Sensei
剣道家
- Nov 4, 2019
- 6,336
I've noticed that there are many forum members who suffer from bipolar disorder, including yours truly, and that there also are many who suspect that they might. Since bipolar disorder is a very complex, almost incomprehensible, mental health condition, I thought I should compile a guide about it. It could perhaps be used as a resource to link to, at least for me if no one else. I can't emphasize enough that I welcome corrections and additions.
I don't mean to offend anyone by writing this, but I would very much appreciate if bitter tirades against dysfunctional psychiatric care systems and arbitrary use of psychotherapy and medication are saved for other, better suited threads.
General
• Bipolar disorder is still known as manic depression in the common population. The name was officially changed in 1980 and is seldom if ever used in psychiatry today.
• Bipolar disorder belongs to a group of mental health conditions called mood disorders, which also include clinical forms of depression, most notably major depressive disorder. Bipolar disorder has considerably higher disability and mortality levels, though.
• Bipolar disorder is one of the most serious mental health conditions, in some respects the most serious one, and just as serious as schizophrenia. Simplified, you could say that schizophrenia engenders abnormal thoughts and bipolar disorder abnormal feelings.
• In the common population, it's said that if you suffer from bipolar disorder you have highs, called mania, and lows, called depression, and that you "go crazy" when you have mania. This is principally correct, but an extremely crude simplification.
• Bipolar disorder is not just highs and lows, but also general emotional instability. It is often likened to a rollercoaster, but it's perhaps better to liken it to a seismically unstable area with frequent earthquakes and volcano eruptions. Even between ups and downs, bipolars can be unstable and have serious symptoms.
• Bipolar disorder is still a mystery in many respects. Most notably, it's not known exactly how it works neurobiologically, only that it's some form of chemical imbalance in the brain and that the transmitters work differently. It's not known why medicines like lithium work either, only that they work.
• It's a common opinion among professionals that bipolar disorder is the most complex of all mental health conditions. There are enormous individual variations and no theories or statistics about bipolar disorder can be trusted to 100 %. Hence, there are out of necessity some simplifications and generalizations in this guide.
Prevalence
• It's not known have long bipolar disorder has existed, but it's most probably several millennia, perhaps even since the dawn of man. It was first identified as a distinct mental illness about two thousand years ago in Ancient Greece.
• There are several different estimates, but roughly speaking, 1 % of the population develops "true" bipolar disorder, i.e. bipolar disorder I and II. It's not entirely clear how large a percentage develops subclinical symptoms, but it may be as high as 4 %.
• Contrary to other mental health conditions, bipolar disorder is strangely equal. It's as common in women as in men, in all social strata, and in every country. This has never been satisfactorily explained.
• Bipolar disorder can, simplified, be inherited and bipolars get fewer children than the general population, so the prevalence should drop, but strangely enough, it remains stable. It's suspected that the explanation is evolutionary.
Etiology
• Bipolar disorder is a genetic disorder, and it doesn't seldom run in families. However, the disorder as such can't be inherited. What's inherited is a gene sequence which increases the risk of becoming bipolar. So, if you have two identical twins with bipolar parents, one can develop the disorder and the other one can remain healthy. Also, some can be "struck by lightning" and develop bipolar disorder without having a single relative with any kind of mental disorder. In short, you aren't born bipolar, you become bipolar.
• Maybe as many as 35–50 % of all bipolars have experienced trauma in their childhood, and it's suspected that it increases the risk of developing bipolar disorder, but this has not been researched very thoroughly yet. Social factors seem to increase the risk too, but this has been researched even less.
• There's a link between bipolar disorder and intelligence. Studies with very large populations show that the risk of developing bipolar disorder may be as much as eight times higher for individuals who perform on top level in school or score very high on intelligence tests.
• A study with a very large population, 29 million, shows that there's a link between bipolarity and which month you're born. Bipolars are significantly more often born in January, and significantly more seldom born in August and September. There's a similar pattern for schizophrenia. There are several theories why this is, but no one knows for sure.
• Just as with schizophrenia, bipolar disorder is almost invariably triggered by a stressful event or stressful conditions. It can be stress at work, sleep deprivation, shift work, abuse, divorce, getting fired from work, pregnancy, loss of a family member, or something completely different.
• There are many different estimates, but the majority develop bipolar disorder when they're in their late teens or in their adolescence, roughly 18–30 years old, but it's not unusual to be older or younger than that. It rarely happens to children and middle-aged people, though.
Symptoms
• The individual variations are very large. Two individuals who have the same bipolar diagnosis may have very different symptoms. There are probably very few bipolars who have identical symptoms.
• The defining symptoms of bipolar disorder are the so-called mood swings, i.e. the cycles of extreme emotional states and neutral states in between. These extreme emotional states are called episodes.
• Episodes don't necessarily follow logic. Often, there's no discernible trigger – they "just happen". Bipolars can get depressive episodes when life's fantastic and manic/hypomanic episodes when life's miserable. Contrary to most other mental health conditions, changes in the environment, such as a positive or negative event, usually don't make any significant difference. An episode must simply have its course.
• There are four kinds of episodes: manic, hypomanic, depressive, and mixed episodes.
