Myths & Facts: Bipolar Spectrum Disorder

A DISEASE DEFINED by its symptoms rather than by the underlying cause, bipolar spectrum disorder refers to a family of classifications used to describe abnormally changing moods that include both highs (manic) and lows (depression). The disorder can range from mild symptoms that do not interfere with a person’s ability to function in daily life to a deeply debilitating condition that in extreme cases requires hospitalization to effectively treat.

While the specific causes behind bipolar disorders aren’t precisely known, the symptoms are well enough described that an accurate diagnosis can be made in nearly all cases. Common symptoms that may lead a physician to make a diagnosis of a bipolar spectrum disorder are bouts of depression alternating with periods of mania (high energy). This is distinct from what is referred to as unipolar depression, also known as major depressive disorder, in which there are no manic episodes.

Symptoms of what we today call bipolar spectrum disorder were first noted in the first century AD by Greek physician Aretaeus of Cappadocia.¹ However, his belief that these seemingly disparate symptoms shared a common cause did not become widely accepted until the mid-19th century. In 1854, a rough approximation of our modern understanding of the disease was separately described by French physicians Jules Baillarger and Jean-Pierre Falret as “dual-form insanity” and “circular insanity,” respectively. A half-century later, German psychiatrist Emil Kraepelin differentiated bipolar disorder from schizophrenia based on its episodic nature, coining the term “manic-depressive psychosis.”¹ But, it was only in the 1960s that manic-depressive disease was itself differentiated from depressive psychosis — giving us our contemporary model of bipolar vs. unipolar disorders.

While there is no cure for bipolar spectrum disorder, with modern treatment options, most patients can lead productive, healthy lives. Symptoms can be controlled or decreased via medication, and patients can learn proven coping mechanisms to help them navigate the emotional swings that accompany a bipolar disorder.

One stumbling block that keeps many patients from seeking treatment from their physician, though, is the continuing prevalence of many myths and misconceptions still associated with bipolar disorder, lending to the condition a stigma that many patients want to avoid.

Separating Myth from Fact

Myth: Bipolar syndrome is an extremely serious mental illness.

Fact: While some patients obviously exhibit more serious symptoms than others, Amit Anand, MD, of the Cleveland Clinic points out: “We have learned over the last few decades that milder forms of bipolar disorder are much more common. Most people with bipolar disorder live in the community and may never be admitted to a psychiatric hospital.”²

Myth: Bipolar disorder is a single condition.

Fact: The disease is properly known as bipolar spectrum disorder, a description of a range of similar conditions of varying severity. Four distinct types of bipolar disorder are currently recognized:³

• Bipolar I: With this disorder, manic episodes last a week or longer, coupled with multiple episodes of major depression; or symptoms are debilitating to the point hospitalization is required. During manic episodes, patients may engage in risky behavior. Serious cases may involve hallucinations or breaks from reality during a manic episode.

• Bipolar II: This is similar to bipolar I, but manic episodes are not as pronounced (hypomania). It is not a milder form of bipolar I, but rather a separate related condition.⁴

• Cyclothymic: With this type, numerous manic and depressive episodes occur over a period of two years, but the episodes are not severe enough to warrant a diagnosis of bipolar I or II.

• Unspecified bipolar disorders: Symptoms of these disorders do not match any of the other three definitions.

Myth: Researchers know the cause of bipolar spectrum disorder.

Fact: To date, scientists do not know what exactly causes bipolar spectrum disorder. Studies indicate it is likely a combination of factors: family history, brain structure, emotional distress and/or substance abuse.⁴ Genes play a role, but in roughly 20 percent of identical twins, one may have bipolar disorder while the other does not, so genetics are clearly not the sole determining factor.³ Researchers continue to search for the combination of risk factors and triggers that can lead to the onset of bipolar disorder in the hope understanding the cause may lead to a cure or even prevention.

Myth: Bipolar disorder is a “fake” disease, a handy excuse for people who don’t want to deal with their mood swings.

Fact: According to the National Institutes of Health, “Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks.”³ Those suffering from bipolar disorder are often unable to adequately function during an episode, whether it is manic or depressive. The disorder costs, on average, more than 65 lost work days annually per patient in the United States, or about a 25 percent drop in productivity per patient in an average year.⁵

In some instances, those with bipolar I may suffer psychosis during a manic episode, and may require hospitalization to prevent them from causing harm to themselves or others. A manic or hypomanic episode will feature at least three of these symptoms:⁴

• Overly energetic or anxious
• Abnormally upbeat
• Lowered need for sleep
• Racing thoughts
• Difficulty focusing or concentrating
• More talkative than normal
• Overly risky behavior

A major depressive episode will include many of these symptoms:⁴

• Feeling helpless
• Decreased energy
• Sleeping more than normal
• Heightened sense of guilt
• Lower self-esteem
• Indecisiveness
• Fixation on death or suicide
• Unexplained weight loss or weight gain

A diagnosis of a bipolar disorder follows very clearly delineated criteria. And, when properly diagnosed, the disease responds positively to treatment. A physician who suspects bipolar disorder will work with a patient to answer the following questions:

• Have you experienced any episodes as described above?
• Is there a family history of bipolar disorders?
• How much alcohol or other drugs do you use?

A physical exam will be ordered to look for any other possible causes of symptoms such as a thyroid condition.⁶ A referral to a psychiatrist will also generally be made to further explore the patient’s symptoms and possible underlying causes.

Myth: It is easy for doctors to determine if a patient has a bipolar disorder.

