Introduction to Bipolar Disorder

Mania and Depression in Bipolar Disorder

Mania, or a manic episode, is defined by the American Psychiatric Association (APA) as a period of at least one week of elevated, euphoric, irritable, or expansive mood, accompanied by at least 3 of the following:

• Inflated self-esteem or grandiosity
• Increased energy levels
• Decreased need for sleep
• Increased talkativeness or pressured speech
• Racing thoughts or flight of ideas
• Distractibility
• Increased activity or psychomotor agitation
• Excessive involvement in pleasurable activities that have high potential for painful consequences

In addition, to meet the criteria of a manic episode, the mood disturbance must cause a significant impairment of occupational and social functioning as well as either:

• Necessitate hospitalization for the safety of the patient or people close to the patient
• Include psychotic features of delusions or hallucinations.

The symptoms cannot be related to other any medical condition or be the result of medication side effects or substance abuse.

Depression, or a depressive episode is defined by the APA as at least a two-week period with depression or irritable mood, diminished interest, loss of pleasure in most activities, or a change from previous functioning, plus at least 4 of the following:

• Feelings of worthlessness or inappropriate guilt (may be accompanied by delusions)
• Sleep disturbance (increased or decreased amount)
• Fatigue or loss of energy
• Decreased concentration or indecisiveness
• Significant weight loss without dieting, weight gain, or change in appetite
• Psychomotor agitation that is noticeable by other people
• Suicidal ideation or thoughts of death in general

In addition, in order to meet the criteria of a depressive episode, the symptoms must cause significant impairment of social and occupational functioning, must not be related to any other medical condition, must not be due to side-effects of medication or substance abuse, and must not be accounted for by bereavement.

Hypomania, as defined by the APA, is similar to mania in that it involves an elevated, expansive, or irritable mood, but differs in being generally of a shorter duration with a minimum of four days.

Like mania, hypomania must be accompanied by at least three of the following symptoms:

• Inflated self esteem
• Decreased need for sleep
• More talkative than usual
• Racing thoughts
• Distraction by unimportant or irrelevant stimuli
• Increased agitation or activity
• Excessive involvement in pleasurable activities that have a high potential for harm to the patient or to others

In addition, to meet the criteria of hypomania:

• There must be a change in functioning observable by others
• The episode must not be severe enough to require hospitalization
• The episode must not cause marked impairment in social or occupational functioning
• There must not be evidence of psychosis
• The episode must not be related to any other medical condition, or be the result of medication side effects or substance abuse.

Hypomania can be deceptive since patients may be experiencing an elevated mood, making them feel as though they are functioning well and are being more productive than usual. But this feeling can usually not be sustained and may either escalate into a full-blown mania or deteriorate into depression.

Mixed episodes must meet the criteria for both mania and depression almost every day for at least one week. There is generally a feeling of excitability or agitation concurrent with irritability, depression and trouble sleeping. Mixed episodes are much more common than previously recognized. The mood disturbances are characterized by:

• Being severe enough to cause impairment of functioning in the workplace, in social activities, or in relationships with others
• Requiring hospitalization to prevent harm to the patient as well as to others
• Being accompanied by psychotic features

In addition, the episode must not be related to any other medical condition or be the result of medication side effects or substance abuse.

Mixed episodes may be the most disabling of all since the swings and fluctuations are so rapid and intense. Mixed episodes are associated with a very high risk of suicide.

There are two behavior traits associated with bipolar disorder that may be particularly difficult on patients and their families, namely agitation and suicide ideation.

Agitation

Agitation can occur during any phase of bipolar disorder and when it occurs can significantly impact the person's functioning at all levels as well as relationships with family and friends. During the acute phase of mania, when energy levels are increased and there is less need for sleep, agitation may manifest itself in restless, irritable, or aggressive behavior which can result in significant problems for the bipolar patient since judgment is usually notably impaired. During mixed and depressive states, agitation is associated with fluctuating energy levels and concomitant irritability which can also result in considerable distress for the patient and their family and friends.

Women are as likely as men to exhibit aggressive behavior during states of agitation, however, the pattern of their aggression is different. Whereas men tend to punch, kick and/or use weapons if available, women usually slap and scratch. The pattern of being reasonable and friendly one moment and aggressive or violent the next is common to both men and women.

Children and adolescents also exhibit symptoms of agitation but instead of being related to discreet episodes of mania, mixed, or depressive moods usually found in adults, in children the symptoms, such as irritability, aggression, belligerence, appear to be more diffuse and can be the source of considerable dysfunction.

Suicide Ideation and Bipolar Disorder

Approximately 15-20% of people with bipolar disorder commit suicide. If a person with bipolar disorder speaks of suicide or has thoughts of suicide, it is critical that they be taken seriously and that action is taken immediately to seek help from a professional.

The risk of suicide is thought to be higher earlier in the course of bipolar disorder. In addition, the American Psychiatric Association notes that the overwhelming majority of suicides take place during a depressive episode or during the depressive interval of a mixed episode.

Factors that may place the bipolar patients at higher risk for suicide include:

• Substance abuse
• Psychosis
• Untreated depression
• Discouragement that medications are not working fast enough
• Recovering from depression and the patient realizes what a burden they may have been and how much trouble they have caused

Warning signs that a person with bipolar disorder may be contemplating suicide include:

• Speaking of feeling suicidal or wanting to die
• Putting affairs in order
• Giving away belongings
• Writing a suicide note
• Feeling helpless
• Feeling hopeless
• Drug abuse
• Feeling as if the patient is a burden on the family
• Sudden change in personality
• Participation in high risk activity
• Personal crisis

If anyone suspects that a bipolar patient may be suicidal, the National Institute of Mental Health (NIMH) suggests taking 3 steps:

• IMMEDIATELY call a doctor, emergency room, or 911
• Make sure the suicidal person is not left alone
• Make sure to prevent the person from gaining access to drugs, weapons or any other substance that could cause harm (e.g., household chemicals)

Patients who pose an immediate serious threat to themselves or others around them may require immediate hospitalization.