Bipolar Disorder: Diagnosis and Treatment

Detailed description of Bipolar Disorder, the difference between Bipolar I and Bipolar II, the difficulty in getting an accurate diagnosis and what treating Bipolar Disorder entails.

(Ed. Note: Our first episode of the HealthyPlace TV Show focused on the "devastation caused by untreated Bipolar Disorder." You can view it by clicking the "on-demand" button on the player.)

Bipolar Disorder is a serious psychiatric disorder that is characterized by mood changes including "highs and lows" and is the same disorder that in the past was called Manic-Depressive Illness. The person with Bipolar Disorder has at least one "high" episode (though they often have repeated such episodes), and usually has multiple episodes of depression. These mood states are different from the patient's "normal mood," and generally last 4-7 days or more.

To make the diagnosis of Bipolar Disorder, a person must have at least one "high" episode. These "high" periods include the person feeling so "high, hyper, full of themselves" or irritable that others notice that they are "not themselves." In addition, during these periods of time, the person notices: less need for sleep, racing thoughts, a pressure to talk, restlessness, and often engaging in behavior that can potentially cause harm (like overspending, gambling, risk taking, engaging in risky or inappropriate sexual activity).

Difference Between Manic and Hypomanic Episodes of Bipolar Disorder

There are two types of "highs" known as manic or hypomanic episodes. A manic episode generally lasts a week or more and involves significant problems in social or job/school activities and often is characterized by thinking that is psychotic (where the person is out of touch with reality). A hypomanic episode is usually shorter in duration (4 days or longer), less severe, and usually does not disrupt work or home activities, although it is noticed to be unusual and abnormal for the person. These hypomanic periods are often unrecognized by the patient, who will frequently describe them as periods where they are "high, full of energy and able to accomplish a lot." These high periods are ended either by the person's mood returning to "normal" or going into periods of depression. Each period of abnormal mood, be it high or low is called an "episode."

Those with depressive and manic episodes are said to be suffering from Bipolar I disorder, while those with depressive and hypomanic episodes are described as suffering from Bipolar II disorder. Bipolar II is now more common than Bipolar I, but both are serious disorders affecting 1% to as many as 10% of the adult population. Bipolar disorder, be it type I or II, generally begins in adolescence or early adulthood, but can have its onset in childhood or in later adulthood as well.

The Difficulty of Accurately Diagnosing Bipolar Disorder

Bipolar disorder can exist for many years before it is accurately diagnosed. This delay can be the result of several factors.

1. If the early episodes are those of hypomania, the patient may mistakenly think they are just feeling "good or perhaps no longer depressed." Many patients actually like the feelings of hypomania because they feel so good and can get much accomplished.
2. If the first episode is manic, it can be mistakenly believed to be the result of drugs, medical conditions, or another psychiatric illness.
3. And to complicate diagnosis even further is the fact that the depressive episode of Bipolar Disorder may appear to be like the depression symptoms of Major Depression (routine or major depression). In fact the symptoms of bipolar depression and common unipolar depression are the same, and often patients with Bipolar Disorder have several recurrent depressive episodes before ever having their first manic or hypomanic episode. (Remember that the diagnosis of Bipolar Disorder requires at least one manic or hypomanic episode).

The Importance of Getting A Correct Bipolar Disorder Diagnosis

The problem with misdiagnosing Bipolar Disorder as common unipolar depression is that the treatments of the two conditions are different. In fact, the medications used to treat single or repeated episodes of Major (Unipolar) Depression - called antidepressant medications - can cause a person with Bipolar Disorder to either go into a manic or hypomanic episode, or cause a worsening of the Bipolar Disorder.

To further complicate the diagnosis of Bipolar Disorder is the reality that patients can have other co-existing psychiatric disorders such as: substance abuse, ADHD, anxiety disorders, psychotic disorders, etc., as well as other medical disorders (thyroid problems, diabetes, etc). These co-existing disorders can mask or worsen the symptoms of Bipolar Disorder making correct diagnosis difficult.

Treating Bipolar Disorder

Correct diagnosis is important, however, because appropriate treatment of Bipolar Disorder depends upon it. Appropriate treatment generally involves the use of: medication, psychotherapy and the use of a social support system (family or others). With appropriate treatment, Bipolar Disorder can be controlled in the same way that diabetes can be controlled.

Medication treatment for Bipolar will include the use of medicines called "mood stabilizers," to keep the mood swings in control. From time-to-time, the person may require medications to treat the manic or hypomanic episodes and may need other medications for treating the depressive episodes. Unfortunately, all the medications can have some side-effects, and unless the patient "buys in" to the need for medication, if they experience side-effects, they often discontinue the bipolar medications thereby putting themselves at risk for more mood episodes. Another problem during manic or hypomanic episodes is that the patient may begin to enjoy the "high" and voluntarily stops medication.

Support for Patients with Bipolar Disorder

The first part of treatment then must be helping the patient, family and support system to understand and accept the diagnosis of Bipolar Disorder and the need for treatment. This can be done through education and understanding, and reinforced by psychotherapy. Psychotherapy can be invaluable in dealing with life stressors and psychological issues that can bring on "episodes." In addition, therapy can help clear up distorted thinking and improve self-esteem.

Family and other support persons are critical in helping the Bipolar Disorder patient to accept and cope with their illness. This can be a difficult task, especially when they are in a manic or hypomanic episode, and deny the need for treatment. When the patient is in the "normal phase," in-between episodes, this is the time when understandings or even "contracts" with the patient can be made so that they will accept observations or recommendations from support persons when they become manic or depressed.

The good news is that with appropriate medication, therapy and support, the symptoms of Bipolar Disorder can be effectively controlled and often the patient can live a productive and satisfying life.

Dr. Harry Croft is a Board-Certified Psychiatrist and Medical Director of HealthyPlace.com. Dr. Croft is also the co-host of the HealthyPlace TV Show.

next: Adult ADHD: A Real Psychiatric Condition
~ other mental health articles by Dr. Croft