Bipolar disorder - Wikipedia

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood ... Bipolardisorder FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Mentaldisorderthatcausesperiodsofdepressionandabnormallyelevatedmood "Manicdepression"and"Bipolardisorders"redirecthere.Forthemedicaljournal,seeBipolarDisorders(journal).Forotheruses,seeManicdepression(disambiguation). MedicalconditionBipolardisorderOthernamesBipolaraffectivedisorder(BPAD),[1]bipolarillness,manicdepression,manicdepressivedisorder,manic–depressiveillness(historical),[2]manic–depressivepsychosis,circularinsanity(historical),[2]bipolardisease[3]Bipolardisorderischaracterizedbyepisodesofdepressionandmania.SpecialtyPsychiatrySymptomsPeriodsofdepressionandelevatedmood[4][5]ComplicationsSuicide,self-harm[4]Usualonset25yearsold[4]TypesBipolarIdisorder,bipolarIIdisorder,others[5]CausesEnvironmentalandgenetic[4]RiskfactorsFamilyhistory,childhoodabuse,long-termstress[4]DifferentialdiagnosisAttentiondeficithyperactivitydisorder,personalitydisorders,schizophrenia,substanceusedisorder[4]TreatmentPsychotherapy,medications[4]MedicationLithium,antipsychotics,anticonvulsants[4]Frequency1–3%[4][6] Bipolardisorder,previouslyknownasmanicdepression,isamentaldisordercharacterizedbyperiodsofdepressionandperiodsofabnormallyelevatedmoodthatlastfromdaystoweekseach.[4][5]Iftheelevatedmoodissevereorassociatedwithpsychosis,itiscalledmania;ifitislesssevere,itiscalledhypomania.[4]Duringmania,anindividualbehavesorfeelsabnormallyenergetic,happyorirritable,[4]andtheyoftenmakeimpulsivedecisionswithlittleregardfortheconsequences.[5]Thereisusuallyalsoareducedneedforsleepduringmanicphases.[5]Duringperiodsofdepression,theindividualmayexperiencecryingandhaveanegativeoutlookonlifeandpooreyecontactwithothers.[4]Theriskofsuicideishigh;overaperiodof20years,6%ofthosewithbipolardisorderdiedbysuicide,while30–40%engagedinself-harm.[4]Othermentalhealthissues,suchasanxietydisordersandsubstanceusedisorders,arecommonlyassociatedwithbipolardisorder.[4] Whilethecausesofthismooddisorderarenotclearlyunderstood,bothgeneticandenvironmentalfactorsarethoughttoplayarole.[4]Manygenes,eachwithsmalleffects,maycontributetothedevelopmentofthedisorder.[4][7]Geneticfactorsaccountforabout70–90%oftheriskofdevelopingbipolardisorder.[8][9]Environmentalriskfactorsincludeahistoryofchildhoodabuseandlong-termstress.[4]TheconditionisclassifiedasbipolarIdisorderiftherehasbeenatleastonemanicepisode,withorwithoutdepressiveepisodes,andasbipolarIIdisorderiftherehasbeenatleastonehypomanicepisode(butnofullmanicepisodes)andonemajordepressiveepisode.[5]ItisclassifiedasCyclothymiaiftherearehypomanicepisodeswithperiodsofdepressionthatdonotmeetthecriteriaformajordepressiveepisodes.[10] Ifthesesymptomsareduetodrugsormedicalproblems,theyarenotdiagnosedasbipolardisorder.[5]Otherconditionsthathaveoverlappingsymptomswithbipolardisorderincludeattentiondeficithyperactivitydisorder,personalitydisorders,schizophrenia,andsubstanceusedisorderaswellasmanyothermedicalconditions.[4]Medicaltestingisnotrequiredforadiagnosis,thoughbloodtestsormedicalimagingcanruleoutotherproblems.[11] Moodstabilizers—lithiumandcertainanticonvulsantssuchasvalproateandcarbamazepineaswellasatypicalantipsychoticssuchasaripiprazole—arethemainstayoflong-termpharmacologicrelapseprevention.[12]Antipsychoticsareadditionallygivenduringacutemanicepisodesaswellasincaseswheremoodstabilizersarepoorlytoleratedorineffective.Inpatientswherecomplianceisofconcern,long-actinginjectableformulationsareavailable.