─ A manic episode is what people most commonly associate bipolar disorder with, and it's usually very debilitating. Typically, a manic episode means sleeping very little, racing thoughts, pressured speech, irritability, excessive spending, driving fast, quitting employment, breaking up relationships, binge drinking, trying drugs, risky sexual behaviour, and similar. It's not unusual to get psychoses, typically delusions of grandeur and megalomania. Consequently, sectioning and detention are common. Manic episodes are usually very exhausting and can even be physically dangerous, especially for older people. Due to this extreme behaviour, one manic episode can be enough to destroy a person's life, and suicides are not unusual during manic episodes.
─ A hypomanic episode can be said to be a light manic episode. It's usually not harmful, but sleeping very little, getting exhausted, being irritable, spending more than usual, and being more sexually active are not uncommon. In many, if not most cases, it's a through and through positive experience with increased optimism, creativity, focus, energy and capacity to work, though. For many, if not most bipolars, a hypomanic episode is more of an asset than a disability. Suicides during hypomanic episodes seem to be very rare.
─ As the name suggests, a depressive episode entails severe depression. Some of the symptoms for bipolar depression are different from other forms of depression, and there are indications that bipolar depressions might be worse as well. Contrary to other forms of depression, there's often no discernible trigger – they "just happen". On average it takes two months to develop a non-bipolar depression, whereas a bipolar depression can kick in within a few days, even a few hours sometimes. Perhaps most importantly, a bipolar depression only lasts for a limited time period and usually ends even though life circumstances have not changed. Depressive episodes can entail psychoses, usually delusions of persecution and paranoia, but it doesn't seem to be very common. Not very surprisingly, most suicides happen during depressive episodes.
─ A mixed episode is, as the name suggests, a kind of hybrid between a manic/hypomanic episode and a depressive episode. It means being energetic and suicidal at the same time, which obviously is a very dangerous combination. Many suicides happen during mixed episodes. There's a theory that there always are manic/hypomanic elements in depressive episodes and vice versa, but it has yet to be confirmed.
• There are large individual variations, but a manic episode usually lasts a few weeks to a few months, a hypomanic episode usually a few days to a few weeks, and a depressive episode four months on average. How long mixed episodes last on average seem to be uncertain, but they probably only last for weeks, not months.
• There's seldom a balance between manic/hypomanic episodes and depressive episodes. Most bipolars do in fact have more depressive episodes. There are some differences between different diagnoses. There are usually many more depressive episodes for every hypomanic episode in bipolar disorder II, than there are depressive episodes for every manic episode in bipolar disorder I. For bipolar disorder I, the ratio between manic and depressive episodes can sometimes be close to 1:1, whereas for bipolar disorder II the ratio between hypomanic and depressive episodes can be as extreme as 1:40.
• Bipolars may have something called rapid cycling, which means having more than four episodes a year. It's been suggested that rapid cycling might be quite common and that it's more common in bipolar disorder II than I. There's also ultra-rapid cycling which means that the mood swings occur within the course of weeks instead of months, and ultradian cycling, with mood swings within the course of days or even hours. It's notoriously difficult to treat rapid cycling, and the prognosis is usually not good.
• The episodes are the defining symptoms of bipolar disorders, but that's not the whole picture. Many bipolars are always emotionally unstable and moody, even between episodes, and suffer extreme anxiety, so extreme that it often makes them acutely suicidal.
• Bipolars often have sleeping problems. There are neurobiological changes in the so-called clock genes of bipolars, and consequently, they often have irregular sleeping habits, suffer from insomnia, and sleep too little.
• Bipolars can suffer so-called neuropathic pain, usually in the form of migraines or chest pains. This hasn't been researched thoroughly and it's uncertain how common it is.
Diagnosis
• Bipolarity is regarded as a spectrum nowadays and diagnoses are not as easily demarcated in practice as in theory. Initially, the most important thing is to simply decide if it's bipolar disorder or not, but later on a more precise diagnosis is usually necessary, as different diagnoses require somewhat different treatment.
• Bipolar disorder is often difficult to diagnose. It's been estimated that, at a minimum, 40 % get an incorrect diagnosis initially. It's very common that bipolar disorder, especially bipolar disorder II, gets misdiagnosed as major depressive disorder, and the reason is that the first episode usually is depressive, so there's no history of manic or hypomanic episodes. In other words, it's possible to be bipolar without having had a manic or hypomanic episode yet. It should be pointed out that major depressive disorder just is one of several possible misdiagnoses.
• It's not unusual that borderline personality disorder and schizoaffective disorder are misdiagnosed as bipolar disorder, as they share some distinct symptoms such a suicidality, but more rarely the other way around.
• Comorbidity is very common, especially for bipolar disorder II. Common secondary disorders are borderline personality disorder, ADHD, ADD, social anxiety disorder, panic disorder, and OCD. Perhaps most common is substance abuse, though, which is classified as a mental health condition nowadays. It's estimated that 30–50 % of all bipolars develop addiction some time during their lifetime, usually to alcohol and opioids. Obviously, this makes diagnosis even more complicated, as alcoholics can be in delirium, for instance.
• If bipolar disorder isn't properly diagnosed, it can have serious consequences, as incorrect treatment basically equals no treatment at all. Conventional psychotherapy has little to no effect and antidepressants, especially SSRI's, usually have little, no, or adverse effects. It's not unusual that antidepressants trigger manic episodes in bipolars.
Diagnoses
• Simplified, there are four major bipolar diagnoses: bipolar disorder I, bipolar disorder II, cyclothymia, and bipolar disorder not otherwise specified (NOS).
