Photo courtesy of Delfina Carmona
Understanding Bipolar Disorder
Understanding Bipolar Disorder
“I’ve seen people use the word ‘bipolar’ in a sort of corrupted way to imply all kinds of things that in reality have nothing to do with the real disorder,” says psychiatrist Joseph Goldberg.
We’ve come a long way in reducing the stigma around mental disorders, but there are still a lot of misconceptions—and a lot of people struggling to get help. It’s been estimated that one in five people in the US is affected by a mood disorder, and that 6 million Americans are affected by bipolar disorder. Why isn’t the condition discussed more openly? And why has it traditionally been difficult to treat?
Goldberg, who has a private psychotherapy practice in Connecticut, has studied mood disorders for more than twenty-five years. He understands the complexity of bipolar disorder and how misconceptions surrounding it can add to confusion and misdiagnoses. He explains how bipolar disorder is similar to and distinct from depression and other mood disorders and episodic life events. The role that genetics and environment and lifestyle and creativity can play. The available treatment options. And the hope of additional therapies to come.
A Q&A with Joseph Goldberg, MD
Bipolar disorder is a mood disorder that affects about 2 percent of the population. People with this condition experience symptoms of depression as well as high periods. The high periods involve elevated mood and high levels of energy, causing a decreased need for sleep, overactivity, fast thoughts, fast speech, and impulsive behaviors. High and low periods represent a change from how the person usually feels.
Bipolar I disorder, otherwise known as manic-depressive disorder, is characterized by at least one manic episode at some point in a patient’s life. A manic episode occurs when a high period creates issues with day-to-day functioning, such as overspending, job loss, or relationship problems. These symptoms can also become more severe, leading to a sense of grandiosity that makes individuals believe that they are divine messengers or have supernatural powers.
If the highs are characterized by milder symptoms and don’t necessarily cause issues for the individual, we call this condition hypomania. An example of these milder symptoms can be an individual feeling unusually cheerful and energetic. They may take on extra tasks and come across as overconfident or more charismatic than they usually are. And when such episodes are paired with periods of depression, it is considered bipolar II disorder.
Another form of bipolar disorder is called cyclothymia, which refers to individuals who experience high and low periods, but these periods lack a sufficient number of symptoms and do not last long enough to be episodes.
The term “rapid cycling” is also used sometimes to describe cases in which people have clear and distinct episodes of mania, hypomania, or depression that happen at least four times over the course of one year.
“Depression” is a broad term used to describe different mood states, which may apply to many different kinds of specific mood disorders. These can include:
Psychotic depression: This occurs when an individual who has severe depression has also lost the ability to tell reality from nonreality. These individuals typically have false beliefs or delusions or experience hallucinations.
Dysthymia: Otherwise known as persistent depressive disorder, dysthymia is characterized by a low-grade depression that lasts at least two years.
Adjustment disorders with depressed mood (or “situational” depressions): Conditions in which the person experiences similar symptoms to depression, but they don’t involve as many emotional and physical symptoms as clinical depression. This often refers to a patient who is struggling to cope with a major source of stress, a life-changing event, or a great loss.
Secondary depression: Depression that is a result of a medical condition, such as thyroid problems, Lyme disease, brain tumors, Parkinson’s disease, certain vitamin deficiencies, etc.
Depression is sometimes used as shorthand to describe major depressive disorder (MDD), which is a well-defined collection of symptoms causing a person to have persistent feelings of sadness or loss of interest. In addition to feeling sad or depressed, this condition may be accompanied by changes in sleep, energy, thinking, behavior, self-image, and appetite and an inability to feel pleasure. There does not need to be an obvious cause for major depressive disorder.
A major depressive episode (MDE) is considered a medical illness and describes an episode where a person does not simply have a “normal” reaction to stressful life events (such as grief after someone dies or sadness after a breakup or job loss). Major depressive episodes are thought to occur in people who have a biological vulnerability to developing major depressive disorder or bipolar disorder. In other words, they can occur in someone who has major depressive disorder or bipolar disorder. This is similar to how having one panic attack doesn’t mean an individual has a panic disorder; rather, they had a panic episode. However, if the person has recurring panic attacks, among other things, then they would be diagnosed as having a panic disorder. Major depressive episodes classify an episode of the syndrome of depression, and major depressive disorder entails reoccurrences of major depressive episodes and nothing else.
Bipolar disorder describes the condition in which people have major depressive episodes in addition to mania or hypomania. These people are therefore not considered to have major depressive disorder, in which highs don’t occur. Major depressive disorder is therefore sometimes called “unipolar depression.” Otherwise, the major depressive episodes in people with bipolar disorder are essentially the same as in people with major depressive disorder.