[12]Thereissomeevidencethatpsychotherapyimprovesthecourseofthisdisorder.[13]Theuseofantidepressantsindepressiveepisodesiscontroversial:theycanbeeffectivebuthavebeenimplicatedintriggeringmanicepisodes.[14]Thetreatmentofdepressiveepisodes,therefore,isoftendifficult.[12]Electroconvulsivetherapy(ECT)iseffectiveinacutemanicanddepressiveepisodes,especiallywithpsychosisorcatatonia.[a][12]Admissiontoapsychiatrichospitalmayberequiredifapersonisarisktothemselvesorothers;involuntarytreatmentissometimesnecessaryiftheaffectedpersonrefusestreatment.[4] Bipolardisorderoccursinapproximately1%oftheglobalpopulation.[12]IntheUnitedStates,about3%areestimatedtobeaffectedatsomepointintheirlife;ratesappeartobesimilarinfemalesandmales.[6][16]Symptomsmostcommonlybeginbetweentheagesof20and25yearsold;anearlieronsetinlifeisassociatedwithaworseprognosis.[17]Interestinfunctioningintheassessmentofpatientswithbipolardisorderisgrowing,withanemphasisonspecificdomainssuchaswork,education,sociallife,family,andcognition.[18]Aroundone-quartertoone-thirdofpeoplewithbipolardisorderhavefinancial,socialorwork-relatedproblemsduetotheillness.[4]Bipolardisorderisamongthetop20causesofdisabilityworldwideandleadstosubstantialcostsforsociety.[19]Duetolifestylechoicesandthesideeffectsofmedications,theriskofdeathfromnaturalcausessuchascoronaryheartdiseaseinpeoplewithbipolardisorderistwicethatofthegeneralpopulation.[4] Contents 1Signsandsymptoms 1.1Manicepisodes 1.2Hypomanicepisodes 1.3Depressiveepisodes 1.4Mixedaffectiveepisodes 1.5Comorbidconditions 2Causes 2.1Genetic 2.2Environmental 2.3Neurological 3Proposedmechanisms 4Diagnosis 4.1Differentialdiagnosis 4.2Bipolarspectrum 4.3Criteriaandsubtypes 4.3.1Rapidcycling 4.4Coexistingpsychiatricconditions 4.5Children 4.6Elderly 5Prevention 6Management 6.1Psychosocial 6.2Medication 6.2.1Moodstabilizers 6.2.2Antipsychotics 6.2.3Antidepressants 6.2.4Combinedtreatmentapproaches 6.2.5Otherdrugs 6.3Children 6.4Resistancetotreatment 7Prognosis 7.1Functioning 7.2Recoveryandrecurrence 7.3Suicide 8Epidemiology 9History 10Societyandculture 10.1Cost 10.2Advocacy 10.3Notablecases 10.4Mediaportrayals 10.5Creativity 11Research 12Seealso 13Explanatorynotes 14Citations 15Citedtexts 16Furtherreading 17Externallinks Signsandsymptoms Bipolarmoodshifts Lateadolescenceandearlyadulthoodarepeakyearsfortheonsetofbipolardisorder.[20][21]Theconditionischaracterizedbyintermittentepisodesofmaniaand/ordepression,withanabsenceofsymptomsinbetween.[22]Duringtheseepisodes,peoplewithbipolardisorderexhibitdisruptionsinnormalmood,psychomotoractivity(thelevelofphysicalactivitythatisinfluencedbymood)—e.g.constantfidgetingduringmaniaorslowedmovementsduringdepression—circadianrhythmandcognition.Maniacanpresentwithvaryinglevelsofmooddisturbance,rangingfromeuphoria,whichisassociatedwith"classicmania",todysphoriaandirritability.[23]Psychoticsymptomssuchasdelusionsorhallucinationsmayoccurinbothmanicanddepressiveepisodes;theircontentandnatureareconsistentwiththeperson'sprevailingmood.[4] AccordingtotheDSM-5criteria,maniaisdistinguishedfromhypomaniabytheduration:hypomaniaispresentifelevatedmoodsymptomspersistforatleastfourconsecutivedays,whilemaniaispresentifsuchsymptomspersistformorethanaweek.Unlikemania,hypomaniaisnotalwaysassociatedwithimpairedfunctioning.[12]Thebiologicalmechanismsresponsibleforswitchingfromamanicorhypomanicepisodetoadepressiveepisode,orviceversa,remainpoorlyunderstood.