Dr. Jonathan Haverkampf, M.D.
Abstract – Bipolar disorder affects an individual’s affective states (mood). The different flavours of bipolar disorder have in common that there are alterations in mood between above ‘normal’ (hypomania, mania) and normal or below normal (melancholia, depression). The other important mood disorders are the various types of depression, while mania without episodes of depression is a rarity. The first-line treatment of choice in cases of bipolar disorder is medication. However, in the long run, psychotherapy has shown to be successful in making the condition more manageable for individuals suffering from it.
Keywords: bipolar disorder, mania, depression, manic-depressive, medication, psychotherapy, psychiatry
Table of Contents
Bipolar disorder, also known as manic-depressive illness, is a condition which effects the brain and causes pronounced shifts in mood, energy, and activity levels. It affects a patient’s ability to carry out day-to-day tasks. Characteristically, oscillations occur between the ‘up’ or manic state and the ‘down’ or depressed state. The hypomanic state is a less severe ‘up’ period, which may still allow the patient to function in one area, such as the workplace, while confronted with mounting difficulties in other areas of life.
Depending on pattern of the ‘up’ and ‘down’ swings and their intensity, there are four basic versions of bipolar disorder.
Manic episodes last at least 7 days, or manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depression and manic symptoms at the same time) are also possible.
A pattern of depressive episodes and hypomanic episodes, without full-blown manic episodes.
Numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.
Bipolar disorder symptoms that do not match the preceding three categories.
People with bipolar disorder experience periods of unusually intense emotion, changes in sleep patterns and activity levels, and unusual behaviors. These distinct periods are called “mood episodes.” Mood episodes are drastically different from the moods and behaviors that are typical for the person. Extreme changes in energy, activity, and sleep go along with mood episodes.
The definition in the ICD-10 for a hypomanic episode is:
A disorder characterized by a persistent mild elevation of mood, increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, over-familiarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. Irritability, conceit, and boorish behaviour may take the place of the more usual euphoric sociability. The disturbances of mood and behaviour are not accompanied by hallucinations or delusions. 
The definition in the ICD-10 for a manic episode without psychotic symptoms is:
Mood is elevated out of keeping with the patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep. Attention cannot be sustained, and there is often marked distractibility. Self-esteem is often inflated with grandiose ideas and overconfidence. Loss of normal social inhibitions may result in behaviour that is reckless, foolhardy, or inappropriate to the circumstances, and out of character. 
The definition in the ICD-10 for a manic episode with psychotic symptoms is:
In addition to the clinical picture [of a manic state without psychotic symptoms], delusions (usually grandiose) or hallucinations (usually of voices speaking directly to the patient) are present, or the excitement, excessive motor activity, and flight of ideas are so extreme that the subject is incomprehensible or inaccessible to ordinary communication. 
People having a manic episode may:
- Feel very “up,” “high,” or elated
- Have a lot of energy
- Have increased activity levels
- Feel “jumpy” or “wired”
- Have trouble sleeping
- Become more active than usual
- Talk really fast about a lot of different things
- Be agitated, irritable, or “touchy”
- Feel like their thoughts are going very fast
- Think they can do a lot of things at once
- Do risky things, like spend a lot of money or have reckless sex
It is important to keep in mind that a manic phase need not always lead to a positive mood. Irritability or “touchiness” can also often be seen, although irritability should also point one’s diagnostic sense in the direction of a mixed episode.
The definition in the ICD-10 for a manic episode is:
In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called “somatic” symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. 
People having a depressive episode may:
- Feel very sad, down, empty, or hopeless
- Have very little energy
- Have decreased activity levels
- Have trouble sleeping, they may sleep too little or too much
- Feel like they can’t enjoy anything
- Feel worried and empty
- Have trouble concentrating
- Forget things a lot
- Eat too much or too little
- Feel tired or “slowed down”
- Think about death or suicide
Sometimes a mood episode includes symptoms of both manic and depressive symptoms. This is called an episode with mixed features. People experiencing an episode with mixed features may feel very sad, empty, or hopeless, while at the same time feeling extremely energized. Often, the combination leads to irritability, which is then often noticed by family members or work colleagues more than by the affected individuals themselves.
Bipolar disorder can be present even when mood swings are less extreme. For example, some people with bipolar disorder experience hypomania, a less severe form of mania. During a hypomanic episode, an individual may feel very good, be highly productive, and function well. The person may not feel that anything is wrong, but family and friends may recognize the mood swings and/or changes in activity levels as possible bipolar disorder. Without proper treatment, people with hypomania may develop severe mania or depression.
People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania. Therefore, a careful medical history is needed to ensure that bipolar disorder is not mistakenly diagnosed as major depression. Unlike people with bipolar disorder, people who have depression only (also called unipolar depression) do not experience mania. They may, however, experience some manic symptoms at the same time, which is also known as major depressive disorder with mixed features.