─ Bipolar disorder I is "classic manic depression" which entails manic and depressive episodes. Strangely enough, some who suffer from bipolar disorder I only have manic episodes but are still classified as bipolar, as depressive episodes aren't a criterium for this diagnosis in DSM-5. As already mentioned, sufferers of bipolar disorder I often get hospitalized and don't seldom get psychoses. This is the most debilitating form of bipolar disorder and is often exhausting and stigmatizing not only for the sufferer but also for family and friends.
─ Bipolar disorder II is the lesser known form of bipolar disorder. Those who have this diagnosis get hypomanic episodes instead of manic episodes. It's sometimes called "bipolar disorder light", which is misleading as it entails more frequent and more serious depressive episodes and a higher risk of suicide. The depressive episodes are debilitating, but not as debilitating as manic episodes, so sufferers of bipolar disorder II are more often high-functioning or even high-performing compared to the general population.
─ Cyclothymia is a less serious form of bipolar disorder; it should be mentioned that there's not total consensus that it really is a form of bipolar disorder. Cyclothymics have frequent mood swings, but they are less serious than bipolar episodes. That doesn't mean that it can't be very debilitating and lead to much suffering, though. Contrary to all other forms of bipolar disorder, cyclothymia can sometimes disappear.
─ Bipolar disorder NOS is a kind of umbrella diagnosis or, facetiously, "bipolar disorder miscellaneous". This diagnosis is given to bipolars who don't fit all criteria for bipolar disorder I or II, or who have subclinical symptoms. There are no general guidelines for treating this diagnosis. It says something about bipolar disorder that this is the most common diagnosis.
• It's not unusual that people suffering from bipolar disorder II develop bipolar disorder I. It's uncertain how common it is, but estimates claim that it happens to 5–15 %. Likewise, it's not unusual that people suffering from cyclothymia develop bipolar disorder II.
Disability
• WHO, the World Health Organization, sets the international standards for classification of disabilities. WHO consistently ranks bipolar disorder among the ten worst disabilities in the world, together with schizophrenia, Alzheimer's, AIDS, and terminal cancer. Bipolar disorder was at one time ranked as the sixth worst disability in the world, but it's unclear if this ranking still stands.
• Episodes are perhaps not very surprisingly the most debilitating aspects of bipolar disorder. Manic episodes are usually so debilitating that it basically becomes impossible to function at all. Severe depressive episodes can also be very debilitating at work and in social life as they usually last longer and lead to severe fatigue, inactivity, anhedonia, isolation, and similar. For many bipolars, it's difficult to live a regular life as it gets cut up by reoccurring episodes.
• Bipolars often have social disabilities. They have smaller social networks, have more difficulties forming long-lasting bonds, are more often singles, have more seldom been married, and get fewer children than the general population. Bipolars can become partially or completely isolated. The main reason is probably that bipolars are emotionally unstable, moody, and irritable, especially during episodes. Studies suggest that there also may be more subtle reasons, for instance that bipolars supposedly have a more dominant body language than the general population, but this has been researched very little.
• Bipolars often have cognitive disabilities. Episodes wear on the brain and in between them many bipolars experience residual symptoms like weakened attention, memory, and learning capacity. These symptoms are usually temporary, but that doesn't make them less debilitating, especially but not exclusively when at work. There's currently no treatment for this available.
• Bipolars are very often sensitive to stress. Hence, they are usually not well suited for jobs with constant multitasking, tight deadlines, and shift work. They may be very well suited for large and complex tasks and assignments, though.
• Bipolars are much more often unemployed or on partial or full disability than the general population. The total figure may in fact be as high as 50 %, but this is highly uncertain.
Personality traits
• It may seem strange to discuss common personality traits for people suffering from a mental health condition, but standardized personality tests show that there are clear differences between bipolars and the general population.
• Bipolars score higher on neuroticism, i.e. the trait behind worry, anxiety, frustration, guilt, melancholy, loneliness, and similar. This is by no means particular for bipolar disorder, though. In fact, there are indications that most people who suffer from a mental health condition have this personality trait.
• Bipolars are impulsive to a much higher degree than the general population. This may be one of the reasons they suffer social disability. Related to this, they are also more willing to take risks. These personality traits are amplified during hypomanic and especially manic episodes.
• In personality test, bipolars score much higher on creativity and openness to new ideas on average than the general population. Not very surprisingly, many bipolars have creative hobbies, such as writing, painting, and playing music.
• Although this is more uncertain, bipolars might also be more extrovert than the general population. Bipolars are overrepresented among actors, including in Hollywood, so maybe there's something to it.
Treatment
• A plethora of treatments have been tried throughout the last two millennia, but only one has proven to be effective, and that's modern medication. Consequently, bipolars are almost invariably prescribed medicines. The primary purpose of the medication is to prevent episodes.
• Almost 20 medicines are used to treat bipolar disorder, and the most common ones are lithium and lamotrigine. Usually, two medicines are used, one to counter mania/hypomania and one to counter depression. The medication must be tailored to the individual and it's trial and error basically. It's very common that several medicines have to be tried out before effective ones are found and it usually takes weeks, not seldom months, before the effects kick in.
• Lithium is a strange substance. It's for instance used in glasswork, batteries, fireworks, and hydrogen bombs. The therapeutic window, i.e. the gap between an ineffectual dose and a poisonous one, is very small. Hence, bipolars on lithium have to give blood samples at regular intervals, and also think about drinking much water and not changing their diet dramatically among other things. Lithium has minor or no side effects for most users, though. Interestingly, lithium is the only medicine that is known to decrease the risk of suicide.