[24] Manicepisodes An1892colorlithographdepictingawomandiagnosedwithhilariousmania Alsoknownasamanicepisode,maniaisadistinctperiodofatleastoneweekofelevatedorirritablemood,whichcanrangefromeuphoriatodelirium.Thecoresymptomofmaniainvolvesanincreaseinenergyofpsychomotoractivity.Maniacanalsopresentwithincreasedself-esteemorgrandiosity,racingthoughts,pressuredspeechthatisdifficulttointerrupt,decreasedneedforsleep,disinhibitedsocialbehavior,[23]increasedgoal-orientedactivitiesandimpairedjudgement,whichcanleadtoexhibitionofbehaviorscharacterizedasimpulsiveorhigh-risk,suchashypersexualityorexcessivespending.[25][26][27]Tofitthedefinitionofamanicepisode,thesebehaviorsmustimpairtheindividual'sabilitytosocializeorwork.[25][27]Ifuntreated,amanicepisodeusuallylaststhreetosixmonths.[28] Inseveremanicepisodes,apersoncanexperiencepsychoticsymptoms,wherethoughtcontentisaffectedalongwithmood.[27]Theymayfeelunstoppable,orasiftheyhaveaspecialrelationshipwithGod,agreatmissiontoaccomplish,orothergrandioseordelusionalideas.[29]Thismayleadtoviolentbehaviorand,sometimes,hospitalizationinaninpatientpsychiatrichospital.[26][27]TheseverityofmanicsymptomscanbemeasuredbyratingscalessuchastheYoungManiaRatingScale,thoughquestionsremainaboutthereliabilityofthesescales.[30] Theonsetofamanicordepressiveepisodeisoftenforeshadowedbysleepdisturbance.[31]Manicindividualsoftenhaveahistoryofsubstanceusedisorderdevelopedoveryearsasaformof"self-medication".[32] Hypomanicepisodes An1858lithographcaptioned'Melancholypassingintomania' Hypomaniaisthemilderformofmania,definedasatleastfourdaysofthesamecriteriaasmania,[27]butwhichdoesnotcauseasignificantdecreaseintheindividual'sabilitytosocializeorwork,lackspsychoticfeaturessuchasdelusionsorhallucinations,anddoesnotrequirepsychiatrichospitalization.[25]Overallfunctioningmayactuallyincreaseduringepisodesofhypomaniaandisthoughttoserveasadefensemechanismagainstdepressionbysome.[33]Hypomanicepisodesrarelyprogresstofull-blownmanicepisodes.[33]Somepeoplewhoexperiencehypomaniashowincreasedcreativity,[27][34]whileothersareirritableordemonstratepoorjudgment.[9] Hypomaniamayfeelgoodtosomeindividualswhoexperienceit,thoughmostpeoplewhoexperiencehypomaniastatethatthestressoftheexperienceisverypainful.[27]Peoplewithbipolardisorderwhoexperiencehypomaniatendtoforgettheeffectsoftheiractionsonthosearoundthem.Evenwhenfamilyandfriendsrecognizemoodswings,theindividualwilloftendenythatanythingiswrong.[35]Ifnotaccompaniedbydepressiveepisodes,hypomanicepisodesareoftennotdeemedproblematicunlessthemoodchangesareuncontrollableorvolatile.[33]Mostcommonly,symptomscontinuefortimeperiodsfromafewweekstoafewmonths.[36] Depressiveepisodes Mainarticle:Majordepressivedisorder 'Melancholy'byWilliamBagg,afteraphotographbyHughWelchDiamond Symptomsofthedepressivephaseofbipolardisorderincludepersistentfeelingsofsadness,irritabilityoranger,lossofinterestinpreviouslyenjoyedactivities,excessiveorinappropriateguilt,hopelessness,sleepingtoomuchornotenough,changesinappetiteand/orweight,fatigue,problemsconcentrating,self-loathingorfeelingsofworthlessness,andthoughtsofdeathorsuicide.[37]AlthoughtheDSM-5criteriafordiagnosingunipolarandbipolarepisodesarethesame,someclinicalfeaturesaremorecommoninthelatter,includingincreasedsleep,suddenonsetandresolutionofsymptoms,significantweightgainorloss,andsevereepisodesafterchildbirth.[12] Theearliertheageofonset,themorelikelythefirstfewepisodesaretobedepressive.[38]Formostpeoplewithbipolartypes1and2,thedepressiveepisodesaremuchlongerthanthemanicorhypomanicepisodes.[17]Sinceadiagnosisofbipolardisorderrequiresamanicorhypomanicepisode,manyaffectedindividualsareinitiallymisdiagnosedashavingmajordepressionandincorrectlytreatedwithprescribedantidepressants.