Bipolar 101: What is Bipolar Disorder?

The basics of bipolar disorder, including types, symptoms, causes, diagnoses, and treatments.

Hello, 

It’s Sunday March 12th, and this is the third edition of Bipolar and Bipartisan, a new newsletter designed to educate readers about a complicated mental disorder and what’s happening in the world about it. 

Today’s newsletter presents just the facts about bipolar. It’s distilled from easy to read web-pages that have more details. If you’d like to learn more, consider reading information from the National Institute of Health, Mayo Clinic, American Psychiatry Association, WebMD, Bipolar Discoveries, Wikipedia and many other resources you can find with a quick internet search. 

I’m calling it Bipolar 101. These are some of the basic facts about a complicated disorder. Just like in college, some foundational knowledge is required to understand the more finer details. Writing it was a helpful reminder to me, and helped crystallize some of my own understanding. I hope it helps you, too.

Skip to the bottom of the newsletter if you’d just like a podcast suggestion, wellness tip, and book recommendation.

Thanks for reading, 

Tyler

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What is Bipolar Disorder?

Bipolar Disorder is a mental disorder characterized by periods of both mania and depression. 

When bipolar people are experiencing “mania,” emotionally they feel “high” or “up”  and can experience euphoria, happiness, extra energy, elation, racing thoughts, risky, pressured speech, and more. 

When bipolar people are experiencing “depression” they feel “low” or “down” and can experience sadness, despair, hopelessness, fatigue, hopelessness, and suicidal ideation (the scariest part).

What makes bipolar a uniquely challenging disorder is that individuals can often “swing” from mania to depression, and back again, quite quickly. Mood swings for people with bipolar disorder can impact sleep, decision making, motivation, and brain regulation. Bipolar people can also experience “mixed states” when symptoms of mania and depression occur simultaneously. 

Sound familiar? It should. All human beings experience highs and lows, and feel the impact of mood swings. The difference for bipolar people is that periods of mania and depression can last days or months, instead of hours. Bipolar people also experience the intensity of ups and downs much more severely than the general population.

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What types of Bipolar are there?

There are three types of bipolar: Bipolar I, Bipolar II, and Cyclothymic Disorder. The major difference between the three is the severity of mania a patient experiences. 

People with Bipolar I are typically diagnosed following a manic episode, a period of at least one week in which the individual experiences an extreme increase in energy, a break from reality (i.e. psychosis), inability to sleep, dangerous actions, and/or extremely risky behavior. Bipolar I patients experience mania, and their manic episodes are often followed by periods of hypo-mania and major depression. 

• Sidenote: after I had my first manic episode in 2019 and was diagnosed as Bipolar I for the first time, I had a period of hypo-mania that lasted for about a month, before I fell into a nearly year-long depression that followed.  

People with Bipolar II have also experienced at least one major depressive episode in their life. However, Bipolar II people have not experienced a manic episode. Instead, their “ups” are less severe than those with Bipolar I. Their elevated states are classified as “hypo-mania” and typically last at least four days.

It’s worth pausing to say that as scary as mania can be for people with bipolar and their loved ones, so can major depression. Major Depressive Disorder can be diagnosed on its own, and more than 163 million people worldwide have it. Also known as Clinical Depression, the disorder comes with feeling very sad, trouble concentrating, the inability to do simple tasks, and more. Patients with Bipolar I and Bipolar II each have experienced a major depressive period AND they face mania or hypomania, respectively. 

A third form of Bipolar Disorder is known as Cyclothymic Disorder. Still serious, this is the least severe form of bipolar, characterized by at least a two year period in which individuals experience mood swings between hypomanic and depressive symptoms. Children can experience these more mild characteristics, too, and the time period is shorter (one year).  

Important Sidenote: The word “mania” is sometimes used by people — including patients, parents, and caregivers — in the bipolar world as a catch all term to characterize someone who is feeling elevated. But, it’s a little more complicated than that. Technically, psychiatrists and other medical professionals distinguish between “hypo-mania” and “mania.” Hypo-mania is the less severe diagnosis and assessment, compared to a diagnosis of mania, which is more severe and can lead to a manic episode. The word “mania” is often used to describe both states. It’s like the fact that all squares are rectangles, but not all rectangles are squares.

