Bipolar I

What is bipolar I disorder?

Bipolar I disorder is characterized by at least one manic episode lasting at least seven days or requiring hospitalization. A manic episode is marked by elevated mood, excessive energy, and racing thoughts. 

Another hallmark of manic episodes is reckless behavior, such as going on spending sprees or engaging in risky sexual behaviors. Substance abuse is also common. Some individuals have psychotic symptoms during manic episodes, such as delusions and hallucinations. ^[1] Almost all patients will have more than one manic phase throughout their lifetime. ^[3] 

Most patients also have major depressive episodes, which are not required for a diagnosis. Symptoms of a depressive episode are similar to those of major depressive disorder, like feelings of sadness and low energy. Episodes usually occur right before or after a manic episode. ^[3]

Some individuals also experience hypomanic episodes directly before or after a manic episode. Hypomanic episodes are similar to manic episodes but are less severe and do not usually cause significant impairment to work and social functioning. ^[1] 

Many individuals go for long periods between episodes without symptoms. However, up to 30% still experience significant impairment in between episodes. ^[1] Others may have more frequent episodes, known as rapid cycling, where there are four or more periods of bipolar depression, mania, or hypomania per year. ^[1] 

In addition to manic, hypomanic, and depressive episodes, some individuals experience mixed states. During these states, they have both depressive and manic symptoms simultaneously. For example, they may have excessive energy but feel depressed. Mixed episodes can be dangerous if they are accompanied by suicidal ideation. ^[3]

Symptoms of bipolar I disorder

Individuals with bipolar I disorder may experience the following symptoms during manic or major depressive episodes. 

Symptoms of manic episodes include:

• Racing thoughts
• High energy and jumpiness
• Irritable mood
• Feeling elated
• Fast speech that jumps from topic to topic
• An excessive urge for pleasure, including food, sex, or drinking
• Reduced need for sleep
• Feeling overly powerful or important ^[4]

Symptoms of major depressive episodes include:

• Feelings of sadness
• Feelings of hopelessness
• Lack of energy
• Anxiety or restlessness
• Difficulty concentrating
• Lack of interest in activities
• Thoughts of death or suicidal ideation
• Difficulty sleeping or sleeping too much

Causes of bipolar I disorder

The causes of bipolar I disorder are not completely understood. However, some studies have found that the brain structure of those with the disorder differs from those without. ^[4] It’s also suggested that bipolar I can be triggered by stressful life events. ^[3]

Research indicates that there is a strong genetic component to the disorder. Those with an immediate family member with Bipolar I are ten times more likely to develop the disorder than the general population. ^[3] However, no single gene or group of genes has been identified as responsible for the disorder. ^[4]

Complications of bipolar I disorder

When left untreated, patients with bipolar I disorder are at a greater risk for several complications. Those with bipolar I disorder have an increased mortality rate compared to the general population. One study found the risk was up to 6.8% higher. ^[5]

One common cause of death in this population is cardiovascular disease. Some studies have found that individuals with bipolar I disorder have a nearly two-fold risk of developing cardiovascular disease compared to the general population. ^[5]

Patients are also at a significantly higher risk of suicide. Research suggests that anywhere from 25% to 50% attempt suicide, and 15% are successful. ^[3] This risk increases further if the individual has a comorbid substance abuse disorder.

Over half of those with bipolar disorders have a history of substance abuse. ^[2] Substance abuse is associated with worse treatment outcomes and an increased risk of self-harm and suicide. ^[3]

Diagnosing bipolar I disorder

Diagnosis of bipolar I disorder begins with a psychological evaluation. A mental health professional will look at the history of the symptoms and overall medical history. They will also consider the patient’s appearance, behavior, work history, relationship history, and family history.

Based on this, the healthcare professional will determine whether the patient meets the DSM-5’s criteria for bipolar I disorder. They must have had at least one manic episode during their lifetime. The following criteria must be met for a manic episode ^[1]:

• A defined phase of unusual and persistent irritable or elevated mood and increased energy or activitylasting at least one week and present most of the day almost every day. If hospitalization is needed, the criteria for duration do not need to be met.
• During this period, three or more of the following symptoms must be present and significant. Four must be present if the period is marked solely by irritability.
  • Reduced need for sleep
  • Grandiosity or inflated self-esteem
  • Talking more than normal
  • Racing thoughts
  • Difficulty concentrating or becoming easily distracted
  • Increased activity
  • Excessive reckless activity, including risky financial or sexual decisions
• The episode causes significant impairment in the patient functioning in work or social settings, or hospitalization is needed.
• The episode cannot be attributed to the effects of another medical condition or substance. 