Like all psychiatric disorders, the diagnosis of bipolar disorder is clinical, meaning there are no laboratory tests or other visible measurable markers of the condition. In that respect, it is similar to a number of other medical conditions for which there are no known biological markers or laboratory tests that can lead to a diagnosis, such as migraines, tinnitus, irritable bowel syndrome, fibromyalgia, serotonin syndrome, or Alzheimer’s disease.
Diagnoses are based upon a skilled interviewer—such as a psychologist, psychiatrist, social worker, counselor, internist, pediatrician, etc.—determining that there has been at least one time in the person’s life in which they have had a distinct change in their mood (either unusually elevated or irritable in ways that are out of character for them), accompanied by seven additional symptoms. These symptoms are:
Diminished sleep requirements
Talking in unusually fast, loud, and voluminous or uninterruptible ways
The mnemonic DIGFAST is a common tool used to remember these seven symptoms. The symptoms have to coexist for a definable amount of time (at least several days) and, in the case of mania (versus hypomania), cause some sort of trouble for the person’s outward ability to function.
The condition is often both under- and overdiagnosed. It is sometimes underdiagnosed because MDEs are more common than manias or hypomanias in people with bipolar disorder. Also, if an interviewer does not carefully ask about possible past manias or hypomanias, they may recognize only the MDEs and mistake the condition for MDD. People with bipolar disorder often lack good insight or self-awareness about their high periods, so even if a skillful interviewer asks about the seven symptoms, the patient may deny or not be aware of them.
On the other hand, bipolar disorder can also be overdiagnosed if interviewers simply think that mood swings or irritability define its presence, without questioning the accompanying DIGFAST features and their durations to define an episode. I liken it to assuming everyone with chest pain must have heart disease, without clarifying and distinguishing other causes of chest pain besides heart disease. Some people also tend to have temperaments or personality styles that lean toward the dramatic or high-achieving—think type A personalities. These traits can be confused with hypomania, but they are not actually episodes so much as long-standing, unwavering traits that define who a person is.
There has been a long debate in psychiatric literature about differentiating bipolar disorder from other psychiatric conditions (besides MDD), such as borderline personality disorder (BPD) or ADHD. Superficially, bipolar disorder and BPD share certain features, such as mood swings, impulsivity, and irritability. But fundamentally, they differ in the nature of mood swings. In BPD, people tend to run from normal, to depressed, to anxious or angry, but they don’t become euphoric. Euphoria is more suggestive of bipolar disorder. Furthermore, the mood swings in BPD almost always get triggered by interpersonal conflicts and are intensely reactive, arising from affronts to the person’s self-esteem. They often involve problems regulating one’s mood in a moment-to-moment way and can lead to outbursts of anger when circumstances don’t go the way the person wishes.
By contrast, in bipolar disorder, mood swings are not moment to moment. They can last days to weeks versus minutes to hours, and they are governed not as much by interpersonal conflicts but by things like sleep deprivation, seasonal changes, or crossing time zones, or for no obvious reason at all.
Similar to people with bipolar disorder, people with ADHD may experience distractibility and mood swings. However, the distractibility of ADHD is rooted more in being unable to distinguish irrelevant background stimuli (“noise”) from the relevant stimuli someone is trying to attend to (“signals”). ADHD is not a “high-energy” disorder the way bipolar disorder is, and when ADHD is present, it is constant, not episodic. ADHD also does not involve psychosis or suicidal features the way bipolar disorder can.
Manic or hypomanic symptoms also can be mimicked by drug abuse (e.g., stimulants, like Adderall or cocaine, or hallucinogens), thyroid disease, autoimmune diseases (e.g., lupus), or other medical conditions that must be ruled out before an accurate bipolar diagnosis can be made.
Bipolar disorder usually develops in a person’s late teens or early twenties. A major depressive episode will usually occur before the first mania or hypomania episode, and will often occur in adolescence, or in some cases, even before puberty. While it’s rare, manias or hypomanias can be seen in young children. In those instances, one has to be especially careful to rule out other, more common psychiatric disorders of childhood—such as problems with impulse control, developmental disorders that affect anger and impulse modulation, conduct disorders, and emerging personality disorders. It is rare for a person to experience their first manic episode after forty or fifty years old.