• Lamotrigine is actually an anticonvulsant and is used for treating epilepsy as well. In the initial phase of treatment, doses are increased gradually, as lamotrigine can engender Steven–Johnsons syndrome which, somewhat simplified, is an allergic reaction which can be fatal. The incidence is very far below 1 % and the mortality rate is 5 %. Something which is more serious, albeit not common, is that lamotrigine may increase the risk of suicidal ideation and suicide in monotherapy and all psychiatrists are not aware of this.
• Antidepressants are also used to treat bipolarity, but almost invariably in combination with mood stabilisers. When antidepressants, especially SSRI's, are used in monotherapy they usually have little, no, or adverse effects, such as worsening symptoms or triggering manic episodes, as already mentioned above.
• So-called atypical antipsychotics are sometimes also used for treating severe symptoms, which includes both depression and mania. It seems that they mostly are used for short-term treatment of acute symptoms, though. Atypical antipsychotics have less side effects than regular antipsychotics but can for instance lead to overweight.
• Bipolars can of course suffer from trauma and have a negative self-image just like everybody else, and then conventional psychotherapy might help. However, it doesn't have any effect on bipolarity as such; words can't change a chemical imbalance in the brain. To learn to handle their disorder, bipolars can be ordained diagnosis-specific cognitive behavioural therapy (CBT) and psychoeducation. Bipolars can also be ordained training in meditation and mindfulness nowadays, which can mitigate emotional instability and anxiety.
• Bipolars can treat themselves to a degree. Most importantly, they can try to sleep better. Just as with most other mental health conditions, exercise has good effects on the majority, as well. Something as simple as taking magnesium, Omega-3, and vitamin-C supplements also have good effects on a substantial minority.
Prognosis
• Bipolar disorder is a chronic disorder and there's no cure is in sight. The symptoms tend to get worse the older one gets, and this usually means that episodes get more frequent and more severe. This phenomenon is called kindling. Medication can still alleviate symptoms and prevent episodes, though.
• Bipolars who develop bipolar disorder early in life, < 20 years, and bipolars with untreated bipolar disorder have the worst prognosis. Episodes tend to come more frequently and be more serious, the risk of psychoses is increased, economic and social problems get worse, and the risk of suicide is higher.
• An estimated 30–50 % of all bipolars make at least one suicide attempt in their lifetime, and 20 % of all bipolars succeeds in committing suicide; the suicide rate is higher for bipolar disorder II than bipolar disorder I. It's the by far highest rate for any group in society. Bipolars supposedly use "deadlier and more violent" suicide methods than the general population and they also have a much higher success rate.
• Bipolars have a shorter average life span than the general population. Estimates of how much shorter it is span from 8 to 16 years. The most common factor behind this is of course suicide, but death from cardiovascular diseases, which are much more common among bipolars than in the general population, is also an important factor.
• Finally, it's important to point out that it's perfectly possible to live a more or less normal life with effective medication, and some bipolars have cycles with years or even decades between episodes. There are many bipolars who are employed, have families and live in idyllic suburbs like any average Joe or average Jane. So, being bipolar doesn't necessarily mean that one's doomed.
Positives
• Contrary to most, if not all, other mental and physical health conditions, bipolar disorder has some positive sides. There are actually bipolars who see their disorder as a blessing.
• Hypomania and mania are fantastic experiences for many, if not most, bipolars. They experience intoxicating optimism, happiness, energy, drive, gung-ho attitude, and creativity in a way that the general population never will. Especially hypomania can actually improve cognitive abilities and increase individual performance levels. It's telling that there are bipolars who don't want to take their medicines, as that means that they won't have manic/hypomanic episodes again, even though this means that they will have to go through painful depressive episodes too.
• Something called cognitive disinhibition is much more common among bipolars than in the general population. Very simplified, it's the ability to make wild associations and challenge concepts, and it's linked to creativity, intelligence, eccentricity, and psychosis. In other words, bipolars tend to think outside the box to a higher degree than the general population.
• Bipolars score high on leadership tests. They are, however, not overrepresented in leadership positions. Siblings to bipolars are, though. It sounds strange, but it makes sense: they have similar genes as their bipolar siblings but are not handicapped by mental illness. Overall, siblings to bipolars tend to be more successful on average than the general population. The high scores on leadership tests might be connected to the fact that bipolars are overrepresented, although not dramatically, among politicians.
• There's a link between bipolar disorder and linguistic ability. Bipolars tend to be skilled at expressing themselves, especially, but not only, verbally. A manifestation of this is the fact that the prevalence of bipolar disorder is 50 % higher among authors than in the general population. This might also explain the above-mentioned overrepresentation among politicians.
• Bipolars are overrepresented in artistic and scientific professions, probably because they, as already mentioned, more often are creative, open to new ideas, and capable of cognitive disinhibition than the general population. There are indications that the overrepresentation is the largest among the most prominent practitioners of these professions, but that's far from certain.
• Bipolars can be high-performing professionals and even be among the best in the world, especially those who have bipolar disorder II. They are in fact overrepresented among world-famous celebrities. Some notable examples are the singer Mariah Carey, the actor Mel Gibson, the world-champion boxer Frank Bruno, the billionaire media mogul Ted Turner, and the sixth best-selling author of all times Sidney Sheldon.
