bipolar disorder bipolar disorder bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. if the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe, it is called hypomania. during mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. there is usually also a reduced need for sleep during manic phases. during periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. the risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder. bipolar disorderother namesbipolar affective disorder (bpad), bipolar illness, manic depression, manic depressive disorder, manic–depressive illness (historical), manic–depressive psychosis, circular insanity (historical), bipolar diseasebipolar disorder is characterized by episodes of depression and mania.specialtypsychiatrysymptomsperiods of depression and elevated moodcomplicationssuicide, self-harmusual onset25 years oldtypesbipolar i disorder, bipolar ii disorder, otherscausesenvironmental and geneticrisk factorsfamily history, childhood abuse, long-term stressdifferential diagnosisattention deficit hyperactivity disorder, anxiety, major depressive disorder, autism, personality disorder, schizophrenia, substance use disordertreatmentpsychotherapy, medicationsmedicationlithium, antipsychotics, anticonvulsantsfrequency1–3% while the causes of this mood disorder are not clearly understood, both genetic and environmental factors are thought to play a role. many genes, each with small effects, may contribute to the development of the disorder. genetic factors account for about 70–90% of the risk of developing bipolar disorder. environmental risk factors include a history of childhood abuse and long-term stress. the condition is classified as bipolar i disorder if there has been at least one manic episode, with or without depressive episodes, and as bipolar ii disorder if there has been at least one hypomanic episode (but no full manic episodes) and one major depressive episode. it is classified as cyclothymia if there are hypomanic episodes with periods of depression that do not meet the criteria for major depressive episodes. if these symptoms are due to drugs or medical problems, they are not diagnosed as bipolar disorder. other conditions that have overlapping symptoms with bipolar disorder include attention deficit hyperactivity disorder, personality disorders, schizophrenia, and substance use disorder as well as many other medical conditions. medical testing is not required for a diagnosis, though blood tests or medical imaging can rule out other problems. mood stabilizers—lithium and certain anticonvulsants such as valproate and carbamazepine as well as atypical antipsychotics such as aripiprazole—are the mainstay of long-term pharmacologic relapse prevention. antipsychotics are additionally given during acute manic episodes as well as in cases where mood stabilizers are poorly tolerated or ineffective. in patients where compliance is of concern, long-acting injectable formulations are available. there is some evidence that psychotherapy improves the course of this disorder. the use of antidepressants in depressive episodes is controversial: they can be effective but have been implicated in triggering manic episodes. the treatment of depressive episodes, therefore, is often difficult. electroconvulsive therapy (ect) is effective in acute manic and depressive episodes, especially with psychosis or catatonia. admission to a psychiatric hospital may be required if a person is a risk to themselves or others; involuntary treatment is sometimes necessary if the affected person refuses treatment. bipolar disorder occurs in approximately 1% of the global population. in the united states, about 3% are estimated to be affected at some point in their life; rates appear to be similar in females and males. symptoms most commonly begin between the ages of 20 and 25 years old; an earlier onset in life is associated with a worse prognosis. interest in functioning in the assessment of patients with bipolar disorder is growing, with an emphasis on specific domains such as work, education, social life, family, and cognition. around one-quarter to one-third of people with bipolar disorder have financial, social or work-related problems due to the illness. bipolar disorder is among the top 20 causes of disability worldwide and leads to substantial costs for society. due to lifestyle choices and the side effects of medications, the risk of death from natural causes such as coronary heart disease in people with bipolar disorder is twice that of the general population. signs and symptoms late adolescence and early adulthood are peak years for the onset of bipolar disorder. the condition is characterized by intermittent episodes of mania and/or depression, with an absence of symptoms in between. during these episodes, people with bipolar disorder exhibit disruptions in normal mood, psychomotor activity (the level of physical activity that is influenced by mood)—e.g. constant fidgeting during mania or slowed movements during depression—circadian rhythm and cognition. mania can present with varying levels of mood disturbance, ranging from euphoria, which is associated with "classic mania", to dysphoria and irritability. psychotic symptoms such as delusions or hallucinations may occur in both manic and depressive episodes; their content and nature are consistent with the person's prevailing mood. according to the dsm-5 criteria, mania is distinguished from hypomania by the duration: hypomania is present if elevated mood symptoms persist for at least four consecutive days, while mania is present if such symptoms persist for more than a week. unlike mania, hypomania is not always associated with impaired functioning. the biological mechanisms responsible for switching from a manic or hypomanic episode to a depressive episode, or vice versa, remain poorly understood. manic episodes an 1892 color lithograph depicting a woman diagnosed with hilarious mania also known as a manic episode, mania is a distinct period of at least one week of elevated or irritable mood, which can range from euphoria to delirium. the core symptom of mania involves an increase in energy of psychomotor activity. mania can also present with increased self-esteem or grandiosity, racing thoughts, pressured speech that is difficult to interrupt, decreased need for sleep, disinhibited social behavior, increased goal-oriented activities and impaired judgement, which can lead to exhibition of behaviors characterized as impulsive