrenia (Gogtay,
et. al. 2007). This suggests that the common pattern of brain development may be
linked to general risk for unstable moods. Some studies have also found anatomical
differences in areas such as the amygdale (Strakowski, 1999), prefrontal cortex and
hippocampus (Kempton et. al., 2008). However, despite 25 years of research involving
more than 7,000 MRI scans, studies continue to report conflicting findings and there
remains considerable debate over the neuroscientific findings. Two fairly consistent
abnormalities found in a meta-analysis of 98 MRI or CT neuroimaging studies were
that groups with bipolar disorder had lateral ventricles which were on average 17%
larger than control groups, and were 2.5 times more likely to have deep white matter
hyperintensities.
Studies on conducted on the causes of mood disorder suggest that neurotransmitter
also play important role in the development of bipolar disorder. As we know that
neurotransmitter is brain chemical which helps in the transmission of information from
one neuron to other at synapse. Neurobiological investigations suggest that
24 norepinephrine and serotonin are such two transmitters which are associated with
depression. For example, Joseph and Schildkraut (1965) suggested that at least Bipolar Disorder
some forms of depressions are associated with low levels of norepinephrine. Conversely
he suggested that elation or mania was associated with an excess of this
neurotransmitter, which is called noradrenalin. This hypothesis, called catecholamine
hypothesis, was developed after researcher had observed an unexpected drug effect.
The drug reduced the levels of norepinephrine, which caused the people to become
very depressed.
A second theory, known as indolamine hypothesis, suggests that low levels of
serotonin (one of the indolamines) were associated with and perhaps caused
depression (Glossman and Platman, 1969). It has also been observed that
neurotransmitter system has many subtypes and interact in many complex ways with
other neurotransmitters and neuromodulators (products of endocrine system). For
example reserpine (used to reduce blood pressure) also affects dopamine, and in
turn, causes to produce depression. Like reserpine, serotonin was also found to
reduce levels of neurotransmitter and thus causes to increase the depression.
Researchers also became interested in the endocrine system when they found that
patients with such diseases which affect the endocrine system became depressed.
Hypothyroidism, or Crushing’s disease, affecting the adrenal cortex, leads to excessive
secretion of cortisole and, often, depression.
It has been suggested that a hypersensitivity of the melatonin receptors in the eye
could be a reliable indicator of bipolar disorder, in studies called a trait marker, as
it is not dependent on state (mood, time, etc.). In studies, patients diagnosed as
bipolar reliably showed a melatonin-receptor hypersensitivity to light during sleep,
causing a rapid drop in sleep time melatonin levels compared to controls (Lewy et.
al., 1985)). Another study showed that drug-free, recovered, bipolar patients exhibited
no hypersensitivity to light (Whalley et.al , 1991). It has also been shown in humans
that valproic acid, a mood stabiliser, increases transcription of melatonin receptors
and decreases eye melatonin-receptor sensitivity in healthy volunteers while low-dose
lithium, another mood stabiliser, in healthy volunteers, decreases sensitivity to light
when sleeping, but doesn’t alter melatonin synthesis (Hallam et al., 2005). The
extents to which melatonin alterations may be a cause or effect of bipolar disorder
are not fully known.
2.2.3.2 Psychological Factors
Evidence suggests that psychological factors play a significant role in the development
and course of bipolar disorder, and that individual psychosocial variable may interact
with genetic dispositions (Serretti & Mandelli, 2008). There is fairly consistent evidence
from prospective studies that recent life events and interpersonal relationships contribute
to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for
onsets and recurrences of unipolar depression (Alloy et. al., 2005). Environmental
stressors can sometimes be important in setting off either an initial or additional manic
episode.
Two-thirds of manic episodes experienced by patients in one study were preceded
by a life related stress of some kind (Ambelas,1987). Stressful events can also cause
a manic episode in people with a past history of manic episodes or bipolar disorder.
For example, when a major hurricane struck Long Island, New York, in 1985, there
was a dramatic increase in manic episodes among patients with bipolar disorder who
were being treated with lithium (Aronson and Shukla, 1987). All the people who
relapsed already had a high level of stress in their lives and most lacked social
support from a close, confiding relationship.
25
Mood Disorders For each of these people the hurricane resulted in addional stress besides that from
the storm itself. Findings of the studies also suggest that between a third and a half
of adults diagnosed with bipolar disorder report traumatic/abusive experiences in
childhood, which is associated on average with earlier onset, a worse course, and
more co-occurring disorders (Gabriele et.al. 2006). The total number of reported
stressful events in childhood is higher in those with an adult diagnosis of bipolar
spectrum disorder compared to those without, particularly events stemming from a
harsh environment rather than from the child’s own behaviour (Louisa et. al., 2007).
Early experiences of adversity and conflict are likely to make subsequent
developmental challenges in adolescence more difficult, and are likely a potentiating
factor in those at risk of developing bipolar disorder (Miklowitz et. al., 2008).