• Several historical celebrities are suspected of having been bipolar. Constantly reoccurring candidates are Winston Churchill, Ernest Hemingway, Florence Nightingale, and Napoleon Bonaparte. This kind of "retro-diagnoses" are of course not to be trusted completely, but it says something that they had traits and behaviours that resemble bipolar ones.
I don't mean to offend anyone by writing this, but I would very much appreciate if bitter tirades against dysfunctional psychiatric care systems and arbitrary use of psychotherapy and medication are saved for other, better suited threads.
General
• Bipolar disorder is still known as manic depression in the common population. The name was officially changed in 1980 and is seldom if ever used in psychiatry today.
• Bipolar disorder belongs to a group of mental health conditions called mood disorders, which also include clinical forms of depression, most notably major depressive disorder. Bipolar disorder has considerably higher disability and mortality levels, though.
• Bipolar disorder is one of the most serious mental health conditions, in some respects the most serious one, and just as serious as schizophrenia. Simplified, you could say that schizophrenia engenders abnormal thoughts and bipolar disorder abnormal feelings.
• In the common population, it's said that if you suffer from bipolar disorder you have highs, called mania, and lows, called depression, and that you "go crazy" when you have mania. This is principally correct, but an extremely crude simplification.
• Bipolar disorder is not just highs and lows, but also general emotional instability. It is often likened to a rollercoaster, but it's perhaps better to liken it to a seismically unstable area with frequent earthquakes and volcano eruptions. Even between ups and downs, bipolars can be unstable and have serious symptoms.
• Bipolar disorder is still a mystery in many respects. Most notably, it's not known exactly how it works neurobiologically, only that it's some form of chemical imbalance in the brain and that the transmitters work differently. It's not known why medicines like lithium work either, only that they work.
• It's a common opinion among professionals that bipolar disorder is the most complex of all mental health conditions. There are enormous individual variations and no theories or statistics about bipolar disorder can be trusted to 100 %. Hence, there are out of necessity some simplifications and generalizations in this guide.
Prevalence
• It's not known have long bipolar disorder has existed, but it's most probably several millennia, perhaps even since the dawn of man. It was first identified as a distinct mental illness about two thousand years ago in Ancient Greece.
• There are several different estimates, but roughly speaking, 1 % of the population develops "true" bipolar disorder, i.e. bipolar disorder I and II. It's not entirely clear how large a percentage develops subclinical symptoms, but it may be as high as 4 %.
• Contrary to other mental health conditions, bipolar disorder is strangely equal. It's as common in women as in men, in all social strata, and in every country. This has never been satisfactorily explained.
• Bipolar disorder can, simplified, be inherited and bipolars get fewer children than the general population, so the prevalence should drop, but strangely enough, it remains stable. It's suspected that the explanation is evolutionary.
Etiology
• Bipolar disorder is a genetic disorder, and it doesn't seldom run in families. However, the disorder as such can't be inherited. What's inherited is a gene sequence which increases the risk of becoming bipolar. So, if you have two identical twins with bipolar parents, one can develop the disorder and the other one can remain healthy. Also, some can be "struck by lightning" and develop bipolar disorder without having a single relative with any kind of mental disorder. In short, you aren't born bipolar, you become bipolar.
• Maybe as many as 35–50 % of all bipolars have experienced trauma in their childhood, and it's suspected that it increases the risk of developing bipolar disorder, but this has not been researched very thoroughly yet. Social factors seem to increase the risk too, but this has been researched even less.
• There's a link between bipolar disorder and intelligence. Studies with very large populations show that the risk of developing bipolar disorder may be as much as eight times higher for individuals who perform on top level in school or score very high on intelligence tests.
• A study with a very large population, 29 million, shows that there's a link between bipolarity and which month you're born. Bipolars are significantly more often born in January, and significantly more seldom born in August and September. There's a similar pattern for schizophrenia. There are several theories why this is, but no one knows for sure.
• Just as with schizophrenia, bipolar disorder is almost invariably triggered by a stressful event or stressful conditions. It can be stress at work, sleep deprivation, shift work, abuse, divorce, getting fired from work, pregnancy, loss of a family member, or something completely different.
• There are many different estimates, but the majority develop bipolar disorder when they're in their late teens or in their adolescence, roughly 18–30 years old, but it's not unusual to be older or younger than that. It rarely happens to children and middle-aged people, though.
Symptoms
• The individual variations are very large. Two individuals who have the same bipolar diagnosis may have very different symptoms. There are probably very few bipolars who have identical symptoms.
• The defining symptoms of bipolar disorder are the so-called mood swings, i.e. the cycles of extreme emotional states and neutral states in between. These extreme emotional states are called episodes.
• Episodes don't necessarily follow logic. Often, there's no discernible trigger – they "just happen". Bipolars can get depressive episodes when life's fantastic and manic/hypomanic episodes when life's miserable. Contrary to most other mental health conditions, changes in the environment, such as a positive or negative event, usually don't make any significant difference. An episode must simply have its course.
• There are four kinds of episodes: manic, hypomanic, depressive, and mixed episodes.
─ A manic episode is what people most commonly associate bipolar disorder with, and it's usually very debilitating. Typically, a manic episode means sleeping very little, racing thoughts, pressured speech, irritability, excessive spending, driving fast, quitting employment, breaking up relationships, binge drinking, trying drugs, risky sexual behaviour, and similar. It's not unusual to get psychoses, typically delusions of grandeur and megalomania. Consequently, sectioning and detention are common. Manic episodes are usually very exhausting and can even be physically dangerous, especially for older people. Due to this extreme behaviour, one manic episode can be enough to destroy a person's life, and suicides are not unusual during manic episodes.