No one really knows why bipolar disorder usually develops in a person’s late teens or early twenties. There are a few speculative answers. One is that the disorder is partly developmental. It typically occurs at an age when people move away from their home and their family for the first time. The fact that there may be some vulnerability in young adulthood that is unique may be a factor. The stresses that people experience and the possible change in their support system—a shift from living in a home environment to becoming more independent—can present a lot of stress on an individual. There haven’t been studies examining the difference between those who leave home in the late teens and go away to school or work and those who stay home and maybe don’t go to school or work, and the likelihood of bipolar disorder developing. It may not be the biggest factor, but the fact that the support system changes could be a consideration.
A second piece could involve brain maturation. Most brain disorders occur at the ages of nineteen and twenty. The brain may simply not have matured enough or be organized enough at a young age to manifest itself as a syndrome. A thirteen- or fifteen-year-old brain is not the same as a twenty-year-old brain.
Another possible factor is genetic anticipation. This relates to whether an individual comes from a family that has a history of bipolar disorder, schizophrenia, alcoholism, or anxiety, and there seems to be a lot of genetic loading for the disorder. The individual may begin to express the symptoms at an earlier age, and this is thought to be the result of a more powerful family genetic load that gets passed along.
Unlike MDD, bipolar disorder affects both men and women equally. Women are more likely than men to have bipolar II disorder or rapid cycling. Alcoholism is also more of a risk for women with bipolar disorder than for women without bipolar disorder. Alcoholism is much higher in men than women in general, but among the population of men and women with bipolar disorder, that male-to-female ratio is less than in people without bipolar disorder.
The cornerstone of treatment for bipolar disorder is mood stabilizers. “Mood stabilizer” is not a technical term; it is more a colloquial or marketing term, meant to describe medicines that can treat or prevent highs or lows without causing highs or lows. Traditionally, these include lithium and three specific anticonvulsant drugs: Depakote, Tegretol, and Lamictal.
Some of the newer, so-called second-generation antipsychotic drugs, which were first used to treat schizophrenia or other psychotic disorders, have also been shown to be valuable for certain phases of bipolar disorder, such as mania and depression.
Antidepressants tend not to work as well in bipolar depression as in MDD and may sometimes have the risk of overshooting their mark and switching someone’s mood from a low to a mania or hypomania.
When it comes to alternative treatment options, there isn’t anything well-established for treating bipolar disorder. Alternative treatments can mean nutraceuticals (or natural health-food-type products). That would include things like omega-3 fatty acids, fish oil, an amino acid called N-acetyl cysteine, or probiotics. Omega-3 and N-acetyl cysteine are probably the two best-known. In some instances, either or both may have some value, but neither has been shown in large studies to be better than a placebo or to have the size of an effect similar to medicines like mood stabilizers or a typical antipsychotic. That said, they likely won’t hurt. They just have not been shown to be as good as an established medication. Lifestyle issues mainly revolve around protecting one’s sleep patterns and avoiding disruptions to regular bedtimes.
If someone wants to explore complementary approaches, like yoga, Tai Chi, mindfulness meditation, and behavioral relaxation techniques and approaches, there can be some benefit, particularly for depression or anxiety, which can certainly accompany bipolar disorder—but not as much for mania. It depends on what someone is treating. If someone is having trouble managing a great deal of inner tension or anxiety, I might strongly suggest something like mindfulness meditation or yoga—versus prescribing Ativan or Xanax—as a safe strategy for helping them manage it. That said, I wouldn’t recommend yoga for mania.
As a part of the overall comprehensive treatment approach, counseling a patient on protecting their sleep pattern and avoiding disruptions to regular bedtime is essential. It’s similar to how an internist treating someone for diabetes will give them medication and also counsel them on what to eat, how to exercise, and how take care of themselves. So introducing a bedtime routine that serves as a wind down versus a windup is critical. This could look like no bright lights close to bedtime, no naps during the day, not lying in bed during the day, etc. Things like disrupted sleep patterns, poor stress-management skills, and excessive alcohol or substance use would all count as lifestyle factors that could make the illness worse or further destabilize mood. Even if I’m prescribing medications, as a part of the treatment we address the patient’s sleep cycle, their stress levels, and if there are substances in the picture.
Hopefully, future research will broaden our tool set. Many of the research studies on ketamine apply to bipolar as well as unipolar depression. And the possible antisuicide effects of ketamine may be especially relevant to people with bipolar disorder.
Patients and their doctors need to closely monitor the presence or sustained absence of depressive and DIGFAST symptoms, along with medication effects (including side effects). Psychotherapy for bipolar disorder, apart from education about the illness, includes a focus on correcting distorted attitudes and beliefs (colored by depression or mania), managing stresses, keeping a regular sleep cycle, avoiding addictive substances, and managing any coexisting psychiatric problems that might come up, such as anxiety.