or high-risk, such as hypersexuality or excessive spending. to fit the definition of a manic episode, these behaviors must impair the individual's ability to socialize or work. if untreated, a manic episode usually lasts three to six months. in severe manic episodes, a person can experience psychotic symptoms, where thought content is affected along with mood. they may feel unstoppable, or as if they have a special relationship with god, a great mission to accomplish, or other grandiose or delusional ideas. this may lead to violent behavior and, sometimes, hospitalization in an inpatient psychiatric hospital. the severity of manic symptoms can be measured by rating scales such as the young mania rating scale, though questions remain about the reliability of these scales. the onset of a manic or depressive episode is often foreshadowed by sleep disturbance. manic individuals often have a history of substance use disorder developed over years as a form of "self-medication". hypomanic episodes an 1858 lithograph captioned 'melancholy passing into mania' hypomania is the milder form of mania, defined as at least four days of the same criteria as mania, but which does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features such as delusions or hallucinations, and does not require psychiatric hospitalization. overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression by some. hypomanic episodes rarely progress to full-blown manic episodes. some people who experience hypomania show increased creativity, while others are irritable or demonstrate poor judgment. hypomania may feel good to some individuals who experience it, though most people who experience hypomania state that the stress of the experience is very painful. people with bipolar disorder who experience hypomania tend to forget the effects of their actions on those around them. even when family and friends recognize mood swings, the individual will often deny that anything is wrong. if not accompanied by depressive episodes, hypomanic episodes are often not deemed problematic unless the mood changes are uncontrollable or volatile. most commonly, symptoms continue for time periods from a few weeks to a few months. depressive episodes main article: major depressive disorder 'melancholy' by william bagg, after a photograph by hugh welch diamond symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, irritability or anger, loss of interest in previously enjoyed activities, excessive or inappropriate guilt, hopelessness, sleeping too much or not enough, changes in appetite and/or weight, fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicide. although the dsm-5 criteria for diagnosing unipolar and bipolar episodes are the same, some clinical features are more common in the latter, including increased sleep, sudden onset and resolution of symptoms, significant weight gain or loss, and severe episodes after childbirth. the earlier the age of onset, the more likely the first few episodes are to be depressive. for most people with bipolar types 1 and 2, the depressive episodes are much longer than the manic or hypomanic episodes. since a diagnosis of bipolar disorder requires a manic or hypomanic episode, many affected individuals are initially misdiagnosed as having major depression and incorrectly treated with prescribed antidepressants. mixed affective episodes main article: mixed affective state in bipolar disorder, a mixed state is an episode during which symptoms of both mania and depression occur simultaneously. individuals experiencing a mixed state may have manic symptoms such as grandiose thoughts while simultaneously experiencing depressive symptoms such as excessive guilt or feeling suicidal. they are considered to have a higher risk for suicidal behavior as depressive emotions such as hopelessness are often paired with mood swings or difficulties with impulse control. anxiety disorders occur more frequently as a comorbidity in mixed bipolar episodes than in non-mixed bipolar depression or mania. substance (including alcohol) use also follows this trend, thereby appearing to depict bipolar symptoms as no more than a consequence of substance use. comorbid conditions people with bipolar disorder often have other co-existing psychiatric conditions such as anxiety (present in about 71% of people with bipolar disorder), substance abuse (56%), personality disorders (36%) and attention deficit hyperactivity disorder (10–20%) which can add to the burden of illness and worsen the prognosis. certain medical conditions are also more common in people with bipolar disorder as compared to the general population. this includes increased rates of metabolic syndrome (present in 37% of people with bipolar disorder), migraine headaches (35%), obesity (21%) and type 2 diabetes (14%). this contributes to a risk of death that is two times higher in those with bipolar disorder as compared to the general population. substance use disorder is a common comorbidity in bipolar disorder; the subject has been widely reviewed. causes the causes of bipolar disorder likely vary between individuals and the exact mechanism underlying the disorder remains unclear. genetic influences are believed to account for 73–93% of the risk of developing the disorder indicating a strong hereditary component. the overall heritability of the bipolar spectrum has been estimated at 0.71. twin studies have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. for bipolar i disorder, the rate at which identical twins (same genes) will both have bipolar i disorder (concordance) is around 40%, compared to about 5% in fraternal twins. a combination of bipolar i, ii, and cyclothymia similarly produced rates of 42% and 11% (identical and fraternal twins, respectively). the rates of bipolar ii combinations without bipolar i are lower—bipolar ii at 23 and 17%, and bipolar ii combining with cyclothymia at 33 and 14%—which may reflect relatively higher genetic heterogeneity. the cause of bipolar disorders overlaps with major depressive disorder. when defining concordance as the co-twins having either bipolar disorder or major depression, then the concordance rate rises to 67% in identical twins and 19% in fraternal twins. the relatively low concordance between fraternal twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes. genetic behavioral genetic studies have suggested that many chromosomal regions and candidate genes are related to bipolar disorder susceptibility with each gene