Episodes of depression, mania/hypomania, or mixed episodes characterize bipolar affective disorder (BD). Between these episodes, there are usually periods of remission, i.e., complete absence of symptoms or persistence of a few symptoms of low intensity. Bipolar affective disorder is the second most common cause of incapacity for work due to psychiatric reasons.
The development of bipolar disorder is explained by a biopsychosocial model that includes biological (genetic and including changes in neurotransmitters), psychological (personality structure, stressful events), and socio-environmental (e.g., family factors, irregular lifestyle) causes that interact with each other. It should be emphasized that the development of bipolar disorder is not the result of a single cause.
Despite significant progress in understanding the biological basis of bipolar disorder (BD), the causes of this disorder are not fully explained. However, numerous studies indicate a strong influence of genetic factors. It is believed that the risk of developing the disease is influenced (complexly) by many different genes. People who have first-degree relatives (parents, siblings) suffering from this disorder are at increased risk of developing bipolar disorder.
So far, it has been established that, at the biochemical level, bipolar disorder is associated with abnormalities in the secretion and action of neurotransmitters in the brain. It is believed that disorders in the functioning of neurotransmitter systems can lead to mood changes observed in this disorder. In addition, some people with bipolar disorder may experience structural changes in the brain. However, this is not necessarily the cause of the disorder – it can also be its result.
From a psychological perspective, it is believed that personality traits and coping styles can influence the development and course of bipolar disorder. For example, people who tend to experience intense emotions may be more susceptible to its development. In addition, some studies suggest that there is a link between bipolar disorder and certain personality disorders, such as borderline personality disorder.
Another cause that can lead to the manifestation of bipolar disorder is stressful life events, which often precede the first episode of this disorder or lead to a relapse in people who have already been diagnosed. Trauma experienced in early youth, the loss of a loved one, a breakup, difficulties at work, or financial problems can trigger an episode of the disease in a genetically susceptible person.
Much indicates that although bipolar disorder has a strong biological basis, psychological and environmental factors also have a significant impact on the development, course, and treatment of this disorder. Understanding these factors is crucial for appropriate treatment and help for people affected by bipolar disorder.
Depending on the phase of the disease (manic or depressive episode), there are symptoms characteristic of bipolarity.
Symptoms of a manic episode are:
Symptoms of a depressive episode include:
We distinguish several phases.
Bipolar depression is similar to unipolar depression, which is often just called depression. People experience sadness, a loss of joy, and a lack of interest in activities. They may feel tired and have low energy, slowing their thinking and speech. Concentration and memory can also suffer. Common symptoms include excessive sleepiness and a lower sex drive. Sometimes, people might feel anxious or tense.
In bipolar depression, symptoms can include racing thoughts, mood swings, and irritability, which can be different from unipolar depression. Like unipolar depression, people may feel a loss of meaning in their lives, which can lead to thoughts of suicide. Other symptoms can include low self-worth and a negative view of the past, present, and future.
In severe cases, people might experience psychotic symptoms, such as delusions (false beliefs) about guilt, punishment, sin, disaster, or illness. They might also hear voices that encourage them to harm themselves. Depression in bipolar disorder can happen on its own or follow a period of mania or hypomania.
Mania is marked by exaggerated self-esteem and an overly positive outlook on life. People experiencing mania often feel energetic and excessively happy, even when reality doesn't match their feelings. They may sleep very little or not, yet still feel wide awake.
Individuals with mania may behave loudly, appear cheerful and hyperactive, and become irritable. Their thoughts might race and feel chaotic. They often try to take control and push their plans onto others. People may also act impulsively, engaging in risky behaviors and having more frequent, spontaneous sexual encounters. Individuals with mania can become frustrated or angry when others refuse to go along with their plans. They usually don't recognize that something is wrong and often believe they are healthy, showing no interest in seeing a psychiatrist.
