Bipolar Disorder

Bipolar Disorder, which used to be known as manic-depression, is a brain disorder that causes atypical changes in energy and activity levels, mood, and the ability to fulfill day-to-day obligations. Bipolar disorder is characterized by severe symptoms. They are different from the normal mood swings that we all experience from time to time.

Bipolar disorder often develops in late adolescence or early adulthood, with most cases often developing before age 25. However, this is not a hard and fast rule: there have been cases of bipolar disorder developing much earlier or later in life.

What are some signs of Bipolar Disorder?

Bipolar Disorder is characterized by distinct mood episodes. In order to understand Bipolar Disorder, it is first important to understand the different types of clinically significant mood episodes, all of which are characterized by impairment in day-to-day functioning.
Manic Episode: An abnormally elevated, irritable, or expansive mood lasting for at least one week (or shorter if psychiatric hospitalization is necessary). According to the DSM-IV-TR (APA, 200): During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• More talkative than usual or pressure to keep talking
• Flight of ideas or subjective experience that thoughts are racing
• Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli)
• Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Hypomanic Episode: Diagnostic criteria are similar for a hypomanic episode, and the episode is characterized by the same DSM-IV-TR criteria as listed above. However, a hypomanic episode has distinct differences from a manic episode. A hypomanic episode is a persistently elevated, expansive, or irritable mood, lasting at least 4 days. This mood episode is distinctly different from baseline mood and does not result in hospitalization.
Major Depressive Episode (MDE): Signs of a MDE are characterized by 5 or more of the following symptoms nearly everyday for at least 2 weeks (DSM-IV-TR; APA, 2000):

• Depressed or sad mood
• Lack of interest or pleasure in previously enjoyed activities
• Sleep disturbance (hypersomnia or insomnia)
• Feelings or worthlessness or guilt
• Fatigue or loss of energy
• Decreased concentration or difficulty making decisions
• Change in appetite or weight outside of weight-loss efforts
• Physical restlessness or slowing
• Recurrent thoughts of death or dying, recurrent suicidal ideation, or suicide attempts
• Mixed Episode: Signs of mixed episode are that the criteria are met for both an MDE and a manic episode nearly everyday for at least one week.

There are two different types of Bipolar Disorder, which are distinguished by the experience of different mood episodes:
Bipolar I: The person has experienced at least one manic episode, which may alternate with major depressive episodes or mixed episodes.
Bipolar II: The person has experienced recurrent depression with at least one hypomanic episode.

What is the treatment for Bipolar Disorder?

The standard of care for Bipolar Disorder is psychophamocology (medications) with adjunctive psychotherapy. Both cognitive behavioral therapy (CBT) as well as Dialectical Behavior Therapy (DBT) have been shown to be effective for the treatment of Bipolar Disorder.

CBT: Cognitive-behavioral interventions focus on managing unhelpful thinking styles as well as relapse prevention for a depressive or manic episode. Specific cognitive behavioral interventions would include:

Psychoeducation: Educating individuals diagnosed with bipolar disorder on the identification of symptoms of bipolar, as well as the importance of taking medications is an integral part of treatment. Understanding how symptoms manifest for each individual is an essential part of treatment.

Cognitive restructuring: Working to identify and subsequently modify either problematically elevated or depressive thoughts. For example, individuals who have thoughts such as, “I’m invincible- taking risks is what life is all about!” or “I’m irresistible” could lead to behaviors consistent with a manic episode, such as spending sprees, drug binges, or high-risk sexual activity. Working to identify and modify these thoughts could help prevent the consequences consistent with a manic episode. Therapists may also work with individuals on more depressive thoughts, such as “this is pointless” or “I’ll never have a life.” Working on changing these thoughts can help alleviate the cognitive and behavioral changes consistent with depression, such as hypersomnia, low motivation, and isolative behaviors.

Managing anger: Working to validate and also manage anger about having a diagnosis such as Bipolar Disorder as well as the consequences of the illness may be a integral part of treatment.
Sleep Hygiene: Sleep disruption has been shown to be one of the leading influences on bipolar disorder symptoms. How to get healthy sleep, such as modifying bedtime habits, introducing relaxation techniques, and reducing sugar and caffeine intake, may all be part of maintaining healthy sleep habits.
Addressing isolation: Building healthy social connections and identifying supportive social outlets can help to reduce isolation and increase a sense of belonging and connectedness
Mindfulness: Being aware of the present moment has been shown to increase stress management, as well as promote awareness in a non-judgmental way.

DBT: DBT has been shown to be an effective treatment for individuals with Bipolar Disorder. The therapist can works with individuals with Bipolar disorder in DBT to:

• Eliminate life-threatening behaviors (suicide attempts, high-risk behaviors)
• Reduce therapy interfering behaviors (urges to quit therapy, missing sessions, not completing homework assignments)
• Decrease behaviors that destroy the individual’s quality of life (depression, anxiety, problems at work or school)
• Improve attention
• Improve relationships and social functioning
• Tolerating emotions and emotional pain, and being able to understand and manage emotions

-Julie Snyder, Psy.D.
Harbor-UCLA Medical Center