Understanding and Managing Types of Bipolar Disorder

Bipolar disorders, formerly referred to as manic-depressive illness or manic depression, are mental health conditions that affect a person’s mood, energy levels, and daily life ¹. They lead to distinct mood swings and mood episodes, including times of high energy and irritability (manic/hypomanic) and periods of sadness (depressive) ¹. These episodes can disrupt daily life, but individuals can lead fulfilling lives with proper treatment. There are three main types of bipolar disorder: bipolar I, bipolar II, and cyclothymic disorder ¹. Genetic factors play a significant role, with a family history present in 80-90% of cases, and symptoms typically emerge around age 25 ¹. Triggers such as stress and sleep disruptions can worsen mood episodes ¹.

Types of Bipolar Disorders

Episodes of mania, hypomania, and depression characterize several different types of bipolar disorders and related conditions. The main categories include Bipolar I, Bipolar II, Cyclothymic disorder, and other types encompassed within bipolar and related disorders. Healthcare providers diagnose bipolar disorder based on the prevalence of bipolar symptoms as well as the frequency of mood swings and mood episodes.

Bipolar I Disorder

To receive a diagnosis of bipolar I disorder, a person must have experienced one or more manic episodes lasting more than one week. Some people with this type of bipolar disorder also experience depressive episodes, but not everyone will.

Bipolar I Disorder Symptoms

A manic episode is when someone experiences an unusually high or irritable mood, along with a surge in energy and intense activity that lasts for at least one week, most of the day, almost every day, or any duration if hospitalization is required ⁴.

During this time, the person may show three or more of the following changes in behavior ⁴:

Manic episode symptoms

• Elevated mood
• Increased activity
• Impulsivity
• Reduced need for sleep
• Racing thoughts
• Risk-taking behavior

There must be a noticeable change in the person’s behavior, and it must be clear to their friends and family that this is not their usual behavior. The symptoms must be severe enough to interfere with work, family, or social activities. It is common for a person suffering from a manic episode to require hospitalization for safety reasons.

It’s important to rule out other factors, such as drug use or a medical condition, as the cause of these bipolar disorder symptoms. Additionally, if a full manic episode occurs during antidepressant treatment and continues beyond the expected effects of the treatment, it is considered evidence for a bipolar I disorder diagnosis.

Hypomanic episode

Hypomanic episodes are less severe manic symptoms that need to last four days in a row, as opposed to a week ^{1, 4}. Hypomanic symptoms do not lead to severe problems and interference with daily functioning that manic symptoms often cause ^{1, 4}.

Major Depressive Episode

A major depressive episode lasts at least two weeks, and during this time, a person has at least five of the following symptoms, including at least one of the first two ^{1, 4}:

• Feeling sad or hopeless
• Losing interest in things they used to enjoy.
• Thinking they’re worthless or guilty.
• Sleeping too much or too little
• Constant fatigue
• Eating more or less than usual
• Restlessness (like pacing) or slowed speech/movement.
• Trouble concentrating
• Often thinking about death or suicide

Related: What is Depression? From Diagnosis to Treatment

Bipolar II Disorder

To be diagnosed with bipolar II disorder, a person needs to have at least one significant depressive episode along with at least one hypomanic episode. (see symptoms listed above) ^{1, 4}.

People generally return to their usual level of functioning and routine when they are not experiencing an episode. People with bipolar II disorder often seek help after their initial depressive episode, as hypomanic episodes can be enjoyable and might boost performance at work or school ^{1, 4}.

Cyclothymic Disorder

The diagnosis of cyclothymic disorder is assigned to adults who go through a minimum of 2 years (or a full year for children) with both hypomanic and depressive episodes without meeting the criteria for a full-blown episode of mania, hypomania, or major depression ⁴.

Substance-related disorders and sleep disorders may coexist with cyclothymic disorder, and comorbid attention-deficit/hyperactivity disorder is possible, especially in children ⁴.

 Unspecified Bipolar

This category applies when someone shows symptoms of a bipolar and related disorder that cause significant distress or problems in social, work, or other important areas but doesn’t meet all the criteria for any specific disorder in the bipolar and related disorders group ⁴.

