Mood swings are common and relatively normal, especially as a response to events or situations in our lives. However, mood swings can become problematic if they are persistent and cause significant psychological distress. In these cases, the person may be suffering from Bipolar Depression. People with bipolar depression experience episodes of (hypo)mania which may alternate with episodes of depression, depending on the subtype. But what exactly do manic and depressive episodes look like? Find out in this article!

This article will cover the following points:

-   Bipolar Disorder and its subtypes

-   Symptoms

-   Episodes vs cycles

-   Causes

-   Treatment

What is bipolar disorder?

Bipolar disorder (previously known as manic depression) is a type of affective (mood) disorder [2]. Bipolar disorder (BD) is a condition when a person suffers from extreme emotional highs that may or may not alternate with emotional lows (depression) and periods of stable mood. It is a common misconception that BD always means having extreme mood swings. While this is true for one subtype of BD, it does not always have to be the case.  

Subtypes

There are three main types of bipolar disorder defined in the DSM-5 [1].

1. Bipolar I disorder is defined by the presence of at least one manic episode. These episodes may be accompanied by hypomanic or depressive episodes, but it is not required for the diagnosis [2].
2. On the contrary, Bipolar II disorder is only diagnosed when the person experiences at least one hypomanic and one depressive episode, while a full manic episode cannot be present [2].
3. The third subtype is cyclothymia, which is chronic cycling (2 years in adults; 1 year in children and adolescents) between hypomanic and depressive symptoms which are not severe enough to meet the diagnostic criteria for a full-blown mania or depression [2].

This table can help you better understand the criteria for the above-explained subtypes:

The lifetime prevalence of BD is around 1.2% [1, 9]. Males and females appear to be diagnosed with BD equally. The age of onset is typically between 20-25 years. BD is also associated with an increased risk of suicide: around 6% of patients commit suicide.

Symptoms (DSM-5)

Manic episode

It is a distinct period of abnormally and persistently elevated or irritable mood and abnormally and persistently high energy levels which lasts at least 1 week [1]. During this period, 3 or more of the following symptoms are present:

·               Inflated self-esteem or grandiosity

·               Decreased need for sleep

·               Pressured speech

·               Flight of ideas or racing thoughts

·               Distractibility

·               Increased goal-directed behaviour

·               Engaging in activities with high potential for painful consequences

Moreover, the episode must be severe enough to cause marked impairment in social or occupational functioning; require hospitalisation; or feature psychotic symptoms [1].

Hypomanic episode

It is a distinct period of abnormally and persistently elevated or irritable mood and abnormally and persistently high energy levels which lasts at least 4 consecutive days [1]. Three or more of the aforementioned symptoms must be present. The difference from a manic episode is that during a hypomanic episode, the symptoms are not severe enough to cause significant impairment in functioning or to require hospitalization. If there are psychotic features present, the episode is by definition manic.

Major depressive episode

Five or more of the following symptoms have been present during a 2-week period, and one of these symptoms have to be either depressed mood or loss of interest/pleasure [1].

·   Depressed mood

·   Diminished interest or pleasure in almost all activities

·   Significant weight loss or weight gain

·   Hypersomnia or insomnia

·   Psychomotor agitation or retardation

·   Fatigue or loss of energy

·   Feelings of worthlessness or inappropriate guilt

·   Diminished ability to think or concentrate

·   Recurrent thoughts or death, suicidal ideation

The episode causes significant distress or impairment and cannot be attributable to the effect of a substance [1].

Mixed episode

Mixed episodes are characterised by the presence of both manic and depressive symptoms [3]. They are more difficult to diagnose and treat because people who experience mixed episodes have more severe symptomatology, more lifetime episodes, worse clinical outcomes and higher comorbidity rates.

Episodes vs cycles

These terms are often used interchangeably but they are not the same. An episode is an extended period of mood dysregulation [6]. A cycle is a pronounced shift in mood and energy levels from one extreme to another, something like a mood swing.

A person with bipolar disorder can also be described to have rapid cycling. According to DSM-5, this means having four or more mood episodes during a 12-month period [1]. However, this is only the case for adults or late adolescents. Children with BD can experience thousands of cycles (mood swings) per year but are not diagnosed with rapid cycling. This is because episodes usually do not become evident until adolescents [6].