[39] Mixedaffectiveepisodes Mainarticle:Mixedaffectivestate Inbipolardisorder,amixedstateisanepisodeduringwhichsymptomsofbothmaniaanddepressionoccursimultaneously.[40]Individualsexperiencingamixedstatemayhavemanicsymptomssuchasgrandiosethoughtswhilesimultaneouslyexperiencingdepressivesymptomssuchasexcessiveguiltorfeelingsuicidal.[40]Theyareconsideredtohaveahigherriskforsuicidalbehaviorasdepressiveemotionssuchashopelessnessareoftenpairedwithmoodswingsordifficultieswithimpulsecontrol.[40]Anxietydisordersoccurmorefrequentlyasacomorbidityinmixedbipolarepisodesthaninnon-mixedbipolardepressionormania.[40]Substance(includingalcohol)usealsofollowsthistrend,therebyappearingtodepictbipolarsymptomsasnomorethanaconsequenceofsubstanceuse.[40] Comorbidconditions Peoplewithbipolardisorderoftenhaveotherco-existingpsychiatricconditionssuchasanxiety(presentinabout71%ofpeoplewithbipolardisorder),substanceuse(56%),personalitydisorders(36%)andattentiondeficithyperactivitydisorder(10–20%)whichcanaddtotheburdenofillnessandworsentheprognosis.[17]Certainmedicalconditionsarealsomorecommoninpeoplewithbipolardisorderascomparedtothegeneralpopulation.Thisincludesincreasedratesofmetabolicsyndrome(presentin37%ofpeoplewithbipolardisorder),migraineheadaches(35%),obesity(21%)andtype2diabetes(14%).[17]Thiscontributestoariskofdeaththatistwotimeshigherinthosewithbipolardisorderascomparedtothegeneralpopulation.[17] Substanceusedisorderisacommoncomorbidityinbipolardisorder;thesubjecthasbeenwidelyreviewed.[41][needsupdate][42] Causes Thecausesofbipolardisorderlikelyvarybetweenindividualsandtheexactmechanismunderlyingthedisorderremainsunclear.[43]Geneticinfluencesarebelievedtoaccountfor73–93%oftheriskofdevelopingthedisorderindicatingastronghereditarycomponent.[9]Theoverallheritabilityofthebipolarspectrumhasbeenestimatedat0.71.[44]Twinstudieshavebeenlimitedbyrelativelysmallsamplesizesbuthaveindicatedasubstantialgeneticcontribution,aswellasenvironmentalinfluence.ForbipolarIdisorder,therateatwhichidenticaltwins(samegenes)willbothhavebipolarIdisorder(concordance)isaround40%,comparedtoabout5%infraternaltwins.[25][45]AcombinationofbipolarI,II,andcyclothymiasimilarlyproducedratesof42%and11%(identicalandfraternaltwins,respectively).[44]TheratesofbipolarIIcombinationswithoutbipolarIarelower—bipolarIIat23and17%,andbipolarIIcombiningwithcyclothymiaat33and14%—whichmayreflectrelativelyhighergeneticheterogeneity.[44] Thecauseofbipolardisordersoverlapswithmajordepressivedisorder.Whendefiningconcordanceastheco-twinshavingeitherbipolardisorderormajordepression,thentheconcordanceraterisesto67%inidenticaltwinsand19%infraternaltwins.[46]Therelativelylowconcordancebetweenfraternaltwinsbroughtuptogethersuggeststhatsharedfamilyenvironmentaleffectsarelimited,althoughtheabilitytodetectthemhasbeenlimitedbysmallsamplesizes.[44] Genetic Behavioralgeneticstudieshavesuggestedthatmanychromosomalregionsandcandidategenesarerelatedtobipolardisordersusceptibilitywitheachgeneexertingamildtomoderateeffect.[47]Theriskofbipolardisorderisnearlyten-foldhigherinfirst-degreerelativesofthosewithbipolardisorderthaninthegeneralpopulation;similarly,theriskofmajordepressivedisorderisthreetimeshigherinrelativesofthosewithbipolardisorderthaninthegeneralpopulation.[25] Althoughthefirstgeneticlinkagefindingformaniawasin1969,[48]linkagestudieshavebeeninconsistent.[25]Findingspointstronglytoheterogeneity,withdifferentgenesimplicatedindifferentfamilies.