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What are the symptoms of Bipolar?

Perhaps some of the most important information families and friends of those living with Bipolar can learn is the symptoms of hypo-mania, mania, and depression. Knowing the signs can allow those supporting bipolar people to get ahead of problems before they accelerate and prevent major depressions or manic episodes that require hospitalization. 

Symptoms of major depression:

• Depressed mood, and feeling sad

• Thinking about, planning, or attempting suicide

• Lost interest in doing things

• Fatigue and loss of energy

• Either insomnia (i.e. not sleeping) or sleeping too much

• Increased or decreased appetite

• Having trouble concentrating and making decisions

• Feeling hopeless or worthless

Symptoms of hypo-mania:

• Feeling elevated, elated, irritable, and/or anxious 

• A heightened sense of euphoria or righteousness

• More activity and energy than usual; feeling wired 

• Racing thoughts and/or pressured and faster speech; having “flights of ideas”

• Experiencing paranoia

• Decreased need for sleep

• Decreased need for food (because of having extra energy) or excessive appetite (if the body needs more nutrients to keep up with a busy body)

• Increased risky behavior, such as gambling, spending sprees, or reckless driving

• Increased sex drive

Symptoms of mania

Mania is a more severe form of hypo-mania. Mania tends to last longer, causes an impact on social relationships or the ability to do work or schoolwork, and can often mean an individual has lost rationality. Mania sometimes requires hospitalization, but not always. 

Here are some examples to illustrate the differences between mania and hypo-mania:

• Someone with hypo-mania may work long hours for a few days, while someone with mania may work long hours for many weeks at a time, often doing damage to work relationships.

• Someone with hypo-mania may get 4-6 hours of sleep, while someone with mania may get 1-3 hours of sleep.

• Someone with hypo-mania may increase their betting modestly, while someone with mania may place 100x more risky bets than they normally would;

• Someone with hypo-mania may have a vivid dream about a future event, while someone with mania may experience hallucinations — seeing things while awake that do not exist in reality.

• Someone with hypo-mania may honk their car horn more frequently than normal, while someone with mania may drive 50 mph over the speed limit.

• Someone with hypo-mania may have ideas for launching a business, traveling to a foreign country, buying a home, or indulging with an expensive purchase, while someone with mania may act on these impulses by opening a bank account, booking travel, putting an offer on a home, or spending money recklessly.

Finally, it’s important to note that it is common for people with bipolar to experience both depressive and hypo-manic episodes at the same time. This is called a “mixed” state. This state can be the most confusing to individuals, their families, and their doctors — as it’s hard to figure out what medications and non-medication treatment plans to use. 

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What causes bipolar disorder?

Wikipedia has the most detailed yet easy to understand summary of what causes bipolar I could find. The Wiki page summarizes to say:

Genetic influences are strong, given evidence that the disorder runs in families.

• People with bipolar are more likely to have a family member with bipolar. Identical twins are eight times as likely to both get bipolar disorder than fraternal twins. The risk of bipolar is ten-fold higher among first degree relatives compared to the general population.

• Studies have found that genes CACNAIC, ODZ4, and NCAN as well as polymorphisms BDNF, DRD4, DAO, TPH1, and TPH2 are linked to bipolar disorder.

• However, the research to verify early studies on genetic connections to a bipolar diagnosis has seen mixed results, sowing doubt in the academic community about the share of responsibility a bipolar diagnosis can be attributed to nature.

  • Sidenote: the disparities in academic research about bipolar disorder published in peer-reviewed journals is a part of the replicabication crisis in science. Hopefully some of these unresolved research questions can be sorted out by B2, a new research collaborative focused on bipolar research that recently received a $150M philanthropic bet.

