BIPOLAR I DISORDER: A SYNOPSIS OF SYMPTOMS, POSSIBLE CAUSES, AND

TREATMENT METHODS
By
Tasha Shermer

TABLE OF CONTENTS
I.

Abstract

II.

Symptoms of Bipolar I Disorder

a. General diagnostic criteria
b. Manic episodes
c. Depressive episodes
d. Mixed episodes

III.

Possible Causes of Bipolar I Disorder

a. Genetics
b. Environment
c. Trauma

IV.

Treatments for Bipolar I Disorder

a. Alternative treatments
b. Psychotherapy
c. Pharmaceutical therapy
d. Other treatments

V.

References
a.

I.
ABSTRACT
This review will encompass contemporary diagnostic criteria for bipolar disorder, signs
and symptoms of bipolar disorder, current research into causes of bipolar disorder, and a
summary of modern treatment methods for bipolar disorder.
II.
SYMPTOMS OF BIPOLAR I DISORDER
Bipolar disorder was previously known as manic depression due to the two states that are
typical of the disorder: mania and depression. In order to be diagnosed as having Bipolar I
disorder, an individual must have at least one manic episode. According to Richman (2014):
Bipolar disorder exhibits a spectrum of symptoms, from which psychiatrists make their
diagnosis. One of the factors they examine is whether the person is in a depressed, manic,
or hypomanic state. The latter is one in which a person experiences a more controlled
mania. The person may become excessively active and feel elated, but does not become
disorganized or delusional. People with these symptoms may be cyclothymic, that is they
exhibit periods of depression and mania, but for shorter and less intense durations. (p.
608)
Manic episodes involve [] feelings of self-importance, elation, talkativeness,
increased sociability, and a desire to embark on goal-oriented activities, coupled with the
characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for
sleep. (Basile & Cataldo, 2012).
According to the DSM-IV-TR, the following criteria must be met for an episode to
qualify as a bipolar manic episode:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable

mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following symptoms
have persisted (4 if the mood is only irritable) and have been present to a significant
degree:
(1) increased self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)" (APA, 2000, p. 362)
Adolescents diagnosed with bipolar disorder are more likely to experience dysphoric
mania, which manifests as anger and irritability rather than euphoria. However, it is common
among bipolar individuals in other age groups as well. (Basile & Cataldo, 2012).
Individuals with bipolar disorder often experience a period of extreme depression
following a manic episode, however an episode of major depression does not necessarily have to
accompany a manic episode, and is not a requirement for a diagnosis of bipolar I (Basile &

Cataldo, 2012). The DSM-IV-TR outlines these criteria for diagnosing an episode of major
depression:
Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks
and at least five of the following symptoms that cause clinically significant impairment in
social, work, or other important areas of functioning almost every day.
[ . . .]
1. Depressed mood most of the day.
2. Diminished interest or pleasure in all or most activities.
3. Significant unintentional weight loss or gain.
4. Insomnia or sleeping too much.
5. Agitation or psychomotor retardation noticed by others.
6. Fatigue or loss of energy.
7. Feelings of worthlessness or excessive guilt.
8. Diminished ability to think or concentrate, or indecisiveness.
9. Recurrent thoughts of death (APA, 2000, p. 356).
According to Fundukian (2010), bipolar depression presents differently than unipolar
depression:
Bipolar manic depression should be distinguished from unipolar (major) depression.
Individuals who exhibit bipolar disorder depressive episodes often present with signs of
eating more (hyperphagia), sleeping more (hypersomnia), very low energy levels, are
overweight, and experience worsening of mood during evening hours. The bipolar
affected individual also tends to deny or minimize obvious signs of illness. Unipolar
(major) depression usually presents with anxiety, difficulty sleeping, loss of appetite, loss

of weight, and feeling worse during morning hours, which improves as the day
progresses. Close friends, family members, and roommates are often very helpful in
assisting the clinician to make the correct diagnosis. (p. 210)
Bipolar depression also carries a higher risk of suicide than unipolar depression.
According to Basile & Cataldo (2012):
Suicide is the major complication of bipolar disorder and is related to the duration of the
depressive episode. Some 25%50% of individuals with bipolar disorder attempt suicide,
and 11% complete the suicide attempt. The longer the depressive episode lasts, the higher
the risk of suicidal tendencies. Alcoholics and patients with other chronic medical
diseases are particularly prone to planning and implementing a suicide attempt.
There are also mixed episodes, in which an individual experiences symptoms of both
mania and depression. For example, a person may have racing thoughts as in a manic state but
still feel lethargic and fatigued as in a depressed state. Rapid cycling occurs in up to 20% of
individuals diagnosed with bipolar disorder. Rapid cycling involves at least 4 swings from manic
to depressive episodes or vice versa in a 12 month period. Ultra-rapid cycling, in which an
individual experiences manic and depressed states several times in a 24 hour period, is difficult
to distinguish from a mixed state.
III.
CAUSES OF BIPOLAR DISORDER
The exact cause of bipolar disorder has not been identified, but basic biological principles
clearly underpin bipolar disorder because it is the most heritable of all mental health disorders
(Pettigrew, 2012). Genetics is one of the main factors that determines who is likely to develop
bipolar disorder and who isnt. According to Fundukian (2010):