Differential diagnoses 

Several other disorders must be ruled out in order to diagnose bipolar I disorder. These include bipolar II disorder, cyclothymic disorder, and certain medical conditions.

While bipolar I is marked primarily by severe episodes of mania, bipolar II disorder is marked by hypomanic symptoms alternating with major depressive episodes. Unlike bipolar I, depressive episodes are also required for a diagnosis. ^[1]

Like bipolar I, cyclothymic disorder also includes periods of manic and depressive symptoms, but they are never severe enough to qualify for a diagnosis of a manic, hypomanic, or depressive episode. ^[1] 

Certain medications, substance abuse, or withdrawal can sometimes cause mania, so these must be ruled out as the cause. Mania, due to other medical conditions, must also be ruled out, including Huntington’s disease, Cushing syndrome, multiple sclerosis, lupus, endocrine disorders, and others. ^[3]

Prevention of bipolar I disorder

There is no specific way to prevent this disorder, as the causes are not well-understood. However, early recognition, diagnosis, and treatment are key to managing the symptoms of bipolar I and preventing episodes. Treatment can also help to prevent complications. 

Treatment for bipolar I disorder

The primary treatment for bipolar I disorder is a combination of medication and psychotherapy. Since this is a life-long disorder, treatment adherence is essential for positive outcomes.

Medications 

Proper medication is crucial to getting manic episodes under control. Mood stabilizers, such as lithium and divalproex, are the drugs of choice. For more severe cases, individuals may benefit from adding a second mood stabilizer or combining a mood stabilizer with an atypical antipsychotic. ^[3]

Antipsychotics or benzodiazepines are sometimes used as a first-line treatment to calm severe agitation since they are faster-acting. ^[3] Atypical antipsychotic medications are also suggested for mania with psychotic features.

Doctors should closely monitor a patient’s symptoms and side effects when starting a new medication. Then, they should adjust the treatment regimen and dosage as needed. 

Psychotherapy

Several forms of psychotherapy may be recommended, but the focus is generally on medication compliance, education, support, and lifestyle changes. 

Interpersonal and social rhythm therapy (IPSRT) was developed specifically for treating bipolar disorders. ^[4] This treatment aims to minimize sleep disruptions, which can trigger manic episodes, by establishing a daily routine.

Cognitive behavioral therapy (CBT) can also help treat depressive symptoms and sleep difficulties. ^[4] CBT can also help individuals cope with life stressors, which may help them avoid manic episodes. 

ECT

Electroconvulsive therapy (ECT) is a procedure that stimulates the brain and can help relieve both severe manic and depressive symptoms. ^[4] This is sometimes recommended if a patient does not see adequate improvement on medication alone. ^[3]

Self-care for bipolar I disorder

As a complement to therapy, practicing self-care can help improve overall well-being and quality of life. Maintaining good sleep hygiene is crucial since lack of sleep can trigger manic episodes. ^[3] Individuals should avoid alcohol and drugs, which can also be triggering. Stress reduction and mindfulness activities can help. Regular exercise and a healthy diet are also recommended.

Helping someone with bipolar I disorder

You can help someone with bipolar I by educating yourself on the condition. Encourage them to seek and stick with treatment. Help them remember their appointments and remind them to take their medication. Be supportive and patient.

FAQs about bipolar I disorder

How is bipolar I different than bipolar II?

Bipolar I disorder is marked by severe manic episodes, whereas bipolar II is marked by episodes of both hypomania and depression. Hypomanic episodes are less severe than manic episodes. Unlike bipolar I, major depressive episodes are a requirement for the diagnosis of bipolar II. ^[1] For more information on the differences between the two, see our page on bipolar 1 vs. bipolar 2.

What is the outlook for people with bipolar I disorder?

Bipolar I is a life-long disorder, but many patients can live full, normal lives with proper treatment. Comorbid substance abuse or anxiety disorders are associated with poorer outcomes. ^[3] However, long-term compliance with medication and proper sleep hygiene are associated with positive outcomes.

How common is bipolar I?

Bipolar I disorder is relatively common. Roughly one in every 100 people will experience it in their lifetime. ^[3] This disorder affects men and women at an equal rate. The average age of onset is 18 years. ^[1]