Bipolar Disorder

Bipolar disorder is a mental health problem that mainly affects your mood. If you have bipolar disorder, you are likely to have times where you experience:

 

  • manic or hypomanic episodes (feeling high)
  •  depressive episodes (feeling low)
  •  potentially some psychotic symptoms during manic or depressed episodes

Everyone has variations in their mood, but in bipolar disorder, these changes can be very distressing and have a big impact on your life. You may feel that your high and low moods are extreme, and that swings in your mood are overwhelming.

Depending on the way you experience different bipolar moods and symptoms, and how severely they affect you, your doctor may diagnose you with a particular type of bipolar disorder. The table below explains some terms your doctor might use.

Diagnosis What it means

Bipolar I

You may be told you have bipolar I if you have experienced:

  • at least one episode of mania which has lasted longer than a week

You might also have experienced depressive episodes, although not everyone does.

Bipolar II

You may get a diagnosis of bipolar II if you have experienced both:

  • at least one episode of severe depression
  • symptoms of hypomania
Cyclothymia

You may get a diagnosis of cyclothymia if:

  • you have experienced both hypomanic and depressive mood states over the course of two years or more
  • your symptoms aren’t severe enough to meet the criteria for a diagnosis of bipolar I or bipolar II

This can be a difficult diagnosis to receive, because you may feel that you are being told your symptoms are “not serious enough”, but this is not the case. Mental health is a spectrum that encompasses lots of different experiences and cyclothymia can have a serious impact on your life.

How often do bipolar episodes occur?

This can depend on a lot of things, such as:

  • your exact diagnosis
  • how well you’re able to manage your symptoms
  • whether certain situations or experiences can trigger your episodes (for example, you might find that getting very little sleep while going through a stressful life event could trigger an episode of mania)
  • how you define an episode personally

What’s normal for you can also change over time. However, many people find that:

  • mania can start suddenly and last between two weeks and four or five months
  • depressive episodes can last longer – sometimes for several months

Rapid cycling
You may be told your bipolar is rapid cycling if you have experienced four or more depressive, manic, hypomanic, or mixed episodes within a year. This might mean you feel stable for a few weeks between episodes, or that your mood can change as quickly as within the same day, or even the same hour.

Currently, rapid cycling is not officially considered a separate type of bipolar disorder, but more research is needed to know for sure or to better understand it.

Using these terms can help both you and health professionals discuss your diagnosis and treatment more specifically. If your doctor ever uses words or phrases you don’t understand, you can ask them to explain.

Bipolar disorder or manic depression?

The term ‘bipolar’ refers to the way your mood can change between two very different states – mania and depression. In the past, bipolar disorder was referred to as manic depression, so you might still hear people use this term. Some health care
professionals may also use the term bipolar affective disorder (‘affective’ means the disorder relates to mood or emotions).

What are bipolar mood states?

Going through any of these experiences can be extremely difficult to cope with, so it’s worth thinking about how you can look after yourself, and what kind of treatment could help. It’s also worth planning ahead for a crisis.

ania can last for a week or more and has a severe negative impact on your ability to do your usual day-to-day activities – often disrupting or stopping these completely. Severe mania is very serious and often needs to be treated in hospital.

Manic Episodes

Here are some things you might experience during a manic episode:

How you might feel How you might behave
  • happy, euphoric, or a sense of wellbeing
  • uncontrollably excited, like you can’t get your words out fast enough
  • irritable and agitated
  • increased sexual energy
  • easily distracted, like your thoughts are racing, or you can’t concentrate
  • very confident or adventurous
  • like you are untouchable or can’t be harmed
  • like you can perform physical and mental tasks better than normal
  • like you are understand, see or hear things that other people can’t
  • more active than usual
  • talking a lot, speaking very quickly, or not making sense to other people
  • being very friendly
  • saying or doing things that are inappropriate and out of character
  • sleeping very little or not at all
  • being rude or aggressive
  • misusing drugs or alcohol
  • spending money excessively or in a way that is unusual for you
  • losing social inhibitions
  • taking serious risks with your safety

About hypomanic episodes

Hypomania is similar to mania, but has a few key differences:

  • it can feel more manageable – for example, you might feel able to go to work and socialise without any major problems
  • it lasts for a shorter time
  • it doesn’t include any psychotic symptoms

While hypomania is less severe than mania, it can still have a disruptive effect on your life and people may notice a change in your mood and behaviour.