There is no single gene or environmental factor that causes bipolar disorder. Like other
mental illnesses, multiple factors together may contribute to the illness.
[. . .]
No specific gene mutations have been identified that consistently show up in
bipolar patients. However, there appears to be a potential genetic correlation between
bipolar disorder and mutations in specific regions of chromosomes 13, 18, and 21. The
building blocks of genes, called nucleotides, are normally arranged in a specific order and
quantity. If these nucleotides are repeated in a redundant fashion, a genetic abnormality
often results. Some evidence exists for a special type of nucleotide sequence (CAG/CTG
repeats) in patients with type II bipolar disorder on chromosome 18. However, not all
bipolar patients have this mutation and the presence of this sequence does not worsen the
disorder or change the age of onset. Further research is needed to determine which genes
are involved in bipolar disorder. The specific genetic defect for bipolar disorder has not
yet been identified, and it is likely that both genetic and environmental factors contribute
to the disease. (p. 208-209)
Children who have at least one parent with bipolar disorder have a 15%-30% chance of
developing the disorder themselves. Two bipolar parents increases the risk of a child developing
the disorder to 50%-75%. Siblings and fraternal twins risk ranges from 15%-25%, and identical
twins have a 70% likelihood. Identical twin research supports that genes as well as other factors
are involved in the development of bipolar disorder (Martin, 2013).
Although observation and conventional wisdom may lead one to feel bipolar disorder has
a solely biological basis, according to Pettigrew (2012):

An acute episode of mania certainly has a biochemical feel because of the sleeplessness,
elevated mood, and accelerated verbal behavior, so it is easy to understand the emphasis
on a biochemical basis for the disorder. But it needs to be realized that biochemical
theories provide only a unidimensional gradation of symptoms and do not deal with the
bipolar aspect of the disorder, in which there is a switch between complementary aspects,
mania, and depression. In contrast to wholly biochemical accounts, there is an
interhemispheric mechanism of bipolar disorder that adequately accounts for the
complementary aspects.
The dynamics of the interhemispheric switch are determined genetically, as
shown by studies of monozygotic twins, and show significant slowing in bipolar disorder.
The disorder has the highest heritability of all mental disorders, a fact that may be
connected to the high heritability of the interhemispheric switch rate. (p. 350)
It has been shown that the first episode of bipolar disorder is always triggered by an
external stressor (Pettigrew, 2012). Stimuli that trigger an episode have been identified in some
groups of bipolar patients. Seasonal changes were found to coincide with particular types of
episodes in some patients, with depressive episodes being experienced in the fall and winter, and
manic episodes being experienced during the spring and summer (Martin, 2013). The finding that
bipolar disorder is triggered by an environmental stressor has the implication that the
development of the disorder can be prevented if individuals who are genetically predisposed to it
are identified and intervened upon (Pettigrew, 2012). Possible methods of intervention include
mood-stabilizing medication and lifestyle changes.

IV.
TREATMENT OF BIPOLAR DISORDER
Methods for treating bipolar disorder fall into two categories: alternative and allopathic
(traditional).
According to Ford-Martin & Odle (2009):
Alternative treatments for bipolar disorder generally are considered to be complementary
treatments to conventional therapies. General recommendations for controlling bipolar
symptoms include maintaining a calm environment, avoiding overstimulation, getting
plenty of rest, regular exercise, and proper diet. Psychotherapy and counseling are
generally recommended treatments for the disease, whether treated alternatively or
allopathically. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool
in helping patients and their families adjust to the disorder and in reducing the risk of
suicide. Also, educational counseling is recommended for the patient and family. In fact,
a 2003 report revealed that people on medication for bipolar disorder have better results if
they also participate in family-focused therapy. (p. 258)
Traditional Chinese Medicine, acupuncture, biofeedback, rhythm therapy, and
vitamin/mineral supplements are also possible alternative treatments for bipolar disorder (FordMartin & Odle, 2009).
Psychotherapy and psychosocial intervention (which includes patient education along
with psychotherapy) are crucial to the management of bipolar disorder, according to Fundukian
(2010):
It is important for patients to receive social support and illness management skills. Family
and friends must be aware of the high rates of social dysfunction and marital discord.