2.2.4 Treatment
There are a number of pharmacological and psychotherapeutic techniques used to
treat Bipolar Disorder. Hospitalisation may be required especially with the manic
episodes present in Bipolar I.
Because bipolar disorder is a lifelong and recurrent illness, people with the disorder
need long term treatment to maintain control of bipolar symptoms. An effective
maintenance treatment plan includes medication and psychotherapy for preventing
relapse and reducing symptom severity.
2.2.4.1 Medications
Some of the types of medications generally used to treat bipolar disorder are listed
below:
2.2.4.1.1 Mood Stabilising Medications
These are usually the first choice to treat bipolar disorder. In general, people with
bipolar disorder continue treatment with mood stabilisers for years. The following
medications are commonly used as mood stabilisers in bipolar disorder:
Lithium (sometimes known as Eskalith or Lithobid) was the first mood-stabilising
medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s
for treatment of mania. It is often very effective in controlling symptoms of mania and
preventing the recurrence of manic and depressive episodes.
Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for
treating mania, is a popular alternative to lithium for bipolar disorder. It is generally
as effective as lithium for treating bipolar disorder.
More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for
maintenance treatment of bipolar disorder.
Other anticonvulsant medications, including gabapentin (Neurontin), topiramate
(Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies
have shown that these medications are more effective than mood stabilisers.
2.2.4.1.2 Atypical Antipsychotic Medications
These are sometimes used to treat symptoms of bipolar disorder. Often, these
medications are taken with other medications. Atypical antipsychotic medications are
called “atypical” to set them apart from earlier medications, which are called
“conventional” or “first-generation” antipsychotics.
26
Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve Bipolar Disorder
symptoms of severe mania or psychosis. Olanzapine can be used for maintenance
treatment of bipolar disorder as well, even when a person does not have psychotic
symptoms.
Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed
episode.
Aripiprazole is also used for maintenance treatment after a severe or sudden episode.
As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms
of manic or mixed episodes of bipolar disorder.
Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes.
In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first
atypical antipsychotic to also receive FDA approval for the treatment of bipolar
depressive episodes.
Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics
that may also be prescribed for controlling manic or mixed episodes.
2.2.4.1.3 Antidepressant Medications
These are sometimes used to treat symptoms of depression in bipolar disorder.
People with bipolar disorder who take antidepressants often take a mood stabiliser
too, because taking only an antidepressant can increase a person’s risk of switching
to mania or hypomania, or of developing rapid cycling symptoms.
2.2.4.2 Psychotherapy
In addition to medication, psychotherapy, or “talk” therapy, can be an effective
treatment for bipolar disorder. It can provide support, education, and guidance to
people with bipolar disorder and their families. Some psychotherapy treatments used
to treat bipolar disorder include:
Cognitive behavioural therapy (CBT) helps people with bipolar disorder learn to
change harmful or negative thought patterns and behaviours.
Family-focused therapy includes family members. It helps enhance family coping
strategies, such as recognising new episodes early and helping their loved one. This
therapy also improves communication and problem-solving.
Interpersonal and social rhythm therapy helps people with bipolar disorder improve
their relationships with others and manage their daily routines. Regular daily routines
and sleep schedules may help protect against manic episodes.
Psychoeducation teaches people with bipolar disorder about the illness and its
treatment. This treatment helps people recognise signs of relapse so they can seek
treatment early, before a full-blown episode occurs. It is usually done in a group.
Psychoeducation may also be helpful for family members and caregivers.

