Bipolar Disorder

WHAT IS BIPOLAR DISORDER?

Bipolar disorder, formerly known as manic depression, is a problem characterized by excessively energetic moods called mania or manic episodes, which are more intense and very different than normal excitement.¹ Manic episodes are uncontrollable periods of excessive energy that can begin at any time and greatly interfere with a person’s life. During a manic episode, a person can feel extremely happy, restless, irritable, self-confident, or distractible, or some combination of these feelings.

People who are having a manic episode often can’t sleep because they are filled with an excessive amount of irritable energy. They might also experience rapidly paced thoughts that make it impossible to concentrate, remember things, or engage in any activity that requires focus. This can lead to great confusion. As a result of the racing thoughts, they might talk too fast for others to understand what they’re saying. People experiencing a manic episode might notice that others around them look concerned or confused. Often, this is because other people can’t understand them or because they are moving at such a fast pace that others can’t keep up.

The overwhelming energy people experience during a manic episode might lead them to think that they are indestructible, all-powerful, or exceptionally special in comparison to others. This inflated sense of self-esteem might cause them to become angry or irritable with others who don’t agree with their point of view. This grand sense of self-worth might also cause them to think they’re irresistible to others and lead them to aggressively seek out new relationships or to rekindle old relationships with people they haven’t seen in years.

During mania, people may also find themselves engaging in an excessive number of plans and activities. Some of these plans might get out of control because the person hasn’t considered all of the possible pitfalls, like taking on too many projects at work. Some impulsive pleasurable activities, such as shopping sprees and sexual encounters with strangers, might be dangerous or interfere with other relationships, like those with friends and spouses.

Many times, people with bipolar disorder also have episodes of depression or dysthymia (persistent mild depression) in between periods of mania, resulting in severe mood swings from very high to very low. (Click here for more information about depression and dysthymia.)

In order to differentiate how severe a person’s problem is, three different types of bipolar disorder have been identified: bipolar I, bipolar II, and cyclothymia.

A person with bipolar I will have a manic episode that lasts for at least one week. On average, these episodes usually last from three to six months.^{2, 3} Bipolar I may also include episodes of depression or dysthymia in between the manic episodes. In severe cases of bipolar I, the person may even experience visual or auditory hallucinations or delusional thoughts, such as the belief that he or she possess great powers.⁴ On average, a person with bipolar I can expect a manic episode every two to four years,⁴ and the odds of having a second manic episode after the first one are greater than 90 percent.¹

Some people experience a less disabling degree of mania, called hypomania, that doesn’t interfere with their lives as much. Typically, these hypomanic episodes last for at least a few days and include many of the same symptoms as a manic episode.¹ In between these hypomanic periods, a person might also experience depression or dysthymia, but hypomanic episodes never include hallucinations or delusions.⁴ Someone who experiences hypomanic episodes and at least one depressive episode might be diagnosed with bipolar II, while a person who experiences hypomanic episodes and less disabling depressive symptoms, such as dysthymia, might be diagnosed with cyclothymia.

People who experience hypomania might actually look forward to their hypomanic episodes because they become excessively creative and/or productive during these periods. It’s also possible that during hypomania their shyness disappears and they become more outgoing.⁵ People with hypomania might even be able to think a little more quickly and clearly than normal, and they might feel powerful and irresistible to others. However, these feelings can also lead them to make an excessive number of rash judgments, like going on impulsive shopping sprees.

Someone who experiences four or more manic or hypomanic episodes every year has rapid cycling bipolar disorder. An equally severe complication is called a mixed episode. This refers to a span of one week during which a person experiences both depression and mania almost every day.

Officially, all of these bipolar disorders, along with depression and dysthymia, are collectively referred to as mood disorders.

ARE THERE OTHER PROBLEMS RELATED TO BIPOLAR DISORDER?