Environmental conditions have also been linked to bipolar disorder. These are life events or circumstances that may significantly impact one’s likelihood of experiencing hypo-mania, a manic episode, or major depression. These are a few examples of environmental conditions that may interact with genetic ones.

• Recent life events (i.e. divorce, job loss, injury) are often followed by bipolar episodes.

• Challenging interpersonal relationships and tension that result because often precede manic or depressive periods (e.g. at work, in families, among friends).

• There are more reported stressful events, both as a child and as an adult, from people with bipolar compared to the general population.

• Traumatic and/or abusive experiences as a child are reported by 30-50% of bipolar individuals.

Neurology may also explain bipolar disorder, but research is underdeveloped. Might it be that there’s simply something different in the brains of bipolar people? Just like someone who needs to have heart surgery or a lung transplant due to natural causes, perhaps bipolar people just have different brains. For example, some research has found:

• The ventral system regulating emotional perception may not work as well in bipolar people, and problems with the amygdala, insula, ventral striatum, ventral anterior cingulate cortex, and/or the prefrontal context may be off. Likewise, the hippocampus, dorsal anterior cingulate cortex, and other parts of the prefrontal cortex that make up the dorsal system for emotional regulation may have problems.

• MRI research has found that certain brain regions may be smaller or larger in bipolar people, compared to the general population. Smaller regions may include the left rostral anterior cingulate cortex, fronto-insular cortex, ventral prefrontal cortex and claustrum. Larger regions may include lateral ventricles, globus pallidus, subgenual anterior cingulate, and the amygdala. Bipolar people may also have higher rates of white matter hyperintensities.

• There are all sorts of hypotheses about what parts of the brain are responsible for breakdowns during hypo-manic, manic, and depressive states. For example, the “kindling” hypothesis holds that individuals may be born more likely to be bipolar, and that each stressful event in their life slowly reduces the ability for healthy mood regulation and that eventually a threshold is reached after which episodes begin in response to stressful events.

  • Sidenote: Stress impacts all of us; Bipolar or not. Watch this short video on what happens to our brains, hearts, and body when we encounter stress in everyday life. 

What’s the bottom line on what causes bipolar disorder? I’d summarize to say: bipolar disorder can be caused by nature and nurture, and that the causal mechanisms are likely different for each patient. Just like any major medical diagnosis — from cancer to Alzheimer's — researchers are still trying to identify root causes and develop preventative treatment plans. 

For bipolar people, it’s important to acknowledge it’s not our fault. Bipolar people didn’t do anything wrong to be subject to a wicked disorder. Instead, we have a problem with an organ in our body; it just so happens to be that organ is our brain. We may have been dealt a tough genome or irregular brain size at birth. On top of that, we may have lived a more than normally stressful life, that made genetic or neurological problems come to the surface. The good news is there are well-researched diagnoses and treatments. 

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Diagnosis 

Bipolar disorder is most often diagnosed in an outpatient setting, but can occasionally be identified in an inpatient facility when an individual poses a safety threat to themselves or others. 

Psychiatrists will often be the ones to diagnose bipolar people. A psychiatrist is a medical doctor who specializes in mental health. 

To inform their diagnosis, psychiatrists will often request a physical exam (e.g. from a primary care provider). They will also interview patients about their symptoms, and often receive input from the patient’s friends and family who may be able to provide a clearer account of an individual's actions. Psychiatrists may also ask patients to do mood-charting, a practice of tracking one’s feelings on a daily basis. 

• Sidenote: if you are bipolar and struggling to communicate to your psychiatrist or family about how you feel on a daily basis, give mood charting a try. I like the “E-Moods” app which you can download onto your phone. I get asked four questions about my mood each day, and track what medications I’m taking. 

To diagnose patients with bipolar disorder, psychiatrists compare symptoms with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a publication by the American Psychiatric Association. Some psychiatrists, especially those not in the United States, may use the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ISM-10).

It is common for bipolar people to be diagnosed late in adolescence or early in adulthood, as this is when symptoms start to become more noticeable. However, individuals can be diagnosed at any age, including during early childhood or in retirement. 