[49]Robustandreplicablegenome-widesignificantassociationsshowedseveralcommonsingle-nucleotidepolymorphisms(SNPs)areassociatedwithbipolardisorder,includingvariantswithinthegenesCACNA1C,ODZ4,andNCAN.[47][50]Thelargestandmostrecentgenome-wideassociationstudyfailedtofindanylocusthatexertsalargeeffect,reinforcingtheideathatnosinglegeneisresponsibleforbipolardisorderinmostcases.[50]PolymorphismsinBDNF,DRD4,DAO,andTPH1havebeenfrequentlyassociatedwithbipolardisorderandwereinitiallyassociatedinameta-analysis,butthisassociationdisappearedaftercorrectionformultipletesting.[51]Ontheotherhand,twopolymorphismsinTPH2wereidentifiedasbeingassociatedwithbipolardisorder.[52] Duetotheinconsistentfindingsinagenome-wideassociationstudy,multiplestudieshaveundertakentheapproachofanalyzingSNPsinbiologicalpathways.Signalingpathwaystraditionallyassociatedwithbipolardisorderthathavebeensupportedbythesestudiesincludecorticotropin-releasinghormonesignaling,cardiacβ-adrenergicsignaling,PhospholipaseCsignaling,glutamatereceptorsignaling,[53]cardiachypertrophysignaling,Wntsignaling,Notchsignaling,[54]andendothelin1signaling.Ofthe16genesidentifiedinthesepathways,threewerefoundtobedysregulatedinthedorsolateralprefrontalcortexportionofthebraininpost-mortemstudies:CACNA1C,GNG2,andITPR2.[55] BipolardisorderisassociatedwithreducedexpressionofspecificDNArepairenzymesandincreasedlevelsofoxidativeDNAdamages.[56] Environmental Psychosocialfactorsplayasignificantroleinthedevelopmentandcourseofbipolardisorder,andindividualpsychosocialvariablesmayinteractwithgeneticdispositions.[57]Recentlifeeventsandinterpersonalrelationshipslikelycontributetotheonsetandrecurrenceofbipolarmoodepisodes,justastheydoforunipolardepression.[58]Insurveys,30–50%ofadultsdiagnosedwithbipolardisorderreporttraumatic/abusiveexperiencesinchildhood,whichisassociatedwithearlieronset,ahigherrateofsuicideattempts,andmoreco-occurringdisorderssuchaspost-traumaticstressdisorder.[59]Thenumberofreportedstressfuleventsinchildhoodishigherinthosewithanadultdiagnosisofbipolarspectrumdisorderthaninthosewithout,particularlyeventsstemmingfromaharshenvironmentratherthanfromthechild'sownbehavior.[60]Acutely,maniacanbeinducedbysleepdeprivationinaround30%ofpeoplewithbipolardisorder.[61] Neurological Lesscommonly,bipolardisorderorabipolar-likedisordermayoccurasaresultoforinassociationwithaneurologicalconditionorinjuryincludingstroke,traumaticbraininjury,HIVinfection,multiplesclerosis,porphyria,andrarelytemporallobeepilepsy.[62] Proposedmechanisms Furtherinformation:Biologyofbipolardisorder Brainimagingstudieshaverevealeddifferencesinthevolumeofvariousbrainregionsbetweenpatientswithbipolardisorderandhealthycontrolsubjects. Theprecisemechanismsthatcausebipolardisorderarenotwellunderstood.Bipolardisorderisthoughttobeassociatedwithabnormalitiesinthestructureandfunctionofcertainbrainareasresponsibleforcognitivetasksandtheprocessingofemotions.[22]Aneurologicmodelforbipolardisorderproposesthattheemotionalcircuitryofthebraincanbedividedintotwomainparts.[22]Theventralsystem(regulatesemotionalperception)includesbrainstructuressuchastheamygdala,insula,ventralstriatum,ventralanteriorcingulatecortex,andtheprefrontalcortex.[22]Thedorsalsystem(responsibleforemotionalregulation)includesthehippocampus,dorsalanteriorcingulatecortex,andotherpartsoftheprefrontalcortex.[22]Themodelhypothesizesthatbipolardisordermayoccurwhentheventralsystemisoveractivatedandthedorsalsystemisunderactivated.[22]Othermodelssuggesttheabilitytoregulateemotionsisdisruptedinpeoplewithbipolardisorderandthatdysfunctionoftheventricularprefrontalcortex(vPFC)iscrucialtothisdisruption.