The most dangerous problem related to bipolar disorder is suicide. Some studies have estimated that 25 to 50 percent of the people with bipolar disorder will attempt to kill themselves at least once during their lifetime,^6-9 and 10 to 19 percent of those who have bipolar disorder will ultimately die from suicide.7 Most of these suicides will occur during a depressive episode.¹⁰ This rate of suicide is about fifteen times greater than the suicide rate for the general public.¹¹ These sobering statistics highlight the severity of bipolar disorder and the need to get professional treatment.

Another dangerous and related problem is alcohol and drug abuse.¹² In particular, the abuse of stimulants, such as methamphetamines, cocaine, and crack cocaine,¹³ as well as the abuse of marijuana,¹⁴ appears to be especially common among people with bipolar disorder. In one very large study of more than forty-three thousand people in the United States, approximately 28 percent of those who experienced manic episodes also had a problem with drugs or alcohol, as did approximately 27 percent of those who had hypomanic episodes.¹⁵ Sadly, the use of alcohol and drugs appears to increase the chances of suicide in people suffering from bipolar disorder.^{16, 17}

Many people with bipolar disorder also have problems with anxiety disorders, such as panic disorder, social phobia, specific phobias, generalized anxiety disorder, post-traumatic stress disorder, and obsessive-compulsive disorder.^{12, 14, 18-20} In addition, some studies have found relationships between bipolar disorder and antisocial and borderline personality disorders.^{21, 22} Many people with bipolar disorder also have problems with eating disorders, such as bulimia and anorexia.^{14, 23}

WHO IS AFFECTED BY BIPOLAR DISORDER?

A report published by the World Health Organization stated that bipolar disorders were the sixth leading cause of disability in the world in 1990, trailing problems such as heart disease and depression.²⁴ In the United States, bipolar disorders as a whole will affect approximately 4 percent of the adult population at some point in their lives.²⁵

In particular, bipolar I affects under 1 percent to almost 2 percent of the adult population,^{1, 2, 4, 10} or approximately two million Americans.²⁶ Men and women appear to be equally affected by bipolar I,² with the first manic episode usually occurring when a person is in his or her early twenties.¹ However, children and adolescents can also be affected by bipolar disorders.⁵

Bipolar II affects slightly fewer people (under 1 percent of the population^{1, 2}), and it seems to affect men and women differently. Men tend to have a depressive episode for every hypomanic episode they experience, while women have more depressive episodes.¹

Cyclothymia affects from under 1 percent to 5 percent of the population.¹ Cyclothymia can begin as soon as adolescence or early adulthood and is equally common in men and women. The odds of it developing into either bipolar I or bipolar II are 15 to 50 percent.¹

In general, women experience more rapid cycling²⁷ and are at a greater risk for experiencing a manic or a hypomanic episode during pregnancy or shortly after childbirth.²⁸

WHAT CAUSES BIPOLAR DISORDER?

Most scientific researchers agree that there is no single cause of bipolar disorder.⁵ However, the development of the disorder is strongly influenced by genetic risk factors.²⁹ If someone in a person’s immediate family has bipolar disorder, that person’s odds of developing the disorder are six to eight times greater than someone who is not related to a person with bipolar disorder.⁴ However, first-degree relatives share more than just genetic makeup; they also share common experiences, socioeconomic status, and other life situations that might trigger bipolar disorder.

Brain chemicals called neurotransmitters might also contribute to the development of bipolar disorder. In particular, an abnormally high level of the neurotransmitter dopamine is often associated with the development of manic episodes while abnormally low levels of serotonin and norepinephrine are often associated with depressive episodes.^{30, 31} Other theories suggest that the cause of the problem might lie in the way neurons in the brain transmit their signals, either transmitting too easily during mania or not transmitting enough during depression.³⁰

If a person does have a genetic or a biological risk for developing bipolar disorder, certain environmental factors, such as stress, might trigger manic or hypomanic episodes.³² Potential stressors include disruptions in the person’s daily routine, changes in sleep schedule or work schedule, and family conflicts.³³ Research has shown that changes in sleep patterns very often trigger manic episodes.³⁴

WHAT TREATMENTS ARE EFFECTIVE FOR BIPOLAR DISORDER?