Causes

As with many other mental disorders, the exact causes are unknown [9]. However, several risk factors have been identified.

·       Genes – People with first-degree relatives with BD are more likely to also develop it. The heritability of BD is thought to be around 70-90% [3].

·       Stress – The ‘kindling’ hypothesis has been proposed as an explanation for the role of stress. The first episode is thought to be triggered by exposure to a stressor while subsequent ones can occur without stressors [3].

·       Disruption in circadian rhythms – This refers to the so-called zeitgeber hypothesis. Unstable daily routines lead to disruption of circadian rhythms. In vulnerable individuals, it can lead to affective episodes [4].

Treatment

Bipolar disorder is a lifelong condition [1]. Only about 30% of patients achieve full functional recovery but around 90% achieve symptomatic recovery.

Somatic treatment

BD is mainly treated with medication. Mood stabilisers are typically used, most commonly lithium. Lithium has been found to be the most effective treatment for acute and maintenance treatment of affective episodes [5]. However, after long-term use, it can lead to severe side effects including blurred vision, confusion, or kidney failure [8].

Moreover, if the manic episode is particularly severe, anti-psychotics are likely to be used, sometimes in conjunction with mood stabilisers. A study by Fagiolini and colleagues [3] found that second-generation anti-psychotics appear to be the most effective treatment option for mixed episodes. Antidepressants are typically not used in bipolar patients because they do not appear to improve depressive symptoms and often worsen manic symptoms [3].

Psychological treatment

One type of therapy used for bipolar disorder is interpersonal social rhythms therapy (IPSRT). The rationale behind this therapy is that regularity of social routines and stable interpersonal relationships can prevent a person from relapsing [4]. A study by Frank and colleagues [4] found that IPSRT appears to be efficient for the prevention of reoccurring episodes and it works by improving the regularity of patient’s social rhythms.

Another type of therapy is cognitive therapy (CT) or cognitive behavioural therapy (CBT). A study by Lam and colleagues [7] found that CT designed specifically for relapse prevention in BD appears to be effective in conjunction with mood stabilisers.

!!! PLEASE reach out for professional help if you or someone you know may be experiencing these symptoms !!! See these resources that can help you, under “psychological support”.

Extra resources:

-      Living with bipolar disorder: https://www.youtube.com/watch?v=KSwqdl0Q9F8

-      What it’s actually like to live with bipolar disorder: https://www.youtube.com/watch?v=Rp5SeMrivRA

References

1. American Psychiatric Association. (2013). Diagnostic criteria and codes. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA.

2. Carvalho, Andre F., Joseph Firth, and Eduard Vieta. "Bipolar disorder." New England Journal of Medicine, 383(1), 58-66.

3. Fagiolini, A., Coluccia, A., Maina, G., Forgione, R. N., Goracci, A., Cuomo, A., & Young, A. H. (2015). Diagnosis, epidemiology and management of mixed states in bipolar disorder. CNS Drugs, 29(9), 725-740. https://doi.org/10.1007/s40263-015-0275-6

4. Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., ... & Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62(9), 996-1004. doi:10.1001/archpsyc.62.9.996

5. Kessing, L. V., Bauer, M., Nolen, W. A., Severus, E., Goodwin, G. M., & Geddes, J. (2018). Effectiveness of maintenance therapy of lithium vs other mood stabilizers in monotherapy and in combinations: a systematic review of evidence from observational studies. Bipolar Disorders, 20(5), 419-431. https://doi.org/10.1111/bdi.12623

6.     Kowatch, R. A. (2016). Diagnosis, phenomenology, differential diagnosis, and comorbidity of pediatric bipolar disorder. The Journal of Clinical Psychiatry, 77. https://doi.org/10.4088/JCP.15017su1c.01

7. Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, N., ... & Sham, P. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Archives of General Psychiatry, 60(2), 145-152. doi:10.1001/archpsyc.60.2.145

8. NHS. (August 2020). Lithium. Retrieved on February 19, 2022 from https://www.nhs.uk/medicines/lithium/

9. Nolen-Hoeksema, S. (2014). Abnormal psychology (Sixth). McGraw-Hill Education.