─ A hypomanic episode can be said to be a light manic episode. It's usually not harmful, but sleeping very little, getting exhausted, being irritable, spending more than usual, and being more sexually active are not uncommon. In many, if not most cases, it's a through and through positive experience with increased optimism, creativity, focus, energy and capacity to work, though. For many, if not most bipolars, a hypomanic episode is more of an asset than a disability. Suicides during hypomanic episodes seem to be very rare.
─ As the name suggests, a depressive episode entails severe depression. Some of the symptoms for bipolar depression are different from other forms of depression, and there are indications that bipolar depressions might be worse as well. Contrary to other forms of depression, there's often no discernible trigger – they "just happen". On average it takes two months to develop a non-bipolar depression, whereas a bipolar depression can kick in within a few days, even a few hours sometimes. Perhaps most importantly, a bipolar depression only lasts for a limited time period and usually ends even though life circumstances have not changed. Depressive episodes can entail psychoses, usually delusions of persecution and paranoia, but it doesn't seem to be very common. Not very surprisingly, most suicides happen during depressive episodes.
─ A mixed episode is, as the name suggests, a kind of hybrid between a manic/hypomanic episode and a depressive episode. It means being energetic and suicidal at the same time, which obviously is a very dangerous combination. Many suicides happen during mixed episodes. There's a theory that there always are manic/hypomanic elements in depressive episodes and vice versa, but it has yet to be confirmed.
• There are large individual variations, but a manic episode usually lasts a few weeks to a few months, a hypomanic episode usually a few days to a few weeks, and a depressive episode four months on average. How long mixed episodes last on average seem to be uncertain, but they probably only last for weeks, not months.
• There's seldom a balance between manic/hypomanic episodes and depressive episodes. Most bipolars do in fact have more depressive episodes. There are some differences between different diagnoses. There are usually many more depressive episodes for every hypomanic episode in bipolar disorder II, than there are depressive episodes for every manic episode in bipolar disorder I. For bipolar disorder I, the ratio between manic and depressive episodes can sometimes be close to 1:1, whereas for bipolar disorder II the ratio between hypomanic and depressive episodes can be as extreme as 1:40.
• Bipolars may have something called rapid cycling, which means having more than four episodes a year. It's been suggested that rapid cycling might be quite common and that it's more common in bipolar disorder II than I. There's also ultra-rapid cycling which means that the mood swings occur within the course of weeks instead of months, and ultradian cycling, with mood swings within the course of days or even hours. It's notoriously difficult to treat rapid cycling, and the prognosis is usually not good.
• The episodes are the defining symptoms of bipolar disorders, but that's not the whole picture. Many bipolars are always emotionally unstable and moody, even between episodes, and suffer extreme anxiety, so extreme that it often makes them acutely suicidal.
• Bipolars often have sleeping problems. There are neurobiological changes in the so-called clock genes of bipolars, and consequently, they often have irregular sleeping habits, suffer from insomnia, and sleep too little.
• Bipolars can suffer so-called neuropathic pain, usually in the form of migraines or chest pains. This hasn't been researched thoroughly and it's uncertain how common it is.
Diagnosis
• Bipolarity is regarded as a spectrum nowadays and diagnoses are not as easily demarcated in practice as in theory. Initially, the most important thing is to simply decide if it's bipolar disorder or not, but later on a more precise diagnosis is usually necessary, as different diagnoses require somewhat different treatment.
• Bipolar disorder is often difficult to diagnose. It's been estimated that, at a minimum, 40 % get an incorrect diagnosis initially. It's very common that bipolar disorder, especially bipolar disorder II, gets misdiagnosed as major depressive disorder, and the reason is that the first episode usually is depressive, so there's no history of manic or hypomanic episodes. In other words, it's possible to be bipolar without having had a manic or hypomanic episode yet. It should be pointed out that major depressive disorder just is one of several possible misdiagnoses.
• It's not unusual that borderline personality disorder and schizoaffective disorder are misdiagnosed as bipolar disorder, as they share some distinct symptoms such a suicidality, but more rarely the other way around.
• Comorbidity is very common, especially for bipolar disorder II. Common secondary disorders are borderline personality disorder, ADHD, ADD, social anxiety disorder, panic disorder, and OCD. Perhaps most common is substance abuse, though, which is classified as a mental health condition nowadays. It's estimated that 30–50 % of all bipolars develop addiction some time during their lifetime, usually to alcohol and opioids. Obviously, this makes diagnosis even more complicated, as alcoholics can be in delirium, for instance.
• If bipolar disorder isn't properly diagnosed, it can have serious consequences, as incorrect treatment basically equals no treatment at all. Conventional psychotherapy has little to no effect and antidepressants, especially SSRI's, usually have little, no, or adverse effects. It's not unusual that antidepressants trigger manic episodes in bipolars.
Diagnoses
• Simplified, there are four major bipolar diagnoses: bipolar disorder I, bipolar disorder II, cyclothymia, and bipolar disorder not otherwise specified (NOS).
─ Bipolar disorder I is "classic manic depression" which entails manic and depressive episodes. Strangely enough, some who suffer from bipolar disorder I only have manic episodes but are still classified as bipolar, as depressive episodes aren't a criterium for this diagnosis in DSM-5. As already mentioned, sufferers of bipolar disorder I often get hospitalized and don't seldom get psychoses. This is the most debilitating form of bipolar disorder and is often exhausting and stigmatizing not only for the sufferer but also for family and friends.