Symptoms of hypomania can include:

How you might feel

How you might behave

  • happy, euphoric, or a sense of wellbeing
  • very excited, like you can’t get your words out fast enough
  • irritable and agitated
  • increased sexual energy
  • easily distracted, like your thoughts are racing, or you can’t concentrate
  • confident or adventurous
  • more active than usual
  • talking a lot or speaking very quickly
  • being very friendly
  • sleeping very little
  • spending money excessively
  • losing social inhibitions or taking risks

After a manic or hypomanic episode you might:

  • feel very unhappy or ashamed about how you behaved
  • have made commitments or taken on responsibilities that now feel unmanageable
  • have only a few clear memories of what happened while you were manic, or none at all
  • feel very tired and need a lot of sleep and rest

About depressive episodes

Here are some things you might experience during a depressive episode:

How you might feel How you might behave
  • down, upset or tearful
  • tired or sluggish
  • not being interested in or finding enjoyment in things you used to
  • low self-esteem and lacking in confidence
  • guilty, worthless or hopeless
  • agitated and tense
  • suicidal
  • not doing things you normally enjoy
  • having trouble sleeping, or sleeping too much
  • eating too little or too much
  • misusing drugs or alcohol
  • being withdrawn or avoiding people
  • being less physically active than usual
  • self-harming, or attempting suicide

Many people find that a depressive episode can feel harder to deal with than manic or hypomanic episodes. The contrast between your high and low moods may make your depression seem even deeper.

The lows can be flat and devoid of colour, or intense and torturous. Sometimes it’s full of demons, and pain inside so bad nothing physical could hurt you.

About mixed episodes

Mixed episodes (also called ‘mixed states’) are when you experience symptoms of depression and mania or hypomania at the same time or quickly one after the other. This can be particularly difficult to cope with, as:

  • it can be harder to work out what you’re feeling
  • it can be harder to identify what help you need
  • it might feel even more challenging and exhausting to manage your emotions
  • you may be more likely to act on suicidal thoughts and feelings
  • your friends, family or doctor might struggle to know how they can support you best

The mixed episodes are the worst. The most unpredictable and most dangerous ones, I find them difficult to explain.

About psychotic symptoms

Psychotic symptoms can include:

  • delusions, such as paranoia
  • hallucinations, such as hearing voices

Not everyone with a diagnosis of bipolar disorder experiences psychosis, but some people do. It’s more common during manic episodes, but can happen during depressive episodes too. These kinds of experiences can feel very real to you at the time, which may make it hard to understand other people’s concerns about you.

Then [with mania] comes the paranoia, the shadows, the voices, the thought someone is behind me following me everywhere I go, ready to get me.

What causes bipolar disorder?

No one knows exactly what causes bipolar disorder. Researchers suggest that a combination of different factors, including physical, environmental and social, increase your chance of developing the condition. Some experts believe that experiencing a lot of emotional distress as a child can cause you to develop bipolar disorder. This can include experiences like:

  • sexual or physical abuse
  • neglect
  • traumatic events
  • losing someone very close to you, such as a parent or carer

This could be because experiencing trauma and distress as a child can have a big effect on your ability to regulate your emotions.

Stressful life events

You may be able to link the start of your symptoms to a very stressful period in your life, such as:

  • a relationship breakdown
  • money worries and poverty
  • experiencing a traumatic loss

Although lower levels of stress are unlikely to cause bipolar disorder, for some people they can trigger an episode of mania or depression.

Brain chemistry

Evidence shows that bipolar symptoms can be treated with certain psychiatric medications, which are known to act on the neurotransmitters (messenger chemicals) in your brain.

This suggests that bipolar disorder may be related to problems with the function of these neurotransmitters – and this is supported by some research. However, no one knows for certain exactly how these neurotransmitters work and whether problems with these are a cause or a result of bipolar disorder.

Genetic inheritance

If you experience bipolar disorder, you are more likely to have a family member who also experiences bipolar moods and symptoms (though they might not have a diagnosis). This suggests that bipolar disorder might be passed on through families.

However, this does not necessarily mean that there is a ‘bipolar gene’ – family links are likely to be much more complex. For example, researchers think that environmental factors can also be triggers for experiencing symptoms of bipolar disorder. And for most people, family members are an influential part of your environment as you grow up.

Can drugs cause bipolar disorder?

