Free Shipping on orders over $99

Bipolar Disorder: Diagnosis and Causes

Behaviour, Depression, Mental Health | December 8, 2014 | Author: The Super Pharmacist

mental health, depression, mental

Bipolar Disorder: Diagnosis and Causes

All of us experience changes in our moods. Some days, we may feel irritable and frustrated. On other days, we are happy and excited. Individuals with bipolar disorder, however, experience much more extreme mood states that impair their daily life and negatively affect their relationships.

Bipolar disorder is a complex, chronic, recurrent life-long illness causing profound individual suffering and societal costs. Bipolar disorders affect about 2% of the world’s population, with subthreshold forms of the disorder affecting another 2%. Even with treatment, about 37% of patients relapse into depression or mania within 1 year, and 60% within 2 years.

Psychiatric diagnosis

Bipolar disorder is a psychiatric diagnosis defined in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. It is a disorder characterised by periods of extreme, often inappropriate, and sometimes unpredictable mood states. In the past, this disorder was called manic-depression. The term, 'manic-depression' was coined to describe the high emotional states of mania and depression that were experienced.

Bipolar DisorderBipolar individuals experience alternating periods of manic episodes (joyful or excited states) and depressive episodes (very sad, hopeless or empty states). Mood episodes may also include symptoms of both mania and depression (a mixed state).

There are many variations of this disorder. A person with bipolar disorder tends to experience more extreme states of mood than other people. Moods can change quickly (many times a day) or last for months.

Bipolar individuals tend to have very 'black and white' thinking, where everything in life is either a positive aspect or a negative.

Mood patterns of this nature are associated with distress and disruption, and a relatively high risk of suicide. Bipolar disorder is also associated with a variety of cognitive deficits, particularly in organising and planning. The disorder may also skew the ability to judge others' emotions and alter sense of awareness. Bipolar individuals can be overly observant and analytical of their environment, and in some cases,
paranoid of others.

Different Types of Bipolar Disorder

The latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, adult bipolar disorder now has five possible diagnoses:

  • Bipolar I Disorder
  • Bipolar II Disorder
  • Cyclothymic Disorder
  • Substance-Induced Bipolar Disorder
  • Bipolar Disorder Associated with Another Medical Condition
  • Bipolar Disorder Not Elsewhere Classified

Diagnosing Bipolar I Disorder 

The qualifying event for a diagnosis of bipolar I disorder is a single episode of mania (not drug-induced).

A depressive episode is not required for the diagnosis although the vast majority of people who experience mania also have episodes of major depression. A manic episode is defined as a profound mood disturbance characterised by elation, irritability, or expansiveness of at least 1 week duration and at least 3 of the following symptoms:

  • Grandiosity (an exaggerated sense of one's importance)
  • Decreased need for sleep
  • Excessive talking or pressured speech
  • Racing thoughts or flight of ideas
  • Distractibility
  • Increased level of goal-focused activity at home, at work or sexually
  • Engaging in activities with a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Diagnosing Bipolar II Disorder 

Bipolar II disorder is defined as one or more major depressive episodes, at least one hypomanic episode, and the absence of manic episodes.

Diagnosing Bipolar II Disorder During a major depressive episode, the individual demonstrates a depressed mood or a loss of interest or pleasure in daily activities consistently for at least 2 weeks.

This mood represents a change from the person’s normal mood and significantly impairs social, occupational, educational or other important functioning.  

A major depressive episode is characterised by at least 5 of the following:

  • Depressed mood
  • Markedly diminished pleasure or interest in nearly all activities
  • Significant weight loss or gain or significant loss or increase in appetite
  • Hypersomnia or insomnia
  • Psychomotor retardation or agitation
  • Loss of energy or fatigue
  • Feelings of worthlessness or excessive guilt
  • Decreased concentration ability or marked indecisiveness
  • Preoccupation with death or suicide; patient has a plan or has attempted suicide

A major depressive episode is generally not diagnosed when the same symptoms could be attributed to bereavement (normal feelings of sadness after the loss of a loved one). Hypomanic episodes are characterised by an elevated, expansive, or irritable mood of at least 4 consecutive days’ duration with the presence of at least 3 of the following symptoms:

  • Grandiosity or inflated self-esteem
  • Diminished need for sleep
  • Pressured speech
  • Racing thoughts or flight of ideas
  • Clear evidence of distractibility
  • Increased level of goal-focused activity at home, at work, or sexually
  • Engaging in activities with a high potential for painful consequences

A hypomanic episode is associated with a change in functioning that is uncharacteristic of the person. For example, the individual may be far more productive or outgoing and sociable than they usually are. This change in functioning and in mood is noticeable by others (usually friends or family members). Hypomanic episodes have the same symptoms as manic episodes with two important differences: (1) the mood is not severe enough to cause serious impairment in social or occupational functioning or necessitate hospitalisation; (2) there are no psychotic features present in a hypomanic episode. The observable symptoms of a hypomanic episode must not be due to medication or substance abuse or caused by a general medical condition (eg, hyperthyroidism or diabetes).

Diagnosing Cyclothymic Disorder 

Diagnosing Cyclothymic Disorder Cyclothymic disorder is a type of chronic mood disorder widely considered to be a milder or subthreshold form of bipolar disorder.

Cyclothymia is characterised by numerous mood disturbances, with periods of hypomanic symptoms that do not meet the criteria for a hypomanic episode, alternating with periods of mild or moderate symptoms of depression that do not meet the criteria for a major depressive episode.

Causes of Bipolar Disorder

The modern understanding of bipolar disorder is that it is primarily a biological illness with genetic, biochemical, hormonal and environmental influences.

Observations of family histories have long confirmed that a strong genetic component to bipolar disorders. In all, about 80-90% of people diagnosed with bipolar disorder have a family history of either bipolar disorder or major depression. First-degree relatives of people with bipolar disorder are approximately 7 times more likely to develop bipolar disorder than the general population. Although bipolar disorder has a heritable basis, genetics is not the whole story. Studies of identical twins (who share 100 percent of the same genes) show that if one twin has bipolar disorder, the other twin does not develop bipolar disorder 20 percent or more of the time.

Clearly, other factors must be involved. Imbalances in brain neurochemistry and hormonal factors have been implicated. Environmental stressors may also serve to trigger an underlying genetic or biochemical predisposition.  Australia’s best online discount chemist


Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64:543–52.

Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68:241–51.

Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Am J Psychiatry. 1995;152:1635–40.

Youngstrom E. Myths and realities about bipolar disorder. American Psychological Association.   Published 23 Oct 2012. Accessed 18 Oct 2014.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

Soreff S. Bipolar Affective Disorder Treatment & Management. Medscape. Updated 8 Aug 2014. Accessed 20 Oct 2014.

Calabrese JR. Review of the Evidence Base for Depressive Episode Treatments in Bipolar Disorder. Medscape. 17 Sept 2014. Accessed 19 Oct 2014.

Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722.

Pacchiarotti I, Bond DJ, Baldessarini RJ, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry. 2013;170:1249-1262.

Sidor MM, Macqueen GM. Antidepressants for the acute treatment of bipolar depression: a systematic review and meta-analysis. J Clin Psychiatry. 2011;72:156-167.

Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ 2013;346:f3646.

Calabrese JR, Bowden CL, Sachs G. et al. A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently depressed patients with bipolar I disorder. The Journal of Clinical. Psychiatry 2003; 64: 1013–1024.

Frye M.A. Clinical practice. Bipolar disorder – a focus on depression. N Engl J Med 2011;364: 51–59.

Croarkin PE, Thomas MA, Port JD, et al. Neurometabolite effects of lamotrigine treatment in bipolar depression. Poster presented at: 68th Annual Society of Biological Psychiatry; May 16-18, 2013; San Francisco, CA.

Calabrese JR, Keck PE Jr, Macfadden W, et al. A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression. Am J Psychiatry. 2005;162:1351-1360.

Thase ME, Macfadden W, Weisler RH, et al; BOLDER II Study Group. Efficacy of quetiapine monotherapy in bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study). J Clin Psychopharmacol. 2006;26:600-609.

Suppes T, Datto C, Minkwitz M, Nordenhem A, Walker C, Darko D. Effectiveness of the extended release formulation of quetiapine as monotherapy for the treatment of acute bipolar depression. J Affect Disord. 2010;121:106-115.