Regrettably, many people who need help for bipolar disorder don’t get it.³⁵ In one large study of adults in the United States, within a year of the problem’s onset only ³⁹ percent of those affected by the disorder sought help; and on average, people waited six years before seeking treatment for their manic symptoms.³⁶ This is unfortunate, considering that there are many treatments to control the disruptive course of the disorder.

Because of the strong biological factors associated with the disorder, the primary treatment for bipolar disorder is medication. Currently, the first line of mood stabilizing medications for manic symptoms includes lithium (Eskalith), valproic acid (Depakote), carbamazepine (Tegretol), olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), quetiapine (Seroquel), and aripiprazole (Abilify).³⁷ The second choice for medications includes the antipsychotic medications haloperidol (Haldol), chlorpromazine (Thorazine), and clozapine (Clozaril), as well as the anticonvulsant medications clonazepam (Klonopin) and lorazepam (Ativan).³⁷ Although some evidence suggests that lithium might lower a person’s risk of suicide,³⁸ the use of lithium also requires the person to undergo regular blood tests to prevent the buildup of toxins.

Certain antidepressants are also used to control depressive symptoms related to bipolar disorder.¹⁰ Those more commonly prescribed include fluoxetine (Prozac), bupropion (Wellbutrin), paroxetine (Paxil), venlafaxine (Effexor), sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa), as well as the anticonvulsant medication lamotrigine (Lamictal).³⁷

The type of medication, or the combination of medications, a person receives will depend on the type of mania experienced, the stage of the problem, and any hallucinatory or delusional symptoms.³⁷ Unfortunately, the use of any of these medications will result in some accompanying side effects that might make the person want to quit using them.^{10, 39} However, stopping the use of medication, no matter how good or bad the person feels, almost always leads to the reoccurrence of manic symptoms. People should not stop taking their medications without first consulting a medical professional to discuss alternative medications.

Due to the high numbers of people who stop taking their bipolar medications,^{40, 41} psychotherapy is a necessary additional treatment for controlling the problem.¹⁰ The six primary goals of psychotherapy for bipolar disorder are to help people adhere to their medication schedules, recognize and avoid potential relapse factors, reduce life stressors, maintain daily routines, support them in their struggle with the disorder, and improve family communication.^{10, 32}

Among the many types of psychotherapy shown to be effective in controlling bipolar disorder, cognitive behavioral therapy has been the most widely researched.⁴² Cognitive behavioral therapy aims to reduce the negative thoughts and behaviors that might add stress to a person’s life in order to lessen the risk of manic episodes.⁴³ In clinical studies, people who both took medication and utilized cognitive behavioral therapy experienced improvements in their lives,^{44, 45} some for as long as one year after treatment.⁴⁶ In one study, the participants who used medication and cognitive behavioral therapy stuck to their medication schedules better, had fewer bipolar episodes, experienced better social functioning, and developed better coping strategies for dealing with stress when compared with a group that received general support and medication.⁴⁷ The use of group cognitive behavioral therapy has also been effective.^{48, 49}

Another psychotherapeutic treatment that has been proven effective is a form of family therapy.³² This kind of treatment will help the person identify and reduce family stressors that might bring on manic episodes and also maintain a regular schedule of medication.³³ In clinical trials, family therapy has been shown to be effective at achieving these goals.^{50, 51} Other therapies, such as interpersonal therapy,^{52, 53} group therapy,^{54, 55} and psychodynamic therapy,56 as well as general psychoeducation,⁵⁷ have also demonstrated some successes in improving the lives of people who are dealing with bipolar disorder.

Lastly, newer research has also given hope that omega-3 fatty acids can successfully control some types of depression and mania.^58-60 Omega-3s are commonly found in some fish oils, walnuts, flaxseeds, and soybeans, as well as nutritional supplements.