Medication, drugs or alcohol can’t cause you to develop bipolar disorder, but they can cause you to experience some bipolar moods and symptoms. For example:

  • Some antidepressants can cause mania or hypomania as a side effect when you are taking them or as a withdrawal effect when you are coming off them. If you begin to experience mania after taking or after coming off antidepressants for depression, this might lead your doctor to give you an incorrect diagnosis of bipolar disorder, or prescribe you more medication. But in this case it’s usually worth waiting to see if your symptoms pass without treatment first.
  • Alcohol or street drugs can cause you to experience symptoms similar to both mania and depression. It can often be difficult to distinguish the effects of alcohol and drugs from your mental health symptoms.

If you’re concerned about the effects of medication, alcohol, or street drugs on your mental health, it’s important to discuss it with your doctor.

How does a diagnosis get made?

To make a diagnosis your doctor will ask you about:

  • how many symptoms you experience
  • how long your manic or depressive episodes last
  • how many episodes you’ve had, and how frequently they occur
  • the impact your symptoms have on your life
  • your family history

They may also:

  • ask you to keep a diary of your moods to help them assess you
  • check for any physical health problems, such as thyroid problems which can
    cause mania-like symptoms

You can only be diagnosed with bipolar disorder by a mental health professional, such as a psychiatrist – not by your GP.
However, if you’re experiencing bipolar moods and symptoms, discussing it with your GP can be a good first step. They can refer you to a psychiatrist, who will be able to assess you.

“Once properly diagnosed, I knew the cause. I understood that I was someone with an illness. I was not a failure, not a bad person.”

How long will diagnosis take?

Because bipolar disorder involves changes in your moods over time, your doctor may want to observe you for a while before making a diagnosis. Bipolar disorder also has some symptoms in common with other mental health diagnoses (such as depression, borderline personality disorder (BPD), schizoaffective disorder, and schizophrenia),  so your doctor may want to take care that they diagnose you correctly.
Because of this it might take a long time to get a correct diagnosis – sometimes it can take years.

What can I do if I disagree with my diagnosis?

If you feel the diagnosis you’ve been given doesn’t fit the way you feel, it’s important to discuss it with your doctor.

What treatments can help?

This will usually depend on what kind of episode you’re experiencing.

During depressive episodes

  • You’re likely to be offered medication – this might be new medication or adjusting your current medication.
  • You might also be offered a structured psychological treatment that’s proven to help with depression, such as cognitive behavioural therapy (CBT). 

During manic or hypomanic episodes

  • You’re likely to be offered medication – this might be new medication or adjusting your current medication.
  • You’re unlikely to be offered a talking treatment if you are currently experiencing a manic or hypomanic episode.

What can I do in the longer term?

The aim of treatment should be to help you maintain stable moods and manage your symptoms well. As you start to feel more stable, the majority of your support could come from a community mental health team (CMHT) or your GP, although your GP should arrange for you to still be in touch with a mental health specialist.

Your health professionals should work with you to help you identify:

  • Clear emotional and social recovery goals for you to work towards and regularly reflect on and revise with your doctor.
  • A crisis plan, so you know what to do if you experience any of your early warning signs or triggers, or begin to feel very distressed.
  • How you feel day-to-day, so you can be aware of how best to manage your mood and notice any changes.
  • A medication plan, including dates where you can review your dose, how well the medication is working and any side effects you experience.

If you are receiving a talking therapy, you might set some of these goals with your therapist. You should share these goals with your GP. You may also want to share them with your family, friends and carer if you have one.

Which talking therapies might I be offered?

There are several talking therapies you might be offered to help you manage your bipolar disorder in the long term. These are a few that have been tested and shown to work well for some people, although other therapies may work too:

  • Cognitive behavioural therapy (CBT) – looks at how your feelings, thoughts and behaviour influence each other and how you can change these patterns.
  • Interpersonal therapy – focuses on your relationships with other people and how your thoughts, feelings and behaviour are affected by your relationships, and how they affect your relationships in turn.
  • Behavioural couples therapy – focuses on recognising and trying to resolve the emotional problems that can happen between partners.

Other types of talking therapies you may be offered are:

  • Enhanced relapse prevention/ individual psychoeducation – this is a brief intervention to help you learn coping strategies.
  • Group psychoeducation – this involves working in a group of people with shared experiences, led by a trained therapist, to build up knowledge about bipolar disorder and self-management.
  • Family-focused therapy – this involves working as a family to look at behavioural traits, identify risks and build communication and problem-solving skills.