Yes. But the genetics of bipolar disorder are not the same as those found in nonpsychiatric medical illnesses—like cystic fibrosis, Huntington’s disease, or muscular dystrophy—which are Mendelian, or autosomal dominant or recessive, or X-linked. Bipolar disorder can be overrepresented in families, but there isn’t likely a single gene that confers risk.
Geneticists call bipolar disorder a “complex trait” for which there are likely many diverse genes that all exert small effects on areas like impulsivity, sleep-wake cycle regulation, suicidality, cognition, creativity, hopelessness, etc. If one of two identical twins has bipolar disorder, the other twin has about a 65 to 80 percent chance of also developing the condition, meaning that it’s not all genetic and owes a fair amount to the environment or interactions between the environment and the individual.
In terms of what this could mean about the role of the environment—no one is 100 percent sure. But the second best answer is that if you take identical twins and rear them apart and look at how much they are each affected or not affected by bipolar disorder, I don’t know that anyone has been able to say that the “higher-stress” individuals are more likely to develop depression or bipolar disorder or some other psychiatric disorder. Because how you interpret stress is subjective. Everyone interprets life stresses differently. The environment, by definition, imposes stress, and there is interest in the extent to which stress—however you define it, good stress or bad stress—may actually affect the expression of genes and proteins. The term for this is epigenetics. Whatever the nongenetic component is, whether it’s helpful or detrimental, the way one copes with stress can either turn on—or not turn on—certain genes and proteins that will affect the way genes are expressed.
We published a study a while ago that showed that significant childhood adversity—whether it’s sexual abuse, physical abuse, emotional abuse, physical neglect, emotional neglect—may affect brain development. Early life adversity seems to play an important role in the potential for developing many different kinds of psychiatric problems, including mood disorders, and it also makes them harder to treat. These are a few things that are not directly genetic that we pay attention to.
If someone has a family history of bipolar disorder, they may benefit from enhanced approaches on how to manage stress. People who study resilience will talk about the importance of exposing kids to mastery experiences and challenges where they have to figure things out—not overwhelming challenges but solvable problems, like puzzles. As they acquire and develop a sense of mastery, it gives them an inner reserve and a frame of reference for the next stress that comes their way. The ability to learn and become proficient at problem-solving is probably one of the most important ways to develop resilience for managing stress.
Creativity is essentially a combination of novel problem-solving ability, fluency of thinking, empathy, willingness to take risks or employ unconventional thinking, and intelligence. People with bipolar disorder tend to be overrepresented in the arts in part because they may be more inclined toward each of these characteristics. Not everything that gets inherited in this complex trait is necessarily detrimental.
Another misconception in terms of creativity and treating bipolar disorder is that when you treat the disorder, the patient won’t be as creative. Treating bipolar disorder has not been shown to lessen an individual’s capacity for creative thinking or engagement and interest in creative tasks. To the contrary, making the symptoms of bipolar disorder more manageable and less extreme may facilitate someone’s ability to capitalize on creative skills, formulate more coherent ideas, and implement plans more realistically and feasibly. One might argue that good psychotherapy is about stimulating someone’s capacity for creative thinking and problem-solving skills in situations that initially may seem unsolvable. The ability to adopt different perspectives and new points of view is in a way the essence of psychotherapy, and it is highly dependent on an intact capacity for creative thinking.
There are a lot of misconceptions surrounding how people with bipolar disorder behave. For example, it is a misconception that mood swings are abrupt and constant in people with bipolar disorder and that people with the disorder tend to be mercurial or unreliable and untrustworthy as a result of mood instability. I’ve found that most of the time, people with bipolar disorder are not experiencing these rapid mood episodes any differently than you or I would, and they generally strive to lead completely normal lives. In today’s society and in our modern language, the term “bipolar” has been misappropriated. I’ve seen people use the word “bipolar” in a sort of corrupted way to imply anything from unpredictable to scattered, goofy, outrageous, and all kinds of things that in reality have nothing to do with the disorder. The term has become increasingly popularized to mean something it’s not.
Joseph Goldberg, MD, is a psychiatrist, a psychotherapist, and a psychopharmacologist specializing in mood disorders. He is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York and maintains a private practice in Norwalk, Connecticut. He has published over 180 research papers and three books on the psychopharmacology of depression and bipolar disorder. He is also on the board of directors of the American Society for Clinical Psychopharmacology.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.