─ Bipolar disorder II is the lesser known form of bipolar disorder. Those who have this diagnosis get hypomanic episodes instead of manic episodes. It's sometimes called "bipolar disorder light", which is misleading as it entails more frequent and more serious depressive episodes and a higher risk of suicide. The depressive episodes are debilitating, but not as debilitating as manic episodes, so sufferers of bipolar disorder II are more often high-functioning or even high-performing compared to the general population.
─ Cyclothymia is a less serious form of bipolar disorder; it should be mentioned that there's not total consensus that it really is a form of bipolar disorder. Cyclothymics have frequent mood swings, but they are less serious than bipolar episodes. That doesn't mean that it can't be very debilitating and lead to much suffering, though. Contrary to all other forms of bipolar disorder, cyclothymia can sometimes disappear.
─ Bipolar disorder NOS is a kind of umbrella diagnosis or, facetiously, "bipolar disorder miscellaneous". This diagnosis is given to bipolars who don't fit all criteria for bipolar disorder I or II, or who have subclinical symptoms. There are no general guidelines for treating this diagnosis. It says something about bipolar disorder that this is the most common diagnosis.
• It's not unusual that people suffering from bipolar disorder II develop bipolar disorder I. It's uncertain how common it is, but estimates claim that it happens to 5–15 %. Likewise, it's not unusual that people suffering from cyclothymia develop bipolar disorder II.
Disability
• WHO, the World Health Organization, sets the international standards for classification of disabilities. WHO consistently ranks bipolar disorder among the ten worst disabilities in the world, together with schizophrenia, Alzheimer's, AIDS, and terminal cancer. Bipolar disorder was at one time ranked as the sixth worst disability in the world, but it's unclear if this ranking still stands.
• Episodes are perhaps not very surprisingly the most debilitating aspects of bipolar disorder. Manic episodes are usually so debilitating that it basically becomes impossible to function at all. Severe depressive episodes can also be very debilitating at work and in social life as they usually last longer and lead to severe fatigue, inactivity, anhedonia, isolation, and similar. For many bipolars, it's difficult to live a regular life as it gets cut up by reoccurring episodes.
• Bipolars often have social disabilities. They have smaller social networks, have more difficulties forming long-lasting bonds, are more often singles, have more seldom been married, and get fewer children than the general population. Bipolars can become partially or completely isolated. The main reason is probably that bipolars are emotionally unstable, moody, and irritable, especially during episodes. Studies suggest that there also may be more subtle reasons, for instance that bipolars supposedly have a more dominant body language than the general population, but this has been researched very little.
• Bipolars often have cognitive disabilities. Episodes wear on the brain and in between them many bipolars experience residual symptoms like weakened attention, memory, and learning capacity. These symptoms are usually temporary, but that doesn't make them less debilitating, especially but not exclusively when at work. There's currently no treatment for this available.
• Bipolars are very often sensitive to stress. Hence, they are usually not well suited for jobs with constant multitasking, tight deadlines, and shift work. They may be very well suited for large and complex tasks and assignments, though.
• Bipolars are much more often unemployed or on partial or full disability than the general population. The total figure may in fact be as high as 50 %, but this is highly uncertain.
Personality traits
• It may seem strange to discuss common personality traits for people suffering from a mental health condition, but standardized personality tests show that there are clear differences between bipolars and the general population.
• Bipolars score higher on neuroticism, i.e. the trait behind worry, anxiety, frustration, guilt, melancholy, loneliness, and similar. This is by no means particular for bipolar disorder, though. In fact, there are indications that most people who suffer from a mental health condition have this personality trait.
• Bipolars are impulsive to a much higher degree than the general population. This may be one of the reasons they suffer social disability. Related to this, they are also more willing to take risks. These personality traits are amplified during hypomanic and especially manic episodes.
• In personality test, bipolars score much higher on creativity and openness to new ideas on average than the general population. Not very surprisingly, many bipolars have creative hobbies, such as writing, painting, and playing music.
• Although this is more uncertain, bipolars might also be more extrovert than the general population. Bipolars are overrepresented among actors, including in Hollywood, so maybe there's something to it.
Treatment
• A plethora of treatments have been tried throughout the last two millennia, but only one has proven to be effective, and that's modern medication. Consequently, bipolars are almost invariably prescribed medicines. The primary purpose of the medication is to prevent episodes.
• Almost 20 medicines are used to treat bipolar disorder, and the most common ones are lithium and lamotrigine. Usually, two medicines are used, one to counter mania/hypomania and one to counter depression. The medication must be tailored to the individual and it's trial and error basically. It's very common that several medicines have to be tried out before effective ones are found and it usually takes weeks, not seldom months, before the effects kick in.
• Lithium is a strange substance. It's for instance used in glasswork, batteries, fireworks, and hydrogen bombs. The therapeutic window, i.e. the gap between an ineffectual dose and a poisonous one, is very small. Hence, bipolars on lithium have to give blood samples at regular intervals, and also think about drinking much water and not changing their diet dramatically among other things. Lithium has minor or no side effects for most users, though. Interestingly, lithium is the only medicine that is known to decrease the risk of suicide.