Fact: It can take several months or longer to arrive at a definitive diagnosis. Making a diagnosis of a bipolar disorder is as much a process of elimination as discovery. Whenever a physician suspects the possibility of a bipolar disorder, the first order of business is to look for other causes of symptoms. Once those have been eliminated, the doctor and patient can begin looking for confirmation of a bipolar disorder.

While there is no single test to diagnose a bipolar disorder, protocols are well-established and described in Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.

After a physical and a family history have been conducted and no other cause for symptoms has been discovered, a physician will request a patient keep a mood diary, making daily note of moods for weeks or even months. And, family members and friends may, with the patient’s approval, be asked about their observations of any mood changes.

Bipolar I and II diagnoses are fairly straightforward due to their distinctive manifestation of symptoms; the other subsets can be more challenging to differentiate from related illnesses such as attention deficit hyperactivity disorder and borderline personality disorder.⁷

In addition, many bipolar disorder patients also suffer from other physical or mental ailments, with anxiety disorders and substance abuse among the top concurrent afflictions, which can make it more difficult to isolate the specific cause of symptoms.³

Myth: Bipolar disorder is very common.

Fact: Most studies indicate less than 5 percent of the population suffers from a bipolar disorder at any point in their lives.³ During any one year in the United States, approximately 2.8 percent of the population has a bipolar disorder. There is little difference between genders or among age or ethnic groups.⁸

However, among those diagnosed with a bipolar disorder, 82.9 percent were assessed as having a serious impairment — the highest of any mental illness.³ Yet, it is also known those with milder forms are less likely to seek medical help, request a diagnosis or accept treatment, so it is likely this statistic is skewed since those with more serious cases are the most likely to seek treatment and be diagnosed.⁷

Myth: Bipolar disorder cannot be effectively treated.

Fact: While there is no cure for bipolar disorder, most cases can be effectively treated. Mood stabilizers can help prevent or lessen episodes of mania and depression, psychotherapy can provide the tools needed to more successfully manage symptoms, and lifestyle changes such as exercise and diet can assist in managing symptoms.

Lithium is the most common mood stabilizer, which has been used to treat bipolar disorder since the 1950s. It is a long-term maintenance treatment, and it is only effective when consistently used — particularly between episodes when patients feel fine and may think they don’t need medication. Other mood stabilizers include valproic acid, carbamazepine and lamotrigine, all of which are anticonvulsants originally developed to treat epilepsy but later discovered to be effective in treating bipolar disorder.⁶

When mood stabilizers are not able to prevent a depressive or manic episode from occurring, the specific symptoms of an episode may be treated with secondary drugs. For instance, antipsychotics can be used during manic episodes, and may include aripiprazole, olanzapine, quetiapine or risperidone. During depressive episodes, antidepressants may be prescribed, but care must be taken since many bipolar disorder patients react differently to antidepressants than do those suffering from other types of depressive disorders.

While medications can help tremendously in evening out episodes of bipolar disorder, they are always used in conjunction with psychotherapy. In fact, therapy is a main component of any treatment regimen for bipolar disorder. Working with patients to help them identify triggers, establish regular routines for sleep and exercise, and manage their emotions can assist in leveling some of the highs and lows.³ Family therapy can also provide patients’ loved ones with support and help them understand the disorder.

Myth: Young people do not develop bipolar disorders.

Fact: The percentage of young people developing bipolar disorders is similar to adults: about 2.9 percent. Statistically, among teens, girls are slightly more likely to develop a bipolar disorder than are boys (3.3 percent vs. 2.6 percent).⁹ There are some other differences between younger bipolar disorder patients and adults. Adults tend to endure more depressive episodes than do children or teens,10 and adolescents are more likely to have a bipolar disorder in conjunction with another condition such as attention deficit hyperactivity disorder.

Myth: Bipolar disorder patients have regular cycles of mania and depression.

Fact: Episodes of mania and depression are irregularly timed and often chaotic, and they may even overlap.²

Myth: Artistic personalities with a bipolar disorder will lose their creativity if treated.

Fact: Best-selling author Marya Hornbacher was told this myth when she was diagnosed with a bipolar disorder. However, once she began treatment, she found her ability to maintain focus and a work discipline improved tremendously, with no loss of creativity. “I was very persuaded I would never write again when I was diagnosed with bipolar,” she wrote. “But before [being diagnosed], I wrote one book; and now, I’m on my seventh. When I was working on my second book, I was not yet treated for bipolar, and I wrote about 3,000 pages of the worst book that you have ever seen in your life. And then, in the middle of writing that book, which I just somehow couldn’t finish because I kept writing and writing and writing, I got diagnosed and I got treated. And the book itself, the book that was ultimately published, I wrote in 10 months or so. Once I got treated for my bipolar, I was able to channel the creativity effectively and focus.”¹¹

Myth: Bipolar patients are always either on a high or a low.

Fact: Most bipolar patients will go through long periods of calm without any episodes.11 And, those being treated with mood stabilizers are even more likely to have significant stretches with no episodes.

Dispelling the Myths Now

Given the high risk of attempted suicide associated with bipolar disorder — 33 percent of bipolar I and 36 percent of bipolar II patients¹² — the importance of physicians proactively discussing mood disorders with their patients and working with them to accurately diagnose and treat any symptoms cannot be overstated.

Studies reveal many patients are wary of asking for help dealing with mood disorders for fear of being stigmatized. They may fear ridicule, social isolation or loss of employment. For those who may worry about a mood disorder but resist exploring their symptoms, numerous advocacy organizations can help them learn more about bipolar spectrum disorder and the options available to them, including:

• Depression and Bipolar Support Alliance: dbsalliance.org
• International Bipolar Foundation: ibpf.org
• International Society for Bipolar Disorders: isbd.org