Bipolar Disorder

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Bipolar disorder\: mood disorder characterised by episodes of depression and mania or hypomania; prevalence ~1%, equal
distribution between men and women, common in conjunction with other mental health illnesses and increases risk of
physical health issues (e.g., cardiovascular disease).
Incidence\: bimodal distribution with peaks at 15-24 years and 45-54 years.
Aetiology\: complex and involves genetic (polygenic inheritance, monoamine transporter and BDNF gene polymorphisms,
heritability ~60% in monozygotic twins), environmental (negative life events, circadian rhythm disruptions), and
neurobiological factors (increased dopamine activity, disturbances of HPA axis).
Risk factors\: genetic factors, prenatal exposure to T o x o p l a s m a g o n d i i , premature birth \<32 weeks gestation, childhood
maltreatment, postpartum period, cannabis use.
Types\: Bipolar I (at least one episode of mania), Bipolar II (at least one episode of hypomania, at least one episode of major
depression), cyclothymia (persistent instability of mood with periods of depression and mild elation).
Clinical features\:
Mania\: elevated mood, increased activity, grandiosity, decreased need for sleep, distractibility, psychotic symptoms (mood-
congruent delusions/hallucinations), lasting at least 7 days with signi
Hypomania\: mild elevation of mood, increased energy, increased sociability, talkativeness, decreased need for sleep,
lasting at least several days, with some functional impairment but less severe than mania, no psychotic features.
Di
pathologies), drug use (psychotropic drugs, steroids), recurrent depression (explore episodes of hypomania), emotionally
unstable personality disorder (a
Investigations\: used to exclude organic causes; include baseline blood tests (FBC, U&Es, LFTs, TFTs, CRP, B12, folate,
vitamin D, ferritin), HIV testing, toxicology screen, physical and neurological examination, CT head.
Diagnosis\: consider when evidence of mania (symptoms for at least 7 days), hypomania (symptoms for at least 4 days),
depression with history of manic/hypomanic episodes. Referral to specialist mental health service (e.g., bipolar disorder
service, CAMHS for under 18s).
Management\:
Acute mania\: trial of oral antipsychotics (haloperidol, olanzapine, quetiapine, risperidone), taper o
benzodiazepines for symptom management.
Acute depression\:
interventions (CBT).
Long-term\: mood stabilisers (lithium, sodium valproate), structured psychotherapies (CBT, interpersonal therapy, family-
focused therapies).
Complications\: increased risk of death by suicide, increased risk of general medical conditions (e.g., cardiovascular
disease), side e
e
Article 🔍
A comprehensive topic overviewIntroduction
Bipolar disorder is a mood disorder characterised by episodes of depression and mania or hypomania.
1
It has an associated prevalence of around 1%, which is much lower than the lifetime risk associated with unipolar
depression.
2
The incidence of bipolar disorder follows a bimodal distribution, with two peaks in the age of onset at around 15-24 years
and 45-54 years. There is a roughly equal distribution of prevalence between men and women.
3,4
Bipolar disorder is commonly seen in conjunction with other mental health illnesses (e.g. anxiety disorders). In addition,
bipolar disorder increases a person’s risk of physical health issues including cardiovascular disease.
1
We've also produced a video demonstration of how a patient with bipolar disorder may present.
Mania (Bipolar Disorder Mania (Bipolar Disorder… …

Aetiology

The aetiology of bipolar disorder is complex and involves genetic, environmental, and neurobiological components.
Though bipolar disorder is heritable within families, having an a
will be a
1
Genetic factors
First-degree relatives of a person a
mood disorders and schizoa
dizygotic twins.
1
The genetic risk associated with bipolar disorder is a type of polygenic inheritance (the sum e
penetrance mutations). Some polymorphisms in genes that code for monoamine transporters and brain-derived
neurotrophic factor (BDNF) are associated with an increased risk of bipolar disorder.
Evidence suggests there is an overlap in the genetic risk between bipolar disorder and schizophrenia. 3
contributions may also be associated with copy number variants and gene-gene interactions.
1
Genetic
Environmental factors
The majority of environmental factors which contribute to the aetiology of bipolar disorder are not speci
Instead, they are associated with the risk of psychiatric disorders in general.
1
Negative life events can precipitate depressive or manic episodes in people with bipolar disorder. The literature suggests
that this may be mediated by circadian rhythm disruptions in genetically predisposed individuals.
5
Neurobiological factors
There is some evidence that increased dopamine activity in the brain may be important in the aetiology of mania,
particularly since many drugs that increase dopaminergic signalling in the central nervous system can be associated with
symptoms characteristic of mania such as elevated mood, reduced need for sleep and reduction in social inhibitions.
1
The presentation of psychosis in bipolar disorder suggests there may be region-speci
neurotransmission, though not necessarily a global increase in dopamine signalling.
Neuroimaging studies have so far failed to demonstrate a consistent pattern of abnormalities, though receptor occupancy
studies show an exaggerated response to dopamine receptor activation through dysfunctional secondary messenger
systems.
6Similar to unipolar depression, there are disturbances of the hypothalamic-pituitary-adrenal axis resulting in increased
cortisol secretion. Administration of exogenous corticosteroids can also result in symptoms of mania.
1