2.2.5 Prognosis
For many individuals with bipolar disorder a good prognosis results from good
treatment, which, in turn, results from an accurate diagnosis. Bipolar disorder can be
a severely disabling medical condition. However, many individuals with bipolar disorder
can live full and satisfying lives. Quite often, medication is needed to enable this.
Persons with bipolar disorder may have periods of normal or near normal functioning
27
Mood Disorders between episodes. Ultimately one’s prognosis depends on many factors, several of
which are within the control of the individual. Such factors may include: the right
medicines, with the right dose of each; comprehensive knowledge of the disease and
its effects; a positive relationship with a competent medical doctor and therapist; and
good physical health, which includes exercise, nutrition, and a regulated stress level.
A naturalistic study from first admission for mania or mixed episode (representing the
hospitalised and therefore most severe cases) found that 50% achieved syndromal
recovery (no longer meeting criteria for the diagnosis) within six weeks and 98%
within two years. 72% achieved symptomatic recovery (no symptoms at all) and
43% achieved functional recovery (regaining of prior occupational and residential
status). However, 40% went on to experience a new episode of mania or depression
within 2 years of syndromal recovery, and 19% switched phases without recovery
(Tohen et. al., 2003).

2.3 LET US SUM UP

The characteristic feature of bipolar disorders, sometimes referred to as manic-
depressive disorders, or bipolar affective disorders, is that the person experiences
episodes of both depression and mania or hypomania. Mania is a state of elevated
mood flight of ideas, and increased psychomotor activity. A hypomanic episode is
referred to a period of manic behaviour that is not extreme enough to greatly impair
function. In DSM-IV-TR and ICD-10 bipolar disorder is conceptualised as a
spectrum of disorders occurring on a continuum. The DSM-IV-TR lists three specific
subtypes and one for non-specified:
Bipolar I Disorder
Bipolar I Disorder
Cyclothymia
Bipolar Disorder NOS (Not Otherwise Specified)
Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least
seven days, or by manic symptoms that are so severe that the person needs immediate
hospital care. Usually, the person also has depressive episodes, typically lasting at
least two weeks. A person with bipolar disorder experiences episodes of mania and,
usually, major depressive episodes as well.
Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and
forth with hypomanic episodes, but no full-blown manic or mixed episodes. Hypomanic
episodes do not go to the full extremes of mania (i.e., do not usually cause severe
social or occupational impairment, and are without psychosis), and this can make
Bipolar II more difficult to diagnose. Bipolar II disorder differs from Bipolar I in that
– rather than experiencing one or more florid, dramatic manic episodes – the manic
behaviour is present to a lesser degree. Cyclothymic disorder is a mild form of
bipolar disorder. People who have cyclothymia have episodes of hypomania that shift
back and forth with mild depression for at least two years.
However, the symptoms do not meet the diagnostic requirements for any other type
of bipolar disorder. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed
when a person has symptoms of the illness that do not meet diagnostic criteria for
either bipolar I or II.