COGNITIVE BEHAVIORAL THERAPY FOR BIPOLAR DISORDER

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

Despite the benefits offered by CBT, it’s very important to remember that the primary treatment for bipolar disorder is medication. The skills taught in the CBT treatment are meant to enhance the medical treatment, not act as a substitute for it. Overall, the goals of the CBT treatment for bipolar disorder are to help people maintain their medication regimen and reduce stress in their lives in order to avoid triggering a manic episode.

The CBT treatment for bipolar disorder is often composed of six steps:

Conduct an assessment and provide education
Develop effective communication skills
Develop problem-solving skills
Develop stress reduction skills
Challenge and correct self-defeating thoughts
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the CBT treatment for bipolar disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with bipolar disorder and not some other similar problem. Before beginning treatment, it’s essential to determine whether the person is struggling with bipolar I, bipolar II, or cyclothymia. For this reason, it’s very important for the person to consult with a medical professional as soon as possible. Then, after being stabilized on medication, the person may find it helpful to use CBT skills to maintain a healthy lifestyle.

Once people have been diagnosed with bipolar disorder, it’s important that they understand the basic nature and causes of the disorder (as highlighted above), as well as the basic nature and causes of depression, which is frequently associated with bipolar disorder. (Click here for more information about depression.)

One of the most important and difficult steps during this initial phase is helping the person with bipolar disorder recognize that the illness will be a lifelong struggle. Unfortunately, bipolar disorder does not go away no matter how well a person maintains his or her medication and therapy regimen. In this respect, the disorder is similar to diabetes and other medical illnesses that must be monitored and treated over the course of a person’s lifetime. Therefore, part of the early stages of treatment is helping people accept the fact that they must rely on medication to stabilize their mood, just as insulin helps people with diabetes stabilize their blood sugar levels.

Since bipolar disorder frequently disrupts a person’s family and social relationships, it’s also very important to educate family and friends about the nature of the illness and the roles that they might play in helping to stabilize the disorder. This includes understanding the nature of the illness and the events that trigger manic episodes, and learning how to communicate more effectively. (Click here for more information about being in a relationship with someone with bipolar disorder.)

It’s also important for everyone involved to understand that CBT is an active form of treatment that requires the person with bipolar disorder and his or her loved ones to do work outside of the therapy session.

2. Develop Effective Communication Skills

It has often been observed that frequent highly emotional conversations with others can lead to a person having a manic episode. Therefore, it’s very important that the person with bipolar disorder and his or her family and friends learn to communicate with each other in ways that are more effective and less volatile. This is where effective communication skills can be helpful.

Many people with bipolar disorder have difficulty making requests to get their needs met in fair and reasonable ways. Assertive communication skills can be very effective for making these requests. In addition, problem-solving communication skills are excellent for helping people in the following situations: setting limits with others, listening to others in effective ways, interpreting others’ body language, negotiating with others, and dealing with criticism. (Click here for instructions on developing effective communication skills.)

3. Develop Problem-Solving Skills

Often, the third step of the CBT treatment for bipolar disorder is to learn problem-solving skills. Sometimes people with bipolar disorder lack coping skills for handling difficult or uncertain situations. This can lead to feelings of anxiety and hopelessness that then trigger manic episodes. Problem-solving skills can help the person identify and select healthy solutions to difficult, anxiety-provoking situations. The steps to problem solving include defining the problem, outlining the desired goals, brainstorming possible solutions, evaluating the possible consequences, putting the chosen plan into action, and evaluating the results. This is a very effective skill when used alone by the person with the disorder, and it can be even more powerful when used cooperatively with the person’s family and friends. (>Click here for instructions on problem solving.<)

4. Develop Stress Reduction Skills

Many people experience stress in their daily lives, but for people with bipolar disorder, stress can sometimes trigger manic episodes. This is because stress, particularly chronic stress, takes a very heavy toll on a person’s body, mind, and relationships. Relaxation exercises can help reverse some of these effects, but more importantly, they can also prepare a person to confront the causes of stress in a much healthier way. For example, suppose a woman’s relationship with her husband has been problematic. For the last few years, she has avoided dealing with the conflicts, and as a result she has developed many physical symptoms of stress, such as tight muscles and high blood pressure. Practicing relaxation techniques in a consistent way can help ease these problems. In addition, they can also help if she chooses to address the relationship issues with her husband. Relaxation techniques can prepare a person for confronting stressors and help the person deal with problems in a more effective way.