Young AH, McElroy SL, Bauer M, et al; EMBOLDEN I (Trial 001) Investigators. A double-blind, placebo-controlled study of quetiapine and lithium monotherapy in adults in the acute phase of bipolar depression (EMBOLDEN I). J Clin Psychiatry. 2010;71:150-162.

McElroy SL, Weisler RH, Chang W, et al; EMBOLDEN II (Trial D1447C00134) Investigators. A double-blind, placebo-controlled study of quetiapine and paroxetine as monotherapy in adults with bipolar depression (EMBOLDEN II). J Clin Psychiatry. 2010;71:163-174.

Tohen M, Vieta E, Calabrese J, et al. Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression. Arch Gen Psychiatry. 2003;60:1079-1088.

Loebel A, Cucchiaro J, Silva R, et al. Lurasidone monotherapy in the treatment of bipolar I depression: a randomized, double-blind, placebo-controlled study. Am J Psychiatry. 2014;171:160-168. Abstract

Loebel A, Cucchiaro J, Silva R, et al. Lurasidone as adjunctive therapy with lithium or valproate for the treatment of bipolar I depression: a randomized, double-blind, placebo-controlled study. Am J Psychiatry. 2014;171:169-177.

Peet M. Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants. Br J Psychiatry. 1994;164:549-550.

Church MK, Church DS. Pharmacology of antihistamines. Indian J Dermatol. 2013;58:219-224.

Navari RM. Olanzapine for the prevention and treatment of chronic nausea and chemotherapy-induced nausea and vomiting. Eur J Pharmacol. 2014;722:180-186.

Ranjbar F, Ghanepour A, Sadeghi-Bazargani H, Asadio M, Alizadeh A. The effect of ranitidine on olanzapine-induced weight gain. Biomed Res Int. 2013;2013.639391.

Tohen M, McDonnell DP, Case M, et al. Randomised, double-blind, placebo-controlled study of olanzapine in patients with bipolar I depression. Br J Psychiatry. 2012;201:376-382.

Ishibashi T, Horisawa T, Tokuda K, et al. Pharmacological profile of lurasidone, a novel antipsychotic agent with potent 5-hydroxytryptamine 7 (F-TH7) and 5-HT1A receptor activity. J Pharmacol Exp Ther. 2010;334:171-181.

Prien RF, Caffey EM Jr, Klett CJ. Comparison of lithium carbonate and chlorpromazine in the treatment of mania: report of the Veterans Administration and National Institute of Mental Health Collaborative Study Group. Arch Gen Psychiatry. 1972;26:146-153.

Tohen M, Chengappa KNR, Suppes TR, et al. Efficacy of olanzapine in combination with valproate or lithium in the treatment of mania in patients partially nonresponsive to valproate or lithium monotherapy. Arch Gen Psychiatry. 2002;59:62-69.

Sachs, GS, Grossman F, Ghaemi SN, Okamoto A, Bowden CL. Combination of a mood stabilizer with risperidone or haloperidol for treatment of acute mania: a double-blind, placebo-controlled comparison of efficacy and safety. Am J Psychiatry. 2002;159:1146-1154.

Sachs G, Chengappa KNR, Suppes T, et al. Quetiapine with lithium or divalproex for the treatment of bipolar mania: a randomized, double-blind, placebo-controlled study. Bipolar Disord. 2004;6:213-223.

Meehan K, Zhang F, David S, et al. A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania. J Clin Psychopharmacol. 2001;21:389-397.

Miklowitz DJ, Otto MW, Frank E, Reilly-Harrington NA, et al. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program (STEP). Arch Gen Psychiatry. 2007 Apr;64(4):419–426.

Pandya M, Pozuelo L, Malone D. Electroconvulsive therapy: what the internist needs to know. Cleve Clin J Med. 2007 Sep;74(9):679–685.

Management of Bipolar Disorder Working Group. VA/DoD clinical practice guideline for management of bipolar disorder in adults. Washington, DC: Department of Veterans Affairs, Department of Defense.   Published 2014. Accessed 20 Oct 2014.

backBack to Blog Home