Other signs of mania include using drugs or alcohol, taking out loans, and making impulsive purchases, often for things they don't need. They might also change their appearance, like wearing bold makeup or bright clothes. In severe cases, mania can lead to psychotic symptoms, such as delusions of grandeur or the belief in having special powers.
Hypomania is characterized by symptoms similar to mania, which are, however, less intense, last shorter, and usually do not cause significant destruction of the patient's life, and psychotic symptoms do not appear. The patient retains the ability to control their behavior and is partially critical of their condition. Feeling increased energy and optimism, they have a sense of increased strength and capabilities and, therefore, can undertake various ambitious activities but usually do not complete them.
These activities can be risky and reckless but with a tendency to at least partially control their behavior. The patient often complains about difficulty concentrating. People with hypomania usually do not perceive themselves as requiring treatment. Their environment also frequently does not see such a need.
It is often perceived as a beneficial state, sometimes as an improvement and catching up after a period of depression.
A mixed episode is manifested by the simultaneous occurrence of symptoms of both depression and mania/hypomania. Psychomotor slowing may be accompanied by an acceleration of thoughts, up to racing thoughts, anxiety, and irritability. In turn, greater activity may be accompanied by a sense of sadness, loss of joy and meaning in life, and suicidal thoughts. Mixed states with irritability or increased psychomotor drive with loss of meaning in life (“agitation with depression”) require particularly thorough observation of the patient for suicidal thoughts and tendencies.
A remission period is a state without symptoms of the disease (complete remission) or discreetly persistent or slightly intensified, with few symptoms (incomplete remission). Despite the lack of slight intensification of disease symptoms, periods of remission most often require further check-ups with the attending psychiatrist and systematic taking of medications to prevent another relapse.
If you or someone you care about is experiencing emotional or behavioral problems that cause concern, you must see a doctor. This is especially true if there are signs of depression. If you notice manic symptoms or a mix of moods, you should seek medical help immediately.
If someone thinks about suicide, it's crucial to get help right away. Suicidal thoughts can occur with any mood episode, particularly during depression or mixed states. These thoughts are more alarming if they come with anxiety, irritability, or aggression. Remember, suicidal feelings can also happen during remission, that is, after the main symptoms have lessened.
A visit to a psychiatrist is recommended as soon as possible, even if hypomanic symptoms last only a day or a few days because such a condition always requires in-depth diagnostics and perhaps a change in the diagnosis of a given patient. Hypomanic symptoms may be early symptoms (so-called prodromes) of developing bipolar affective disorder or another mental disorder. On the other hand, it may turn out that they are not “dangerous” in nature, and then, taking into account the context of the life situation, a mental illness is not diagnosed.
When a given person or someone close to them notices a certain cyclical or seasonal nature of mood changes or fluctuations in this person, this is not always bipolar affective disorder. Still, such cyclicality requires diagnostics and psychiatric observation.
Due to the discussed diagnostic difficulties and the special diagnostic vigilance required in cases of bipolar affective disorder, as well as due to the variability of the course of this disease, any initial diagnosis made by a doctor of another specialty, a psychologist or therapist, requires verification by a psychiatrist. While a depressive episode or recurrent depression can be treated by non-psychiatric physicians, bipolar affective disorder requires regular visits and care from a psychiatrist.
Diagnosis of bipolar disorders is performed by a psychiatrist based on the observed clinical picture of the patient and a detailed interview. The diagnostic criteria for bipolar disorders include:
Unfortunately, bipolar disorders can be confused with other disorders – for example, anxiety disorders or depression. Therefore, if a patient or their environment notices signs of a manic state, they must inform the doctor who made the diagnosis because then medications selected solely for depression or calming anxiety states may cause the patient's lousy condition to worsen.
The goals of therapy in the case of bipolar affective disorder are to achieve remission in the course of episodes of the disease, ensure a return to normal pre-morbid functioning, and prevent further relapses of the disease.
