The Who, What and Why of Bipolar Disorders

“When you are happy you enjoy the music. But, when you are sad you understand the


-Frank Ocean

What is Bipolar Disorder?

The phrase “That person is so bipolar” is pejoratively used to describe someone who rapidly gets angry. But, what does it truly mean to be “Bipolar”?

Bipolar disorders are characterized by oscillating depressive and manic episodes with varying severity and time between episodes. Depression involves changes in mood, motivation and ability to complete everyday tasks. A history of depression may not be obvious at the time of a bipolar diagnosis. A manic episode consists of persistently elevated, expansive or irritable mood, often accompanied by increased energy, goal-directed activity, distractibility, grandiose thoughts and reckless behavior. Individuals may also experience delusions or hallucinations. During a manic episode, people often do not believe they need treatment and may subjectively feel better than usual with their elevated mood and increased energy. This frequently leads to delays in seeking treatment and negative social or occupational consequences such as a damaged marriage or losing a job.


How Common Are Bipolar Disorders?

In any given year 1 in 38 people will suffer from a bipolar disorder. The first manic episode generally occurs in the late teens or early twenties with a median age of onset at 25. Greater than 90% of individuals with one manic episode will go on to have another. Each episode increases the risk for more frequent future episodes. It is more common in single and high-income individuals. It is unclear if being single increases risk or if the same characteristics that increase the chances of being single increase the risk of developing bipolar disorder. The ability to generate income dramatically declines once a diagnosis has been established. The earlier the age of onset, the worse the prognosis, however, early identification and treatment improve quality of life.




What Causes Mania?

There are many biological causes that predispose a person to develop mania. Similar to depression, an imbalance of neurotransmitters, especially dopamine, serotonin, and norepinephrine have been implicated. Brain scans have shown decreased right hemisphere activity during a manic episode as well as some other anatomical changes in specific subsets of the population.


Childhood trauma, stressful life events  and heavy use of alcohol or drugs often proceed first episodes of mania. It is thought that these environmental cues trigger biologically susceptible brains that otherwise may have been able to avoid illness.


If I Have Relatives With Bipolar Disorder What Are My Chances of Developing it?

There is a strong genetic component, however, the specific genes that increase risk have not yet been conclusively identified. Relatives of people with bipolar disorder have a 10 fold increased risk of developing it themselves. If one identical twin develops bipolar disorder then the other twin has a 70-90% chance of manifesting the disorder as well.


If the Symptoms Don’t Bother Me is it Still Important to Seek Treatment?

Getting prompt treatment for bipolar disorders is important as it not only helps decrease the duration of acute illness but also effects long term prognosis. When left untreated, mania is likely to last 3 months and the longer it lasts the harder it is to recover. Even once symptoms abate, individuals have difficulty performing cognitively and occupationally at their prior level of functioning. This decreases their potential for stable jobs and relationships and increases anxiety and substance use disorders. About 1/3 of people with bipolar disorder will attempt suicide in their lifetime.


How Are Bipolar Disorders treated?

Like most psychiatric conditions, bipolar disorder is best treated with a combination of pharmacotherapy and psychotherapy. Lithium is the gold standard for pharmacologic treatment. It leads to remission in 50-60% of patients and significantly decreases lifetime risk of suicide. However, it takes weeks for full effect and has a high risk of side effects with long-term use. Anticonvulsants and antipsychotics have good data behind their use and are being used more frequently. There is controversy surrounding treating the depressed phase with antidepressants as this may precipitate a manic episode. Currently, the best medications for the depressed phase appear to be a combination of Prozac and Zyprexa or Lamictal alone. People who do not respond to medications, often benefit from electroconvulsive therapy.


Psychotherapy is most efficacious between episodes or during a depressed phase. Goals of psychotherapy include improving insight into the illness, recognizing the need for treatment and being able to identify signs of impending illness. The depressive phase of the illness is treated the same way as in depressive disorders.


What do you think? Have you or someone you know experienced a bipolar illness? Please share your thoughts and comments below.


Ariel Mintz, MD
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2 Comments on “The Who, What and Why of Bipolar Disorders

  1. Thank you for an informative piece. I want to add a little about Bipolar 2.
    I recently started seeing a new psychiatrist. After 6 years of trying different meds, targeting depression, and Borderline PD my new doctor realized that I have Bipolar 2. It’s different than Bipolar 1, in that depression is stronger but mania is lighter. Even when I mentioned an episode, or “Flip” I had, my therapist and former Doctor both did not recognize it as Bipolar, because it was missing the typical mania.
    Common knowledge about Bipolar refers to Bipolar 1- a condition that causes a person to have grandiose ideas and do dangerous things (not sleeping nights), there is another Bipolar where the mania is more like racing thoughts or irritability. Sometimes the person suffereing could look like the life of the party- when they are actually feeling out of control. It’s called hypomania. This is usually followed by depression.
    In my case, I have “mixed states” which means I am not truly in any state. The depression, irritability, racing thoughts and even high energy are all tumbling after eachother.
    There is so much more to Bipolar than the high manic it is known for.

  2. Thank you for your comment Sugar.

    You are correct that this article is primarily addressing Bipolar I Disorder. Bipolar II is somewhat different and more often goes undiagnosed or misdiagnosed.

    I appreciate you sharing your experience in this comment and I wonder if you could turn it into a full blog post to give people a greater appreciation for what it is like to live with Bipolar II.

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