Typically, relaxation exercises begin with building body awareness to help people scan their bodies for signs of stress and muscles tension. (Click here for instructions on building body awareness.)

Next, it’s very important to learn proper breathing techniques. Many people who are under stress breathe in a very constricted way. Some of them breathe very rapidly. Either of these types of breathing can make a person more vulnerable to stress. Learning proper breathing technique, using long, slow breaths, can help a person relax quickly and easily. (Click here for instructions on proper breathing techniques.)

Progressive muscle relaxation is also a very important exercise. Many people experience stress as muscle tension. Progressive muscle relaxation helps people relax the entire body. Then, once this basic technique is established, people can learn to relax even more quickly by using cue-controlled relaxation and other rapid relaxation techniques. (Click here for instructions on using muscle relaxation techniques.)

Meditation is also helpful for many people. Learning how to stay focused in the present moment is a healthy alternative to being overwhelmed by stress-provoking thoughts. Meditation, or mindfulness, can take many forms, none of which have to be spiritual. People can learn to be mindful of their breathing, to meditate while walking or eating, or to use visualization to meditate. (Click here for instructions on building meditation and mindfulness skills.)

Effective relaxation also includes developing good nutritional habits and engaging in healthy physical exercise. Therefore, people coping with stress should make time in their lives to address these issues, too. (Click here for instructions on developing good nutritional habits and physical exercise regimens.)

Visualization techniques use the power of the imagination to help people relax and create mental space for evaluating stressful situations. Techniques such as special-place visualization can help people relax by imagining a safe place in their mind, where they can completely relax. (Click here for instructions on using visualization and special-place techniques.)

5. Challenge and Correct Self-Defeating Thoughts

The next step of the CBT treatment for bipolar disorder is to challenge and correct self-defeating thoughts. This is a very important step for three reasons: First, self-critical thoughts can often lead to feelings of sadness, hopelessness, and anxiety, which can then trigger manic episodes. Second, self-defeating thoughts often play a large role in the development of depression. Therefore, this step is at the core of the CBT treatment for depression. And third, self-defeating thoughts often cause a person to stop taking medications. For example, a person might think “Why bother taking them if I’m going to have the problem for the rest of my life anyway?” or “I’m feeling better now, so I don’t have to take my medications anymore.” For all of these reasons, challenging and correcting self-defeating thoughts is a crucial step in the CBT treatment for bipolar disorder.

Automatic thoughts are the most observable form of self-defeating thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I don’t deserve anything good happening to me” and “Why bother trying? I’m just going to fail.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad or hopeless. (Click here for information on identifying automatic thoughts.)

Much of the CBT treatment for bipolar disorder will be spent identifying and reevaluating these types of thoughts. This can be done with the use of a thought record. The thought record helps the person look for evidence that both supports and contradicts these thoughts. Then, most importantly, it helps the person create a more balanced thought. For example, if the person struggling with bipolar disorder had the thought “Why bother trying? I’m just going to fail,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that generate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find a new, more balanced thought and ease feelings of sadness and hopelessness. In this example, perhaps a more balanced thought would be “Even though I don’t do everything perfectly, I’m still capable of doing most things pretty well.” And instead of feeling excessively sad, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less sad, say only a 5 out of 10. (Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to manic episodes and depression. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques. (Click here for instructions on challenging core beliefs.)

6. Prevent Relapse

Finally, the last step of the CBT treatment for bipolar disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning manic and depressive episodes in order to take steps to prevent them. And when needed, people should always consider seeking additional help from medical and mental health care professionals.

REFERENCES FOR BIPOLAR DISORDER

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