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Treatment

Treating bipolar disorder requires a comprehensive approach to maintaining a healthy brain, body, and lifestyle. 

Medication is an important part of any bipolar person’s health, but it is not the only answer, and by itself is unlikely to succeed. Some major parts of bipolar disorder treatment include:

Physical care.

During manic episodes or while suicidal, Bipolar I individuals may require full-time hospitalization. There are also other types of physical care bipolar individuals can receive, including medication management, partial hospitalization, and intensive outpatient programs; bipolar people and their families should learn about each of these options, and what environment is right to help prevent or respond to symptoms. It’s also important bipolar people see their primary care doctor regularly, and get bloodwork done at least once every six months.

Medication.

There are countless medications to treat bipolar disorder. The Mayo Clinic lists some of the most common that are prescribed to bipolar people, which fall into five key categories: Mood Stabilizers; Antipsychotics; Antidepressants; Antidepressant-antipsychotics; and Anti-Anxiety medications.

Finding the right medications, and the right dosages, often requires trial and error. There is no math equation or logic chart for psychiatrists to follow to prescribe the right medications to patients based on their symptoms. The research on bipolar medications is extremely complicated, and often inconclusive, likely the result of the fact that there are so many potential causes of the disorder and that individuals will react differently to different medication regimes.

Regardless of the medication treatment plan identified by a psychiatrist, it is critical individuals remain on medications. When bipolar people do not, they tend to relapse — doing damage to themselves and impacting relationships with others.

Therapy.

Individuals with bipolar disorder often meet with therapists to develop coping strategies and talk with a professional about the challenges they are facing. The science of therapy is also quite complicated, with all sorts of treatment plans and philosophies. One of the most common programs is Cognitive Behavioral Therapy. In addition to seeing a therapist 1:1, bipolar people will sometimes participate in group therapy and/or family therapy.

LIFESTYLE.

Rarely mentioned on webpages about bipolar treatment, an individual’s lifestyle may make more of a difference in bipolar care than most researchers give it credit for.

Eating healthy diets, getting 8-10 hours of sleep, and exercising daily are three critical components of a bipolar person’s health. These three items, especially when they lead to good daily routines, can provide bipolar people with the physical and emotional stabilization and regulation their bodies need. In each of these categories, there are no shortage of recommendations and tips.

There are also plenty of other “cures” to a bipolar episode. For me, things like spending time with family and friends, reading, writing, volunteering, getting sunshine, listening to music, smelling a candle, and more help to stabilize my moods. Everyone has their own tips and tricks for wellness, whether they are bipolar or not.

The name of the game with bipolar treatment is mood stabilization. To get there, individuals and families should make sure they are spending as much focus and strategizing on lifestyle as they are on physical care, medications, and therapy. 

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Bipolar Disorder Digest. 

Each newsletter we share three random nuggets. Today, a podcast suggestion, wellness tip, and book recommendation. 

1. A podcast! Some of my friends and family have been listening to “Inside Bipolar,” a podcast hosted by Gabe, a man with bipolar disorder. Gabe’s conversations with a board certified psychiatrist, Dr. Nicole, allows for a fun, informative, and scientific understanding of bipolar disorder. Check it out! 

2. A wellness tip. Stimulating our senses is important to mental health. Think about how you can do so on a daily basis. As I’ve been working on my laptop the last several weeks (including while writing this newsletter), I’ve been listening to soft music in the background and have had a candle lit. I enjoy the smell and sounds, and it helps keep my mind active in healthy ways. I like the “Deep Focus” playlist on Spotify. 

3. A book recommendation. The most famous book about bipolar disorder is “An Unquiet Mind” by Kay Radfeld Jamison. Sad, informative, interesting, and inspiring the memoir follows a psychiatrist who specializes in treating bipolar disorder, who also happens to be bipolar herself. The trials she goes through help those without bipolar disorder to understand what it’s like to have a bipolar mind and humanizes the science of the disorder.