Some of these treatments are more widely available than others. What you are offered can also depend on what you and your doctor agree would be most useful for you.

How can talking therapies help in the long term?

Talking therapies can help you:

  • understand or make sense or meaning out of your bipolar disorder, and reflect on the impact it has had throughout your life
  • identify early warning signs and symptoms
  • develop strategies to cope with early symptoms, triggers, and episodes
  • make a crisis plan
  • set goals and plans for staying well

What treatment can I get in a crisis?

If you start to feel very unwell, or if an episode of depression or mania is lasting for a long time and your regular treatment isn’t working, you may need to access crisis services to help you get through it. This may include:

  • emergency support, such as going to A&E
  • getting support from a crisis resolution and home treatment (CRHT) team
  • hospital admission

What medication is available?

If you are diagnosed with bipolar disorder, it’s likely that your psychiatrist or GP will offer to prescribe medication. This might include:

  • antipsychotics
  • lithium
  • anticonvulsants
  • antidepressants

Which medication you are offered will depend on:

  • Your current symptoms, for example, if you are currently experiencing a manic or depressive episode.
  • Your past symptoms, such as whether you are mainly manic or mainly depressed, and how long the episodes have lasted.
  • How you have responded to treatments in the past.
  • The risk of another episode, and what has triggered episodes in the past.
  • Your physical health, in particular, whether you have kidney problems, weight problems, or diabetes.
  • How likely you are to take the medication consistently.
  • Your sex and age (for example, if you could become pregnant your doctor shouldn’t offer you valproate, as it carries significant risks to your baby).
  • In older people, a test of mental processes such as the one used to diagnose dementia.

Antipsychotics for bipolar disorder

You are most likely to be prescribed an antipsychotic if you have an episode of mania or severe depression in which you experience psychotic symptoms, such as hearing voices. However, some antipsychotics are increasingly prescribed even if you haven’t had psychotic symptoms, as their side effects might be less unpleasant, and they’re safer in pregnancy.

The following antipsychotics are the most recommended by doctors:

  • haloperidol (Dozic, Haldol, Haldol decanoate, Serenace)
  • olanzapine (Zalasta, Zyprexa, ZypAdhera)
  • quetiapine (Atrolak, Biquelle, Ebesque, Seroquel, Tenprolide, Zaluron)
  • risperidone (Risperdal, Risperdal Consta)

If your first antipsychotic doesn’t work, you should be offered a different one from the list above. If the second antipsychotic doesn’t work you may be offered lithium to take together with an antipsychotic.

If you’re prescribed an antipsychotic, you’ll need to have regular health checks with your doctor.

Lithium for bipolar disorder

Lithium can be effective for reducing the likelihood of:

  • mania
  • recurrent depression
  • further mood episodes
  • suicidal feelings

It is typically a long-term method of treatment, usually prescribed for at least six months.

For lithium to be effective, the dosage must be correct. You’ll need regular blood and health checks while taking lithium, to make sure your lithium levels are right for you.

Anticonvulsants for bipolar disorder

There are three anticonvulsant drugs used as mood stabilizers which are licensed to treat bipolar disorder:

  • carbamazepine
  • valproate
  • lamotrigine

Carbamazepine (Tegretol) is also sometimes prescribed to treat episodes of mania. It can be prescribed if lithium is ineffective or unsuitable for you.

Valproate (Depakote, Epilim) can be used to treat episodes of mania and is typically a long-term method of treatment. It can be prescribed if lithium is ineffective or unsuitable for you. However, if you could become pregnant your doctor shouldn’t offer you valproate unless there is a pregnancy prevention program in place, as it carries significant risks to your baby.

Lamotrigine (Lamictal) has antidepressant effects and is licensed to treat severe depression in bipolar disorder. NICE guidelines recommend that it is not used to treat mania. If you are pregnant and taking Lamotrigine, NICE recommends you are checked regularly.

Antidepressants for bipolar disorder

In some circumstances, you might also be offered antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs) – a commonly prescribed type of antidepressant. You might be offered antidepressants in combination with one of the medications described above.

Remember: You should always check with your doctor or pharmacist before taking any drugs together, or closely following one another, in case they could interact with each other badly. For example, combining lithium with SSRI antidepressants can increase the risk of serotonin syndrome (a serious side effect).