 Bipolar Specifiers

The specifiers for Bipolar and Related Disorders provide more details about the different ways these disorders can show up ⁴:

• Bipolar with Mixed Features: This is relevant during a manic, hypomanic, or depressive episode in bipolar I or bipolar II disorder when symptoms from both ends (high and low mood) happen together. For example, a manic episode with mixed features means meeting the criteria for mania but also showing at least three depressive symptoms.
• Bipolar with Rapid Cycling: This happens in both bipolar I and bipolar II disorder and is characterized by having at least four mood episodes in the last 12 months that meet the criteria for mania, hypomania, or major depressive episodes. Rapid cycling episodes have periods of partial or full improvement lasting at least two months or a switch to the opposite mood.
• Bipolar with Peripartum Onset: This is relevant if mood symptoms start during pregnancy or within four weeks after delivery in bipolar I or bipolar II disorder.
• Bipolar with Seasonal Pattern: This applies to a regular seasonal pattern of at least one type of episode (mania, hypomania, or depression). The episodes have a consistent timing related to a specific time of the year over the last two years.

The severity of the disorder is determined by the number and intensity of symptoms, along with the level of functional impairment. Severity is categorized as mild, moderate, or severe.

 Ultra-rapid cycling and Ultradian Cycling

Ultra-rapid cycling, and ultradian cycling or ultra-rapid cycling bipolar disorder (URCBD), is a proposed subtype within the broader category of rapid-cycling bipolar disorder (RCBD). While not formally recognized, URCBD has been suggested for inclusion due to its distinctive features related to the frequency and duration of mood episodes ⁸.

Rapid-cycling bipolar disorder is defined by the occurrence of at least four mood episodes meeting the criteria for manic, hypomanic, or major depressive episodes within the previous 12 months ¹¹. Within the spectrum of RCBD, ultra-rapid cycling is characterized by cycle lengths ranging from days to weeks, including 48-hour cycling, while ultra-ultra-rapid cycling features even shorter cycle lengths, lasting up to 24 hours ¹¹.

In contrast, ultradian cycling presents an even more accelerated pattern of mood episodes, with individuals experiencing multiple shifts within a single day ¹¹. This cycling variant involves mood transitions occurring within 24 hours, reflecting a rapid pace that surpasses the typical cycling observed in bipolar disorder ¹¹.

Treatment and Management

The primary goal of treatment for bipolar disorder is to reduce the severity and frequency of these episodes, enabling individuals to lead as normal a life as possible ⁶. Effective treatment often involves a combination of approaches tailored to the individual’s needs.

Medications

Various psychiatric medications are employed in the treatment of bipolar disorder, and the specific types and dosages are determined based on individual symptoms. These medications may include ⁵:

1. Mood Stabilizers: These are crucial for managing manic or hypomanic episodes. Examples include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others), and lamotrigine (Lamictal).
2. Antipsychotics: When depression or mania symptoms persist despite other treatments, antipsychotic drugs like olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda), or asenapine (Saphris) may be added. These can be prescribed alone or alongside a mood stabilizer.
3. Antidepressants: To manage depression, an antidepressant might be added. Typically, it is prescribed alongside a mood stabilizer or antipsychotic to minimize the risk of triggering a manic episode.
4. Antidepressant-Antipsychotic Combination: Symbyax is a medication combining the antidepressant fluoxetine and the antipsychotic olanzapine. It functions as a treatment for depression and a mood stabilizer.
5. Anti-anxiety Medications: Benzodiazepines and other anxiolytics may be utilized temporarily to alleviate anxiety and improve sleep.

Selecting the most suitable medication involves a trial-and-error process. Patience is necessary, as some medications take weeks to months to exhibit their full effects ⁵. Typically, only one medication is adjusted at a time to identify the most effective treatment with the least disruptive side effects. Medications may need to be modified as symptoms evolve ⁵.