28
The symptoms may not last long enough, or the person may have too few symptoms, Bipolar Disorder
to be diagnosed with Bipolar I or II. However, the symptoms are clearly out of the
person’s normal range of behaviour
Although causes of bipolar disorder likely vary between individuals. But studies
suggest that both biological and psychological factors seem to play a role in
determining whether a person will develop symptoms of bipolar disorder. Studies
conducted on the families of people diagnosed with bipolar disorder show that there
is strong tendency for other family members also to have higher than expected risk
for a mood disorder of some type including bipolar disorder. Twin studies have
indicated a substantial genetic contribution, as well as environmental influence. The
concordance rates for these disorders are much higher for identical twins than for
fraternal twins. Evidence suggested that psychological factors play a significant role
in the development and course of bipolar disorder, and that individual psychosocial
variable may interact with genetic dispositions. There is fairly consistent evidence
from prospective studies that recent life events and interpersonal relationships contribute
to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for
onsets and recurrences of unipolar depression.
There are a number of pharmacological and psychotherapeutic techniques used to
treat bipolar disorder. An effective maintenance treatment plan includes medication
and psychotherapy for preventing relapse and reducing symptom severity.
Some of the types of medications generally used to treat bipolar disorder are:
(1) Mood stabilising medications are usually the first choice to treat bipolar disorder.
Lithium, valproic acid or divalproex sodium are commonly used as mood stabilisers
in bipolar disorder. (2) Atypical antipsychotic medications are sometimes used to
treat symptoms of bipolar disorder. Often, these medications are taken with other
medications. (3) Antidepressant medications are also used to treat symptoms of
depression in bipolar disorder.
In addition to medication, psychotherapy, or “talk” therapy, can be an effective
treatment for bipolar disorder. It can provide support, education, and guidance to
people with bipolar disorder and their families.
For many individuals with bipolar disorder a good prognosis results from good
treatment, which, in turn, results from an accurate diagnosis. Bipolar disorder can be
a severely disabling medical condition. However, many individuals with bipolar disorder
can live full and satisfying lives. Quite often, medication is needed to enable this.

2.4 UNIT END QUESTIONS

1) What do you mean by bipolar disorder? How does it differ from other mood
disorders?
2) Discuss the symptoms of bipolar disorders in detail.
3) What is manic episode? Differentiate between manic and hypomanic episode.
4) Discuss the types of bipolar disorder. Differentiate between bipolar I disorder
and bipolar II disorder.
5) Explain the causes of bipolar disorder.
6) Describe the treatment and prognosis of bipolar disorder.
7) Differentiate between bipolar disorder and other forms of depressive disorder.
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Mood Disorders
2.5 GLOSSARY
Antidepressant medication : General term for a number of drugs used to
relieve depression and to elevate mood.
Antipsychotic medication : Group of drugs used to treat patients who show
severely disturbed behaviour and thought
processes.
Bipolar disorder : Mood disorder in which a person experiences
both manic and depressive episodes.
Cognitive Behaviour therapy : Therapy based on altering cognitive
dysfunctional thoughts and cognitive disorders.
Cyclothymic disorder : A long lasting disorder that includes both mania
and depressive episodes, neither of whichmeet
the criteria for major episodes. Lasts for at
least two years.
Depression : Pervasive feeling of sadness that may begin after
some loss or stressful event, but that continue
long afterwards.
Depressive disorder : Depressive symptoms that meet diagnostic
criteria for either single episode of major
depression, or recurrent episodes.
Dizygotic twins : Twins that develop from two separate eggs.
Episodic (disorder) : Term used to describe a disorder that tends to
abate and to recur.
Major depressive disorder : A severe depression characterised by dysphoric
mood as well as poor appetite, sleep problems,
feelings of restlessness, loss of pleasure, loss of
energy, feeling of inability to concentrate,
recurring thoughts of death or suicide attempts.
Depressive episodes occur most of everyday
for at least two weeks.
Mania : Euphoric, hyperactive state in which an
individual’s judgment is impaired.
Hypomania : A disorder characterised by unusual elevation
in mood that is not as extreme as that found in
mania.
Hypomanic episode : A distinct period of elevated expansive or
irritable mood and other manic behaviours that
is not severe enough to greatly impair social or
occupational functioning and does not require
hospitalisation.
Lithium : Chemical salt used in the treatment of bipolar
disorder.
30
Monozygotic twins : Identical twins developed from one fertilised Bipolar Disorder
egg.
Mood disorder : One of a group of disorders primarily affecting
emotional tones. It can be depression, manic
excitement, or both. It may be episodic or
chronic.
Psychotherapy : Treatment of mental disorders by psychological
methods.
Stress : Effects created within an organism by the
application of a stressor.
Unipolar disorder : Mood disorder in which a person experiences
only depressive episodes, as opposed to bipolar
disorder, in which both manic and depressive
episodes occur.

2.6 SUGGESTED READINGS

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Durand, V. K. & Barlow, D. H. (2000). Abnormal Psychology: An Introduction.
Stamford: Thomson Learning.
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