(See our pages on antidepressants for more information about these drugs, including

Anticonvulsants for bipolar disorder

There are three anticonvulsant drugs used as mood stabilizers which are licensed to treat bipolar disorder:

  • carbamazepine
  • valproate
  • lamotrigine

Carbamazepine (Tegretol) is also sometimes prescribed to treat episodes of mania. It can be prescribed if lithium is ineffective or unsuitable for you.

Valproate (Depakote, Epilim) can be used to treat episodes of mania and is typically a long-term method of treatment. It can be prescribed if lithium is ineffective or unsuitable for you. However, if you could become pregnant your doctor shouldn’t offer you valproate unless there is a pregnancy prevention program in place, as it carries significant risks to your baby.

Lamotrigine (Lamictal) has antidepressant effects and is licensed to treat severe depression in bipolar disorder. NICE guidelines recommend that it is not used to treat mania. If you are pregnant and taking Lamotrigine, NICE recommends you are checked regularly.

Antidepressants for bipolar disorder

In some circumstances, you might also be offered antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs) – a commonly prescribed type of antidepressant. You might be offered antidepressants in combination with one of the medications described above.

Remember: You should always check with your doctor or pharmacist before taking any drugs together, or closely following one another, in case they could interact with each other badly. For example, combining lithium with SSRI antidepressants can increase the risk of serotonin syndrome (a serious side effect).

How can I help myself cope?

Bipolar disorder can make you feel like you have little control. However, there are lots of things you can do to manage your symptoms and increase your wellbeing:

  • get to know your moods
  • take practical steps
  • look after your physical health
  • build a support network

Bipolar disorder and stigma

Many people have heard of bipolar disorder, but this doesn’t mean they understand the diagnosis fully. You might find that some people have misconceptions about you or have a negative or inaccurate image of bipolar disorder. This can be very upsetting, especially if someone who feels this way is a friend, colleague, family member, or health care professional. But it’s important to remember that you aren’t alone, and you don’t have to put up with people treating you badly.

How can friends and family help?

Seeing someone you care about going through the moods and symptoms of bipolar disorder can be distressing. But there are lots of steps you can take to offer support, while also looking after your own wellbeing.

Be open about bipolar disorder

Being open to talking to someone about their experiences can help them feel supported and accepted. 

Make a plan for manic episodes

When your friend or family member is feeling well, try talking to them about how you can support them if they have a hypomanic or manic episode. This can help both of you feel more stable and in control of what’s happening. You could discuss ideas such as:

  • enjoying being creative together
  • offering a second opinion about projects or commitments, to help someone not
    take on too much
  • if they would like you to, helping to manage money while they are unwell
  • helping them keep a routine, including regular meals and a good sleep pattern

Discuss behavior you find challenging

If someone is hearing or seeing things you don’t, they might feel angry, annoyed, or confused if you don’t share their beliefs. It’s helpful to stay calm and let them know that, although you don’t share the belief, you understand that it feels real for them. Or, if possible, try to focus on supporting them with how they are feeling rather than confirming or challenging their perception of reality – what feels real for them is real in those moments.

If someone becomes very disinhibited while manic, they may do things that feel embarrassing, strange, or upsetting to you. It can be helpful to calmly discuss your feelings with them when they are feeling more stable. Try not to be judgemental or overly critical; focus on explaining how specific things they’ve done make you feel, rather than making general statements or accusations about their actions.

Learn their warning signs and triggers

Most people will have some warning signs that they are about to experience an episode of mania or depression. The best way to learn what these are for your friend or family member is to talk to them about these and explore together what they might be. If you have noticed certain behaviors that normally happen before an episode, you can gently let them know.

Many people will also have triggers, such as stress, which can bring on an episode. You can try to understand what these triggers are for your friend or family member, and how you can help avoid or manage them.

Try not to make assumptions
It’s understandable that you might find yourself constantly on the lookout for signs that your friend or family member is starting a bipolar episode, but remember that this might not be the most helpful way to support them.

Always keep in mind that it’s possible for anyone to have a range of emotions and
behavior while still feeling stable overall.

Try not to assume that any change in mood is a sign that someone is unwell. If you’re not sure, talking to your friend or family member is the best way to check.

Look after yourself

It’s important to invest some time and energy into looking after yourself. You may feel very worried about your friend or family member, but make sure that you stay well will enable you to continue to offer support.

 

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