Mild side effects often improve as the proper medications and dosages are determined, and the body adapts to the treatment ⁵. If side effects are bothersome, it’s important to communicate with the doctor or mental health professional ⁵.

Related: Bipolar Disorder Medication: What You Need to Know

Psychotherapy

Psychotherapy, commonly referred to as talk therapy, serves as a cornerstone in the treatment of bipolar disorder ⁷. This therapeutic approach encompasses a range of techniques to identify and modify troubling emotions, thoughts, and behaviors associated with the condition ⁷. Beyond providing essential support, psychotherapy imparts education and guidance, benefiting both individuals with bipolar disorder and their families ⁷. Tailored interventions such as Cognitive Behavioral Therapy (CBT) further enhance the effectiveness of psychotherapy by addressing specific cognitive patterns and behavioral challenges ⁷.

Related: Exploring Different Types of Therapy

 Healthy Lifestyle Habits for Managing Bipolar Disorder ⁹:

• Consistent Sleeping Schedule: Maintain a regular sleep pattern by going to bed and waking up at the same time each day. Consistency in sleep is crucial, as sleep deprivation can contribute to the risk of both manic and depressive episodes. Additionally, oversleeping may signal the onset of a depressive episode. Limiting caffeine intake is essential to prevent disruptions in sleep.
• Nutritious Diet and Regular Exercise: Adopt a healthy diet to provide your body with proper nutrition, complemented by regular exercise to enhance mood. A balanced lifestyle with nutritious food and physical activity can positively impact overall well-being and improve mood.
• Taking Medication: Always take the medicines your doctor prescribes, even when you feel okay. Consistent medication adherence is vital for the long-term management of bipolar disorder, helping to stabilize mood and prevent the recurrence of manic or depressive episodes.
• Consultation with Healthcare Professionals: Seek guidance from your doctor before taking over-the-counter supplements or medications prescribed by another healthcare provider. Open communication with your healthcare team ensures that all aspects of your treatment plan are considered, minimizing the risk of adverse interactions.
• Mood Journaling: Keep a mood journal to track day-to-day emotional fluctuations, identify potential triggers, assess the effectiveness of treatment, and recognize changes in eating or sleeping patterns. This written record can be invaluable for doctors in making informed adjustments to your medication.
• Communication with Primary Care Physician: Keep your primary care physician informed about your bipolar disorder, as they play a crucial role in the long-term management of the condition. Collaborating with a primary care physician and a psychiatrist ensures comprehensive care and coordination.
• Avoidance of Alcohol and Drugs: Steer clear of alcohol and other drugs, as these substances can exacerbate the symptoms of bipolar disorder and interfere with the effectiveness of prescribed medications.
• Stress Reduction: Minimize stress by simplifying your life whenever possible. Incorporate relaxation activities such as meditation or yoga to manage stress levels effectively.
• Building a Support Network: Cultivate a strong support network of family and friends who can assist during crises. Educate your loved ones about bipolar disorder to enhance their understanding and support. Encourage them to help recognize warning signs of manic or depressive episodes, fostering a collaborative approach to managing the condition.

Other treatment options

Electroconvulsive Therapy (ECT)

If severe symptoms continue or other treatments don’t work, doctors may use ECT to manage bipolar disorder ⁷. ECT involves electrical stimulation of the brain and is particularly effective in cases requiring rapid response, such as high suicide risk or catatonia ⁷. Although often considered a last resort, ECT can provide significant relief from severe symptoms and is administered under careful medical supervision ⁷.

 Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation (TMS) is a non-invasive medical procedure involving magnetic pulses to stimulate specific brain areas. Initially approved by the Food and Drug Administration (FDA) for treating Major Depressive Disorder in adults who did not respond to antidepressant medications, TMS later received additional approval for the treatment of obsessive-compulsive disorder (OCD) ¹⁰.

Managing Depressive Symptoms With TMS Therapy

Researchers have explored the potential of TMS as a treatment for various forms of mental illness. While the available research is limited, some recent studies show that TMS may be effective, especially in managing depressive symptoms associated with bipolar disorder.

