What are Bipolar Disorders? What is the Bipolar Spectrum?

Before we discuss bipolar disorders, let’s review the terms “Mood” and “Affect”

Affects and moods refer to different aspects of emotion. Affect is communicated through facial expression, vocal inflection, gestures, and posture. Affect is intended to allow humans and nonhuman primates to appraise satisfaction, distress, disgust, and dangerousness in others. Thus, joy, sadness, anger, and fear are basic affects that serve a communicative function. Affects tend to be short-lived expressions reflecting momentary emotional contingencies.

Moods convey sustained emotions; their more enduring nature means they are experienced long enough to be felt inwardly. Moods are also manifested in subtle ways, and their accurate assessment often requires empathic understanding by observers. The words that people use to describe their inner emotions may coincide with the technical terms used by researchers or clinicians and often vary from one culture to another. 

Sometimes, the inward emotion and the prevailing affective tone may be discordant or incongruent. This conflict could be due to deliberate simulation (i.e., the person does not wish to reveal his or her inner emotion), or it could result from a pathological lesion or process that has altered emotions and their neural substrates.

AFFECT: A person’s immediate expression of emotion

MOOD: The more sustained emotional makeup of a person’s personality 

 

What are Mood Disorders?

Mood disorders are group of psychiatric disorders in which disturbances of mood or affect are severe and persistent enough to cause significant problems in an individual’s life. Moods themselves are not pathological and many of us have experienced a range of mood states. But when moods become severe and persistent enough to cause dysfunction and issues in an individual’s life, then we use the term “mood disorder.”
 
Symptoms of mood disorders usually occur in discrete periods we call episodes. Episodes can last for weeks, months, or even years. During these “episodes,” there is a significant change in the individual’s mood which may negatively impact work performance, relationships, or other important areas of functioning. The most common mood disorder is Major Depressive Disorder (MDD), often referred to as “Unipolar depression.”
 
Bipolar disorders are also mood disorders that differ from unipolar depression by the presence of elevated mood states called hypomania or mania.

Bipolar Disorder

Bipolar disorder is a mental illness characterized by dramatic shifts in a person’s mood, energy and ability to think clearly. People with bipolar disorder experience high and low moods—known as mania and depression, respectively—which differ from the typical ups-and-downs most people experience. The average age-of-onset is about 25. The cause of bipolar disorder is not fully understood but there are a number of contributing factors that include genetic influences, environmental factors linked to stress, and biochemical factors that include changes in brain chemicals (including hormones). If left untreated, bipolar disorder usually worsens. However, with a good treatment plan including psychotherapy, medications, a healthy lifestyle, sobriety, a regular schedule and early identification of symptoms, many people live well with the condition.

What is Mania and Hypomania?

Mania is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood with abnormally and persistently increased goal-directed activity or energy that lasts at least 1 week. Hypomania is similar to mania but less severe. A hypomanic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy that lasts at least four consecutive days. Hypomanic episodes are typically not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. During a manic or hypomanic episode, a combination of the following symptoms is present and represents a noticeable change in behavior (see below).

 

If drugs or medications cause the above symptoms, then we consider this a medication (or substance)-induced manic or hypomanic state. However, a full manic or hypomanic episode that emerges due to medication (e.g., antidepressants) or drugs (e.g., cocaine, amphetamines) but persists beyond the physiological effect of the medication or drug is sufficient for a bipolar diagnosis.

Bipolar Subtypes

Our understanding of mood disorders continues to evolve over time. Most experts consider bipolar disorder to be on a spectrum. As of the writing of this post, the Diagnostic and Statistical Manual Fifth Edition (DSM-5) classifies bipolar disorders into Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and bipolar disorder due to a medical condition.

Rapid cycling in bipolar disorder (BD) is a descriptor that defines a subset of patients that have a large number of episodes over short periods of time. Specifically, rapid cycling is defined as having 4 or more episodes in a 12 month period, but many patients may have significantly more episodes. Individuals with rapid cycling generally have a younger age of onset, greater disease burden, and greater exposure to antidepressants. Cannabis, alcohol, caffeine, steroids, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and Tricyclic Antidepressants have been associated with inducing rapid cycling. 

The Neurobiology of Bipolar Disorder

Bipolar disorder is a complex disorder. A combination of genetic risk factors and environmental risk factors (e.g., childhood trauma) likely result in changes at numerous levels (intracellular, intercellular, network, etc.) that manifest behaviorally as bipolar disorder. The underlying biochemical abnormalities that cause or contribute to bipolar disorder remain unclear. However, studies have suggested neurobiological differences between unipolar and bipolar depression. This is further supported by the lack of efficacy of classic antidepressants in bipolar depression. In fact, there is evidence that classic antidepressants may induce mania and/or cause rapid cycling in patients with underlying bipolar disorder.