Proper diagnosis and treatment help people with bipolar disorder lead healthy and productive lives. Care should be taken that no somatic illness is present, especially a neurological or endocrinological one.
Some bipolar disorder symptoms are similar to other illnesses. In addition, many people have bipolar disorder along with another illness such as anxiety disorder, substance abuse, or an eating disorder. Patients with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.
Sometimes, a patient with severe episodes of mania or depression also has psychotic symptoms, such as hallucinations or delusions. Usually, they match the current state. For example, a patient in a depressed state may fear he is being followed to be arrested for all his ‘sins’, or a patient in a manic state may believe she is powerful, rich and famous and everyone admires her for it.
Anxiety disorder is often diagnosed among people with bipolar disorder.
Attention deficit hyperactivity disorder (ADHD) disorders is often diagnosed among people with bipolar disorder.
Patients with bipolar disorder may also misuse alcohol or drugs, have relationship problems, or perform poorly in school or at work. Family, friends and people experiencing symptoms may not recognize these problems as signs of a major mental illness such as bipolar disorder.
Biology, psychology and a patient’s social environment all seem to play a role in the occurrence and maintenance of bipolar disorder.
Bipolar disorder tends to run in families. Children with a parent or sibling who has bipolar disorder are much more likely to develop the illness, compared with children who do not have a family history of the disorder. However, it is important to note that most people with a family history of bipolar disorder will not develop the illness. Much depends on developing good coping strategies and arranging one’s life according to one’s values, true interests and aspirations.
Eliminating bad stress and generally finding more things in life that are enjoyable and meaningful to oneself, seem to lower the risk of another bipolar episode. Psychotherapy should therefore support the patient in identifying needs, interests, values and aspirations, while also helping him or her in using communication with oneself and others more effectively to get these needs and wants met.
Treatment helps many people—even those with the most severe forms of bipolar disorder—gain better control of their mood swings and other bipolar symptoms. An effective treatment plan usually includes a combination of medication and psychotherapy. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of mood changes, but some people may have lingering symptoms. Long-term, continuous treatment helps to control these symptoms.
Medications generally used to treat bipolar disorder include substances from the following groups:
- Lithium salts
- Second generation antipsychotics
The effect of mood stabilizers can take some time. In the case of lithium, for example, this can be months. However, lithium is the only drug known which probably has an anti-suicidal effect that is useful in cases of more severe depression and may also have neuroprotective effects.
Most mood stabilizers require lab tests at regular intervals. Particularly in the case of lithium, taking the blood level is important, especially early in treatment, because the level should be within a narrow range.
One needs to be careful with antidepressants, because they can push a patient into a manic episode. However, in cases of severe depressive episodes, adding an antidepressant to a mood stabilizer can be a reasonable choice. It is still better to choose an antidepressant which is not overly activating, as may be the serotonin and norepinephrine reuptake inhibitors (SNRIs). This could include a milder selective serotonin reuptake inhibitor, for example, or a substance like bupropion, which mainly works through the dopamine pathway.
Second generation antipsychotics, such as olanzapine or aripiprazole, which is more activating, can also be used as mood stabilizers, although they are usually not first choice, because they may be less reliable and could have potentially more serious side effects.
In the end, the medication should be helpful to the individual patient, which sometimes requires trying out more than one substance. On the other hand, given the known side effect profiles, one can often tailor the right medication to the patient on the first attempt.
Psychotherapy can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:
- Cognitive behavioral therapy (CBT)
- Psychodynamic psychotherapy
- Interpersonal therapy
- Family-focused therapy
Often, a combination of approaches from different therapies, tailored to the individual case, can be more helpful than adhering strictly to one school of thought.
Communication-Focused Therapy (CFT), which was developed by the author, targets a mechanism most forms of psychotherapy in common, communication, and works with awareness, analysis, reflection and insight to bring about change, which can then translate into better communication with oneself and others.  Since communication patterns and processes play a large role in the maintenance of the symptoms and also in any secondary problems from the bipolar condition, as, for example, social isolation in both, depressed and manic phases. CFT has been described by the author for depression , OCD , anxiety , ADHD , bipolar disorder , psychosis, eating disorder, and several other conditions.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.
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 Haverkampf, CJ. Communication-Focused Therapy (CFT) for ADHD. J Psychiatry Psychotherapy Communication, 2017 Dec 31;6(4):114-118.
 Haverkampf, CJ. Communication-Focused Therapy (CFT) for Bipolar Disorder. J Psychiatry Psychotherapy Communication, 2017 Dec 31;5(2):125-129
 Haverkampf CJ CBT and Psychodynamic Psychotherapy – A Comparison. J Psychiatry Psychotherapy Communication 2017 Sept 30 6(2)61-68
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