In a 2019 review of clinical trials exploring transcranial magnetic stimulation (TMS) as a treatment for bipolar disorder, researchers revealed strong evidence supporting its efficacy in reducing depressive symptoms, particularly during bipolar depressive episodes ². However, evidence for its effectiveness in addressing manic symptoms was less consistent ².

A small study from 2020 involving 44 people with bipolar disorder explored the use of TMS during depressive phases ³. The results showed that 77% of those who completed the TMS treatment exhibited a positive response, as indicated by at least a 50% improvement in depression scores on the Montgomery-Asberg Depression Rating Scale (MADRS) ³. Additionally, among those who underwent at least 25 TMS sessions, 41% achieved remission, signifying a significant reduction in depressive symptoms ³.

TMS Vs ECT

Transcranial Magnetic Stimulation offers a non-invasive alternative to Electroconvulsive Therapy (ECT) ⁷. The repetitive form of TMS (rTMS) uses magnetic waves to alleviate depression linked to bipolar disorder ⁷. Although not as potent as ECT, rTMS has advantages such as not requiring general anesthesia and having a lower risk of negative effects on memory and cognitive function ⁷. This makes rTMS a valuable option for individuals seeking alternative treatments or those concerned about potential side effects associated with other interventions ⁷.

Seek Help and Support for Bipolar Disorder

Don’t let bipolar disorder disrupt your life. Neuro Wellness Spa offers cutting-edge treatments and a supportive environment to help you lead a fulfilling life. Our expert team is ready to guide you through personalized solutions, from traditional therapies such as finding the best possible medication for you through in-person and online psychiatry to in-person and online therapy utilizing a range of effective modalities to treat and manage bipolar disorder and alternative treatments like TMS therapy which targets specific parts of the brain responsible for mood regulation.

Contact us now to take the first step towards a balanced, healthier life. Your mental well-being is our priority, and at Neuro Wellness Spa, we’re here to support you on your journey to lasting mental wellness.

References

1. American Psychiatric Association. (2021, January). What Are Bipolar Disorders? Retrieved from https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders

2. Gold, A. K., Ornelas, A. C., Cirillo, P., Caldieraro, M. A., Nardi, A. E., Nierenberg, A. A., & Kinrys, G. (2019). Clinical applications of transcranial magnetic stimulation in bipolar disorder. Brain and behavior, 9(10), e01419. https://doi.org/10.1002/brb3.1419

3. Goldwaser, E. L., Daddario, K., & Aaronson, S. T. (2020). A retrospective analysis of bipolar depression treated with transcranial magnetic stimulation. Brain and behavior, 10(12), e01805. https://doi.org/10.1002/brb3.1805

4. American Psychiatric Association. (2013). Bipolar and Related Disorders. In Diagnostic and Statistical Manual of Mental Disorders(5th ed.).

5. Mayo Clinic (2022, December 13). Bipolar disorder. https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955

6. National Health Service (2023, January 3). Symptoms – Bipolar disorder. https://www.nhs.uk/mental-health/conditions/bipolar-disorder/symptoms/

7. National Institute of Mental Health (2022). Bipolar Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder

8. Smith, A. D. (2022, August 23). Thinking Twice About Ultra-Rapid Cycling Bipolar Disorder. https://www.psychologytoday.com/us/blog/and-running/202208/thinking-twice-about-ultra-rapid-cycling-bipolar-disorder

9. Substance Abuse and Mental Health Services Administration (2023, April 24). Bipolar Disorder. https://www.samhsa.gov/mental-health/bipolar

10. U.S. Food & Drug Administration (2018, August 7). FDA permits the marketing of transcranial magnetic stimulant treatment of obsessive-compulsive disorder. https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder

11. Zhihan, G., Fengli, S., Wangqiang, L., Dong, S., & Weidong, J. (2022). Lamotrigine and Lithium Combination for Treatment of Rapid Cycling Bipolar Disorder: Results From Meta-Analysis. Frontiers in psychiatry, 13, 913051. https://doi.org/10.3389/fpsyt.2022.913051