Risk factors

There is no single cause for the onset of bipolar disorder, however, several risk factors have been identi
associated with an increased likelihood of developing the condition.
These risk factors include\:
3,7
Genetic factors\: combined e
Prenatal exposure to T o x o p l a s m a g o n d i i (the parasite that causes toxoplasmosis)
Premature birth \<32 weeks gestation
Childhood maltreatment
Postpartum period
Cannabis use

Clinical features

There are several types of bipolar disorder and the clinical features di
are bipolar I and bipolar II\:
1
In bipolar I, the person has experienced at least one episode of mania
In bipolar II, the person has experienced at least one episode of hypomania, but never an episode of mania. They must
have also experienced at least one episode of major depression.
Figure 1 demonstrates the di
by a persistent instability of mood involving numerous periods of depression and mild elation, none of which are
su
8
Figure 1. Mood variability in bipolar
disorder and cyclothymia.
Mania
The characteristic clinical features of mania are elevated mood, increased activity level and grandiose ideas of self-
importance. In the ICD-10, mania is characterised by\:
8
Elevated mood out of keeping with the patient’s circumstances
Elation accompanied by increased energy resulting in overactivity, pressure of speech, and a decreased need for sleep
Inability to maintain attention, often with marked distractibility
Self-esteem which is often in
Loss of normal social inhibitions
For a diagnosis, the manic episode should last for at least seven days and have a signi
work and social activities. Mood changes should be accompanied by an increase in energy and several of the other
symptoms mentioned above.
As well as these features, mania can also occur alongside psychotic symptoms such as delusions and hallucinations,
which are often auditory.
8
Psychotic symptoms are mood-congruent in bipolar disorder, so therefore grandiose in nature. Flight of ideas and thought
disorder may also be present.Hypomania
Hypomania is less severe than mania and is characterised by an elevation of mood to a lesser extent than that seen in
mania. In ICD-10, an episode of hypomania is characterised by\:
8
Persistent, mild elevation of mood
Increased energy and activity, usually with marked feelings of wellbeing
Increased sociability, talkativeness, over-familiarly, increased sexual energy and a decreased need for sleep (but not to
the extent that there is a signi
Irritability may be present
Absence of psychotic features (delusions or hallucinations)
For a diagnosis, more than one of these features should be present for at least several days.
Although hypomania does involve some extent of functional impairment, this is lesser than that seen in mania and is not
severe enough to cause the more marked impairment in occupational or social activities.
8

Di

Several di
Schizophrenia
Delusions and hallucinations can occur in both bipolar disorder and schizophrenia.
In bipolar disorder, these are mood congruent and so tend to be grandiose, whilst in schizophrenia, they tend to be more
bizarre and di
proportion, the diagnosis of schizoa
1
Organic brain disorder
Frontal lobe pathologies can result in a loss of social inhibitions, which can also occur in mania or hypomania. Neurological
investigation and imaging through CT or MRI can di
1, 9
Drug use
The e
the drug wears o1
Some prescribed medications (e.g. steroids) can cause elation.
Recurrent depression
This should be distinguished from bipolar II by exploring any possible episodes of hypomania with thorough history
taking.
1
Emotionally unstable personality disorder (EUPD)/borderline personality disorder
This condition is characterised by a
However, mood changes tend to occur more quickly in EUPD. Other features of mania such as grandiose ideas and a
marked increase in energy are generally not seen in EUPD.
1,9
Cyclothymia
This is a condition related to bipolar disorder which also presents with chronic mood disturbance, with both depressive
and hypomanic periods. However, this is di
less severe and do not meet the criteria for a depressive episode.
9

