• Clinical science

Bipolar disorder


Bipolar disorder is a psychiatric illness characterized by alternating periods of elevated mood (mania) and depression, interspersed with periods of normal mood and functioning. Males and females are equally affected and there is a strong genetic component to the disease. During manic episodes, patients can have elevated mood, talkativeness, racing thoughts, and psychosis, and often endanger themselves or others. Depressive episodes present similarly to major depressive disorder and are characterized by sadness, anhedonia, and hopelessness. The shift from mania to depression can occur anytime. The acute treatment of manic episodes includes antipsychotics and benzodiazepines. Lithium and valproic acid are used for long-term treatment.


  • Sex: =
  • Lifetime prevalence
    • General population: 1–3%
    • First-degree relative with bipolar disorder: up to 10%
    • Monozygotic twin: 40-70%


Epidemiological data refers to the US, unless otherwise specified.


  • Multifactorial origin
    • Strong genetic influence → increased risk if first-degree relative is affected (see “Epidemiology” above)
    • ↑ Paternal age → ↑ mutations during spermatogenesis↑ risk of bipolar disorder in offspring
    • Psychosocial factors
      • Childhood traumatic experiences
      • Sexual abuse
      • Stress
      • Changes in life situation


Clinical features

Subtypes and variants

Types of bipolar disorder

Rapid cycling

  • Patients affected by rapid cycling suffer from unipolar (major depression, mania) or bipolar disorders with rapidly alternating episodes (at least 4 manic/hypomanic episodes or major depressive episodes per year).
    • Rapid cycling: at least 4 bipolar mood episodes per year
    • Ultra-rapid cycling: at least 4 bipolar mood episodes per month
    • Ultradian cycling (also ultra-ultra-rapid cycling): alternating bipolar episodes within 1 day on at least 4 days a week

Cyclothymia (F34.0)

  • Persistent hypomanic/depressive mood swings over the course of 2 years, which are not sufficiently severe to justify a diagnosis of bipolar disorder
  • Characteristics
    • A persistent instability of mood involving numerous periods of depression that alternates with hypomania
    • Symptoms are not sufficiently severe or persistent enough to diagnose bipolar disorder

Substance/medication-induced bipolar and related disorder

Diagnostic criteria according to DSM-V
  • Elevated, disinhibited, or irritable mood with/without depressed mood or anhedonia
  • ≥ 1 of the following:
    • Symptoms occur during or immediately after exposure/intoxication/withdrawal to a substance/medication
    • The substance/medication has the potential to produce symptoms (mentioned in category A)
  • Not attributable to a related disorder that is NOT substance/medication induced, suggested by:
    • Symptom onset before ingestion of the substance
    • Persistant symptoms despite not taking the substance for a long time
    • A history another mental disorder
  • Significant dysfunction (work/school)



Bipolar I disorder vs Bipolar II disorder

Diagnostic criteria according to DSM-V
Bipolar I disorder Bipolar II disorder

Although depressive episodes are not necessary to diagnose bipolar I disorder, most individuals who experience manic episodes also experience major depressive episodes over their lifetime.

Manic episode and hypomanic episode

Diagnostic criteria according to DSM-V
Manic episode Hypomanic episode
  • Abnormally elevated, expansive, or irritable mood and increased goal-directed behavior that lasts most of the day for at least 1 week
Abnormally elevated, expansive, or irritable mood and increased goal-directed behavior that lasts most of the day for at least 4 consecutive days
  • ≥ 3 of the following:
    • Increased goal-directed activity (sexually, at work, and/or socially ) or psychomotor agitation
    • Increased talkativeness or pressure of speech
    • Flight of ideas or racing thoughts
    • Loss of social inhibitions, socially inappropriate and reckless behavior, aggressiveness, and hostility
    • Decreased need for sleep
    • Overconfidence
    • Easily distracted
  • Significant dysfunction (work/school), patient requires hospitalization (risk of harm to self or others), or there are psychotic features Hallucinations and delusions are typical for a mania with psychotic symptoms. Delusions are usually mood-congruent (often delusions of grandeur). In this type of mania, communication with the patient may be impossible due to excessive manic excitement, physical activity, flight of ideas, perceptual disorders (e.g., acoustic hallucinations), and delusions.
  • Does NOT result in significant dysfunction, hospitalization, or present with psychotic features
  • Not attributable to an organic psychic disorder or psychotropic substances.
  • Not attributable to an organic psychic disorder or psychotropic substances.
  • Symptoms are recognizable by others.
  • Changes in function that are not characteristic of the individual

If psychotic symptoms are present the episode is, by definition, manic and not hypomanic!

DIG FAST” is an acronym for features of a manic episode: D = Distractibility, I= Irresponsibility, G = Grandiosity, F = Flight of ideas, A = Activity increase, S = Sleep deficit, T = Talkativeness.

Major depressive episode

Diagnostic criteria according to DSM-V
  • ≥ 5 symptoms, for at least 2 weeks, with at least one of the symptoms being depressed mood or anhedonia
    • Depressed mood present most of the day, almost every day
    • Sleep disturbance (insomnia or hypersomnia)
    • Loss of interest or anhedonia
    • Feelings of worthlessness or guilt
    • Fatigue or loss of energy
    • Diminished concentration, ability to think, or make decisions (pseudodementia)
    • Weight change due to appetite change
    • Psychomotor changes
    • Suicidal ideation
  • Clinically significant distress or impaired functioning in important areas of life (e.g., work, school)
  • Not due to effects of psychoactive substances or organic disease
  • The symptoms of a major depressive episode are similar to those of unipolar depression.
  • In some patients, the initial diagnosis may be a recurrent depressive disorder (F33), as depressive symptoms are the only symptoms for several years.

SIG E CAPS” is an acronym for the features of major depressive episode: S= Sleep (insomnia or hypersomnia), I = Interest loss (anhedonia), G = Guilt (low self-esteem), E= Energy (low energy or fatigue), C = Concentration (poor concentration or difficulty making decisions), A = Appetite (decreased appetite or overeating), P = Psychomotor agitation or retardation, and S = Suicidality.



Acute treatment for mania and hypomania

  • The goal of acute treatment is resolution of mania and psychosis (if present).
  • General principles
    • Reduction of external stimuli
    • Assessment for possible offending substances (e.g., cocaine, alcohol, PCP, etc.)
    • Limit access to cars, bank accounts/credit cards, cell phones, etc., due to reckless behavior
  • Medication

Antipsychotics are the preferred initial therapy in agitated patients due to fast onset of action!

All suicidal patients require inpatient hospitalization!

Long-term treatment (maintenance treatment)

In a patient with bipolar disorder, antidepressants should not be used before initiating therapy with mood stabilizers because antidepressants can precipitate a manic episode

Lithium should not be administered to patients with renal dysfunction! An overdose may result in life-threatening lithium toxicity!References:[5][6][7][8][9]