Involvement in national support groups is advisable (e.g., National Depressive and

Manic-Depressive Association).
Psychoeducation usually focuses on all of the following:
assessing which parameters will have an impact on the outcome of the patients
disease
communicating the boundaries and requirements of treatment
undergoing a personal cost-benefit analysis concerning specific treatment
directions
implementing a follow-up program
implementing future directions, which may include adjustment or change
interventions (p. 212)
Pharmaceutical treatments are considered to be the most effective treatment for bipolar
disorder. Basile & Cataldo (2012) state:
A combination of mood-stabilizing agents, antidepressants, antipsychotics, and
anticonvulsants may be used for long-term regulation of manic and depressive episodes.
In the acute phase, the choice of medication for bipolar disorder is dependent on the stage
or type of current episode. Many drugs are used to treat an acute manic episode, primarily
the antipsychotics and benzodiazepines (e.g., lorazepam, clonazepam). In the presence of
psychotic symptoms, atypical antipsy-chotics may be used to treat psychotic symptoms
and acute mania and contribute to mood stabilization. For depressive episodes,
antidepressants may be used. Medications may be added temporarily to treat episodes of
mania or depression that break through despite mood-stabilizer treatment.

10

The medications most important in the treatment of bipolar disorder are called mood
stabilizers. These drugs have an obscure mode of action and have been used to search for the
etiology of the disorder:
Understanding the mode of action of mood stabilizers is limited by the lack of an
underlying model of bipolar disorder. In fact, many researchers have tried to reverse
engineer the basis of bipolar disorder by starting with the actions of the mood stabilizer
and then working backwards to try to understand how it might moderate the fundamental
cause of bipolar disorder. This approach has not been successful. However, if the
evidence that bipolar disorder is based upon a dysrhythmia of interhemispheric switches
is accepted, there is plenty of evidence that illuminates the mode of action of the mood
stabilizers. For example, it is known that the hypothalamic, suprachiasmatic nuclei can
act as a daily interhemispheric switch, whose circadian rhythm is differentially affected
by lithium and lamotrigene. Lithium acts to reduce the action of the phase advance
mechanism, while lamotrigene acts on the phase retardation mechanism in the circadian
cycle. This would explain the action of these two mood stabilizers, with lithium being
most effective on mania and lamotrigene most effective on the depressive part of the
manicdepressive cycle, since mania is triggered by a phase advance and depression by
a phase retardation. Related to these effects is lithiums action to reduce hemispheric
asymmetry. Episodes are characterized by an extreme asymmetry in the interhemispheric
switch (Stuck switch), with a Left (L) bias in mania and a Right (R) bias in depression.
Lithium has a strong action in eliminating RL asymmetry during development and this
is likely to apply also to the interhemispheric switch because it retains many embryonic

11

features not found elsewhere in the adult brain, such as a high concentration of retinoic
acid. (Pettigrew, 2012, p. 350)
Antidepressants are also used to treat bipolar disorder, but they carry the risk of
stimulating a manic episode. According to Basile & Cataldo (2012):
Because antidepressants may stimulate manic episodes in some bipolar patients, their use
in bipolar disorder is controversial. Typically used as short-term treatment,
antidepressants are not specifically approved for treating depression associated with
bipolar disorder but may be prescribed off-label. Selective serotonin reuptake inhibitors
(SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) may be
prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat
unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a
preferred treatment option for bipolar depression. (p. 215)
Electroconvulsive therapy (ECT), also known as electroshock therapy, has been found
to be successful in treating bipolar depression and mania. According to Basile & Cataldo (2012):
ECT usually is employed after all pharmaceutical treatment options have been explored
in patients with severe depression and suicidal thoughts. ECT is given under anesthesia,
and patients are given a muscle relaxant medication to prevent convulsions. The
treatment consists of a series of electrical pulses that move into the brain through
electrodes on the patient's head. Although the exact mechanisms behind the success of
ECT therapy are not known, it is believed that this electrical current alters the
electrochemical processes of the brain, consequently relieving depression. Headaches,
muscle soreness, nausea, and confusion are possible side effects immediately following

12

an ECT procedure. Temporary memory loss has also been reported in ECT patients. In
bipolar patients, ECT is often used in conjunction with drug therapy.
Although bipolar disorder is a debilitating condition and can lead to suicide, if individuals
who are afflicted can be diagnosed and treated, [M]ost individuals with bipolar disorder can
achieve substantial stabilization of mood swings and related symptoms with proper treatment
(Fundukian, 2010). Proper treatment varies from patient to patient, and treatments that once
worked for a patient can stop working. Basile & Cataldo (2012) state:
Drug therapies frequently need adjustment to achieve the maximum benefit for the
patient. Bipolar disorder is a chronic, recurrent illness in over 90% of people with the
disorder. The disorder requires lifelong observation and treatment after diagnosis.
According to the World Health Organization, bipolar disorder is the sixth-leading
cause of disability worldwide. (p. 216)

13

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