Investigations

Investigations can be used to exclude organic causes of a patient’s clinical presentation and are largely context-
dependent. Relevant investigations may include\:
1,9
Baseline blood tests\: FBC, U&Es, LFTs, TFTs, CRP, B12, folate, vitamin D, ferritin
HIV testingToxicology screen
Physical examination including neurological examination
CT head

Diagnosis

Bipolar disorder should be considered when there is evidence of\:
Mania\: symptoms should have lasted for at least seven days
Hypomania\: symptoms should have lasted for at least four days
Depression (characterised by low mood, loss of interest or pleasure, and low energy) with a history of manic or
hypomanic episodes
A mixture of both manic and depressive features is sometimes called a mixed a
10
To con
regionally but may take the form of a bipolar disorder service, a psychosis service, or a specialist integrated community-
based service.
When a child or young person under the age of 18 is suspected of having bipolar disorder, they should be referred to Child
and Adolescent Mental Health Services (CAMHS).
10

Management

Bipolar disorder is managed through the acute treatment of manic and depressive episodes and longer-term mood
stabilisation.
Acute management of mania
In an acute episode of mania, people with a new diagnosis of bipolar disorder should be managed in secondary care with a
trial of oral antipsychotics\:
11
Haloperidol
Olanzapine
Quetiapine
Risperidone
The choice of drug depends on the clinical context and individual patient factors.
If the selected drug is poorly tolerated or shows low clinical e
antipsychotic from the list above would usually be o
If the patient is on antidepressant medication, this should be tapered o11
used as an adjunct to manage symptoms of increased activity and allow for better sleep.
1
Benzodiazepines may be
Acute management of depression in bipolar disorder
Managing depression in the context of bipolar disorder is di
be associated with lower e
a risk of inducing mania or rapid cycling.
1
The recommended pharmacological options for managing depressive episodes in the context of bipolar disorder are\:
11
Fluoxetine + olanzapine
Quetiapine alone
Olanzapine alone
Lamotrigine alone
As well as these pharmacological options, psychological interventions such as cognitive behaviour therapy (CBT) may also
be useful.
11
Long-term management of bipolar disorderAfter the acute episode has resolved, long-term pharmacological management usually involves a mood stabilising
medication such as lithium.
If lithium is not e11
Sodium valproate should not be used in pregnant women due
to its teratogenic e
there is no e
12
Lithium is associated with a signi
e
The use of lithium is also associated with a signi13
Around half of patients will show a
good response to lithium, although those with rapid-cycling bipolar disorder, mixed a
features of psychosis may be less likely to respond well.
1
In addition to pharmacological management, structured psychotherapies have an important role in long-term
management. This can be in the form of cognitive behavioural therapy (CBT), interpersonal therapy or family-focused
therapies.
1

Complications

Complications of bipolar disorder include\:
1, 14
Increased risk of death by suicide
Increased risk of death by general medical conditions such as cardiovascular disease
Side e
Socioeconomic e

References

Harrison P. Shorter Oxford Textbook of Psychiatry. 2017.
Fajutrao L, Locklear J, Priaulx J, Heyes A. A systematic review of the evidence of the burden of bipolar disorder in Europe.
2009. Available from\: [LINK]
Rowland TA, Marwaha S. Epidemiology and risk factors for bipolar disorder. 2018. Available from\: [LINK]
Tsuchiya KJ, Byrne M, Mortensen PB. Risk factors in relation to an emergence of bipolar disorder\: a systematic review. 2003.
Available from\: [LINK]
Alloy LB, Nusslock R, Boland EM. The development and course of bipolar spectrum disorders\: an integrated reward and
circadian rhythm dysregulation model. 2015. Available from\: [LINK]
Cousins DA, Butts K, Young AH. The role of dopamine in bipolar disorder. 2009. Available from\: [LINK]
Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, a
post-partum period. 2014. Available from\: [LINK]
World Health Organization. ICD-10 Classi
Guidelines. 1992. Available from\: [LINK]
National Institute for Health and Care Excellence. Bipolar disorder\: What else might it be? 2021. Available from\: [LINK]
National Institute for Health and Care Excellence. Bipolar disorder\: When should I suspect bipolar disorder? 2021. Available
from\: [LINK]
National Institue for Health and Care Excellence. Bipolar disorder\: Scenario\: Primary care management. 2021. Available
from\: [LINK]

Reviewer

Dr Julie Langan Martin
Senior Lecturer in Psychiatry and Honorary Consultant Psychiatrist
University of GlasgowRelated notes
Anxiety Disorders
Bulimia Nervosa
Depression
Medically Unexplained Symptoms
Personality Disorder