Human studies have found increased concentrations of noradrenaline (norepinephrine) and dopamine (DA) and decreased concentrations of serotonin (5-HT) in manic patients. This suggests that norepinephrine and dopamine dysregulation may play a primary role in manic symptoms. In addition to monoamine dysregulation, there is evidence implicating the glutamate and GABA systems in the pathophysiology of bipolar disorder. Animal studies suggest increased glutamatergic neurotransmission via NMDA receptors in manic patients. In addition, the efficacy of anticonvulsants, NMDA antagonists (e.g., ketamine), and benzodiazepines in the treatment of bipolar disorder suggests that glutamate and GABA systems are involved.

Circadian rhythms are consistently disturbed in patients with bipolar disorder. Researchers are investigating whether circadian rhythm disturbances might lead to mania given the fact that lithium deactivates the transcription factor GSK3B enzyme which is thought to reset the circadian clocks and restore normal brain functioning.

Functional Neuroimaging Studies have demonstrated or suggested that the following areas are implicated in bipolar disorder: prefrontal cortex, limbic areas such as the hippocampus, amygdala, anterior cingulate, and the ventral striatum (nucleus accumbens). A number of brain circuits have been implicated in the pathophysiology of bipolar disorder. Many of these circuits are involved in the regulation of emotion and cognition. Decreased activation of the orbitofrontal (OFC) circuits during a go-no go test in manic patients may explain the impulsive behaviors. Recall that the OFC is an important region within the prefrontal cortex involved in impulse-control and compulsive behaviors. The dorsolateral prefrontal cortex is involved in attentional processes and its dysfunction may also play a role in the pathophysiology of bipolar disorder. Decreased size and activity of the prefrontal cortex (PFC) has been demonstrated in patients with bipolar disorder—similar to that found in patients with unipolar depression. Interestingly, after four weeks of lithium treatment (but no valproic acid) there was an increase in gray matter volume in bipolar patients. Amygdalae are larger and more active in the bipolar patients. Bipolar disorder may be the result of abnormal interactions between the PFC and subcortical regions such as the amygdala—an abnormality not usually seen with unipolar depression. Reasons for the reduction in brain volumes and cell loss remain a mystery but could be from environmental stressors, neurodevelopmental abnormalities, and/or dysfunction in neurotransmitter systems.

Treatment of Bipolar Disorder

The management of bipolar disorder is multidimensional. The main objectives of pharmacotherapy (medication management) in bipolar disorder are to treat the acute manic/hypomanic and depressive episodes and minimize their recurrence.

Manic episodes are treated with one or more of the following: Lithium, valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), asenapine (Saphris), olanzapine (Zyprexa), risperidone (Risperdal), paliperidone (Invega), ziprasidone (Geodon), cariprazine (Vraylar), or aripiprazole (Abilify), clonazepam (Klonopin), diazepam (Valium), or lorazepam (Ativan).

Bipolar depressive episodes are treated with one or more of the following: Lithium, cariprazine (Vraylar), quetiapine (Seroquel), lurasidone (Latuda), Fluoxetine-Olanzapine combination (OFC), or lamotrigine (Lamictal).

Comorbid symptoms such as inattention, low energy, and low motivation can be safely treated with classic psychostimulants as long as a mood stabilizer is also prescribed. Severe anxiety, including social anxiety, can be safely managed with the addition of clonidine, propranolol, gabapentin, pregabalin, or benzodiazepines. In general, antidepressants should be avoided.

Neuromodulatory modalities such as neurofeedback, Transcranial Magnetic Stimulation (TMS), and ketamine infusion therapy should be considered if medication and therapy are not effective (or only partially effective).

While medication, neuromodulatory modalities, and drug abstinence are important in the management of bipolar disorder, they are considered components of a comprehensive treatment plan. As such, individual and/or family psychotherapy and psychoeducation should be considered.

Bipolar Depression

Bipolar Mania and Mixed States

Bipolar Maintenance

Observational studies suggest that with each episode of illness the time between episodes shortens. This highlights the importance of relapse prevention, which may improve long-term prognosis. For Mania Prevention: Lithium (Reduces suicide rates and overall mortality), Aripiprazole, Quetiapine, Olanzapine, Valproic Acid.  For Depression Prevention: Quetiapine, Lamotrigine, Lithium (Reduces suicide rates and overall mortality), Lurasidone

Final Comments

It is important to remember that the management of neuropsychiatric disorders is multifactorial, and medication is only one component. As stated previously, integrating treatment modalities such as psychotherapy, mentorship, sobriety, mindfulness-based stress reduction, and the pursuit of passionate hobbies/interests are all very important in the management of bipolar disorder.

BIPOLAR DISORDER DIAGNOSIS AND TREATMENT GUIDELINES (PDF)

References

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Helping Someone with Bipolar Disorder – HelpGuide.org

How to support someone during a difficult time

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