• Lamotrigine is actually an anticonvulsant and is used for treating epilepsy as well. In the initial phase of treatment, doses are increased gradually, as lamotrigine can engender Steven–Johnsons syndrome which, somewhat simplified, is an allergic reaction which can be fatal. The incidence is very far below 1 % and the mortality rate is 5 %. Something which is more serious, albeit not common, is that lamotrigine may increase the risk of suicidal ideation and suicide in monotherapy and all psychiatrists are not aware of this.
• Antidepressants are also used to treat bipolarity, but almost invariably in combination with mood stabilisers. When antidepressants, especially SSRI's, are used in monotherapy they usually have little, no, or adverse effects, such as worsening symptoms or triggering manic episodes, as already mentioned above.
• So-called atypical antipsychotics are sometimes also used for treating severe symptoms, which includes both depression and mania. It seems that they mostly are used for short-term treatment of acute symptoms, though. Atypical antipsychotics have less side effects than regular antipsychotics but can for instance lead to overweight.
• Bipolars can of course suffer from trauma and have a negative self-image just like everybody else, and then conventional psychotherapy might help. However, it doesn't have any effect on bipolarity as such; words can't change a chemical imbalance in the brain. To learn to handle their disorder, bipolars can be ordained diagnosis-specific cognitive behavioural therapy (CBT) and psychoeducation. Bipolars can also be ordained training in meditation and mindfulness nowadays, which can mitigate emotional instability and anxiety.
• Bipolars can treat themselves to a degree. Most importantly, they can try to sleep better. Just as with most other mental health conditions, exercise has good effects on the majority, as well. Something as simple as taking magnesium, Omega-3, and vitamin-C supplements also have good effects on a substantial minority.
Prognosis
• Bipolar disorder is a chronic disorder and there's no cure is in sight. The symptoms tend to get worse the older one gets, and this usually means that episodes get more frequent and more severe. This phenomenon is called kindling. Medication can still alleviate symptoms and prevent episodes, though.
• Bipolars who develop bipolar disorder early in life, < 20 years, and bipolars with untreated bipolar disorder have the worst prognosis. Episodes tend to come more frequently and be more serious, the risk of psychoses is increased, economic and social problems get worse, and the risk of suicide is higher.
• An estimated 30–50 % of all bipolars make at least one suicide attempt in their lifetime, and 20 % of all bipolars succeeds in committing suicide; the suicide rate is higher for bipolar disorder II than bipolar disorder I. It's the by far highest rate for any group in society. Bipolars supposedly use "deadlier and more violent" suicide methods than the general population and they also have a much higher success rate.
• Bipolars have a shorter average life span than the general population. Estimates of how much shorter it is span from 8 to 16 years. The most common factor behind this is of course suicide, but death from cardiovascular diseases, which are much more common among bipolars than in the general population, is also an important factor.
• Finally, it's important to point out that it's perfectly possible to live a more or less normal life with effective medication, and some bipolars have cycles with years or even decades between episodes. There are many bipolars who are employed, have families and live in idyllic suburbs like any average Joe or average Jane. So, being bipolar doesn't necessarily mean that one's doomed.
Positives
• Contrary to most, if not all, other mental and physical health conditions, bipolar disorder has some positive sides. There are actually bipolars who see their disorder as a blessing.
• Hypomania and mania are fantastic experiences for many, if not most, bipolars. They experience intoxicating optimism, happiness, energy, drive, gung-ho attitude, and creativity in a way that the general population never will. Especially hypomania can actually improve cognitive abilities and increase individual performance levels. It's telling that there are bipolars who don't want to take their medicines, as that means that they won't have manic/hypomanic episodes again, even though this means that they will have to go through painful depressive episodes too.
• Something called cognitive disinhibition is much more common among bipolars than in the general population. Very simplified, it's the ability to make wild associations and challenge concepts, and it's linked to creativity, intelligence, eccentricity, and psychosis. In other words, bipolars tend to think outside the box to a higher degree than the general population.
• Bipolars score high on leadership tests. They are, however, not overrepresented in leadership positions. Siblings to bipolars are, though. It sounds strange, but it makes sense: they have similar genes as their bipolar siblings but are not handicapped by mental illness. Overall, siblings to bipolars tend to be more successful on average than the general population. The high scores on leadership tests might be connected to the fact that bipolars are overrepresented, although not dramatically, among politicians.
• There's a link between bipolar disorder and linguistic ability. Bipolars tend to be skilled at expressing themselves, especially, but not only, verbally. A manifestation of this is the fact that the prevalence of bipolar disorder is 50 % higher among authors than in the general population. This might also explain the above-mentioned overrepresentation among politicians.
• Bipolars are overrepresented in artistic and scientific professions, probably because they, as already mentioned, more often are creative, open to new ideas, and capable of cognitive disinhibition than the general population. There are indications that the overrepresentation is the largest among the most prominent practitioners of these professions, but that's far from certain.
• Bipolars can be high-performing professionals and even be among the best in the world, especially those who have bipolar disorder II. They are in fact overrepresented among world-famous celebrities. Some notable examples are the singer Mariah Carey, the actor Mel Gibson, the world-champion boxer Frank Bruno, the billionaire media mogul Ted Turner, and the sixth best-selling author of all times Sidney Sheldon.
• Several historical celebrities are suspected of having been bipolar. Constantly reoccurring candidates are Winston Churchill, Ernest Hemingway, Florence Nightingale, and Napoleon Bonaparte. This kind of "retro-diagnoses" are of course not to be trusted completely, but it says something that they had traits and behaviours that resemble bipolar ones.
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