Due to the chronic and recurrent nature of the disease, treatment is long-term. It can last several, a dozen, or so years and often involves taking medications for the rest of your life (optimally as preventive treatment). It includes treatment of the first episode of the disease and its subsequent relapses (acute or milder) and preventive (maintenance) treatment during periods of remission. Depending on the severity of the episodes, the method, type, and place of therapy change.
Treatment should be comprehensive, i.e., primarily include pharmacotherapy (medication), psychoeducation, and sometimes psychotherapy.
Psychoeducation plays a significant role in the case of bipolar affective disorder. It consists of informing, teaching, and transferring the knowledge and experience of a psychiatrist or other therapist to the patient. Psychoeducation can be a conversation during diagnosis and treatment and outpatient visits. It can also take the form of separate individual or group meetings.
Psychoeducation can be directed to patients themselves, but it can also and should be proposed to patients' families. A crucial goal of psychoeducation is, among other things, recognizing the patient's characteristic symptoms preceding a relapse (so-called disease harbingers) and knowing how to proceed in such a case.
Psychotherapy depends on the course and degree of intensity of individual episodes of bipolar affective disorder, as well as the patient's ability to maintain regularity. It is most often recommended for long-term periods of remission.
In the case of incomplete remission or ongoing episodes of the disease, it can also be conducted – then mainly in the form of support. Various therapeutic activities for patients are also important (including those aimed at developing the possibilities and skills of controlling behavior).
In chronic pharmacological treatment, mood-stabilizing drugs are used. During this case of depressive episodes, antidepressants are sometimes used (but under constant medical supervision and taking into account contraindications).
In acute episodes, especially with increased agitation or anxiety, classic antipsychotic drugs are often added to achieve faster patient calming and reduce aggressive behavior.
Therapy with some of the drugs mentioned above, both during achieving the optimal dose and periodically during maintenance treatment, requires determining the concentration of the administered medicine in the blood and monitoring the function of other organs (e.g., kidneys, liver, thyroid). Additionally, a blood count, blood glucose, and cholesterol levels should be performed, and changes in body weight should be monitored.
If the patient has other mental disorders co-occurring with bipolar disorder or concomitant non-psychiatric diseases, they most often require the addition of appropriate drugs and psychotherapeutic interactions. Their presence also frequently determines the choice of the basic drug or drugs in the treatment of relapses and prevention of bipolar disorder.
The course, frequency, and severity of individual episodes of bipolar disorder and co-occurring disorders determine whether the psychiatrist decides to treat the patient with one (monotherapy) or two or even more drugs from the same or different groups (polytherapy, combination therapy).
In the case of an acute episode of severe mania or depression, a different treatment strategy is used than in long-term maintenance therapy. Psychiatric hospitalization of the patient is often indicated. However, in the case of a manic episode, it is usually challenging to convince the patient of the need for hospital treatment. Sometimes, it happens that if the symptoms of mania are not severe and do not pose a threat to the patient's life or the health and lives of other people, the patient may refuse any form of treatment.
Sometimes, hospitalization is necessary. If the patient, as a result of disease symptoms (e.g., severe suicidal thoughts, tendencies and behaviors, strong agitation, active aggression), endangers their life or the life and health of other people, they may be admitted to a psychiatric hospital and hospitalized without their consent.
In conditions including a threat to the patient's life in the course of a severe episode of mania or depression, as well as in the case of drug resistance, the doctor may recommend electroconvulsive therapy.
As already mentioned, in the treatment of bipolar disorder, psychoeducation (of both the patient and their loved ones) is particularly important about the disease and the possibilities and methods of proceeding in the case of both the first symptoms predicting its recurrence in a specific patient and an already developed episode of the disease (hypomania, mania, depression or mixed episode).
A significant improvement in the well-being of patients is possible. Long-term pharmacotherapy (treatment with drugs) brings measurable benefits, but relapses of the described disorders are very likely.
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