[22] Meta-analysesofstructuralMRIstudieshaveshownthatcertainbrainregions(e.g.,theleftrostralanteriorcingulatecortex,fronto-insularcortex,ventralprefrontalcortex,andclaustrum)aresmallerinpeoplewithbipolardisorder,whereasotherregionsarelarger(lateralventricles,globuspallidus,subgenualanteriorcingulate,andtheamygdala).Additionally,thesemeta-analysesfoundthatpeoplewithbipolardisorderhavehigherratesofdeepwhitematterhyperintensities.[63][64][65][66] FunctionalMRIfindingssuggestthatthevPFCregulatesthelimbicsystem,especiallytheamygdala.[67]Inpeoplewithbipolardisorder,decreasedvPFCactivityallowsforthedysregulatedactivityoftheamygdala,whichlikelycontributestolabilemoodandpooremotionalregulation.[67]Consistentwiththis,pharmacologicaltreatmentofmaniareturnsvPFCactivitytothelevelsinnon-manicpeople,suggestingthatvPFCactivityisanindicatorofmoodstate.However,whilepharmacologicaltreatmentofmaniareducesamygdalahyperactivity,itremainsmoreactivethantheamygdalaofthosewithoutbipolardisorder,suggestingamygdalaactivitymaybeamarkerofthedisorderratherthanthecurrentmoodstate.[68]ManicanddepressiveepisodestendtobecharacterizedbydysfunctionindifferentregionsofthevPFC.ManicepisodesappeartobeassociatedwithdecreasedactivationoftherightvPFCwhereasdepressiveepisodesareassociatedwithdecreasedactivationoftheleftvPFC.[67]Thesedisruptionsoftenoccurduringdevelopmentlinkedwithsynapticpruningdysfunction.[69] Peoplewithbipolardisorderwhoareinaeuthymicmoodstateshowdecreasedactivityinthelingualgyruscomparedtopeoplewithoutbipolardisorder.[22]Incontrast,theydemonstratedecreasedactivityintheinferiorfrontalcortexduringmanicepisodescomparedtopeoplewithoutthedisorder.[22]Similarstudiesexaminingthedifferencesinbrainactivitybetweenpeoplewithbipolardisorderandthosewithoutdidnotfindaconsistentareainthebrainthatwasmoreorlessactivewhencomparingthesetwogroups.[22]Peoplewithbipolarhaveincreasedactivationoflefthemisphereventrallimbicareas—whichmediateemotionalexperiencesandgenerationofemotionalresponses—anddecreasedactivationofrighthemispherecorticalstructuresrelatedtocognition—structuresassociatedwiththeregulationofemotions.[70] Neuroscientistshaveproposedadditionalmodelstotrytoexplainthecauseofbipolardisorder.Oneproposedmodelforbipolardisordersuggeststhathypersensitivityofrewardcircuitsconsistingoffrontostriatalcircuitscausesmania,anddecreasedsensitivityofthesecircuitscausesdepression.[71]Accordingtothe"kindling"hypothesis,whenpeoplewhoaregeneticallypredisposedtowardbipolardisorderexperiencestressfulevents,thestressthresholdatwhichmoodchangesoccurbecomesprogressivelylower,untiltheepisodeseventuallystart(andrecur)spontaneously.Thereisevidencesupportinganassociationbetweenearly-lifestressanddysfunctionofthehypothalamic-pituitary-adrenalaxisleadingtoitsoveractivation,whichmayplayaroleinthepathogenesisofbipolardisorder.[72][73]Otherbraincomponentsthathavebeenproposedtoplayaroleinbipolardisorderarethemitochondria[43]andasodiumATPasepump.[74]Circadianrhythmsandregulationofthehormonemelatoninalsoseemtobealtered.[75] Dopamine,aneurotransmitterresponsibleformoodcycling,hasincreasedtransmissionduringthemanicphase.[24][76]Thedopaminehypothesisstatesthattheincreaseindopamineresultsinsecondaryhomeostaticdownregulationofkeysystemelementsandreceptorssuchaslowersensitivityofdopaminergicreceptors.Thisresultsindecreaseddopaminetransmissioncharacteristicofthedepressivephase.[24]Thedepressivephaseendswithhomeostaticupregulationpotentiallyrestartingthecycleoveragain.[77]Glutamateissignificantlyincreasedwithintheleftdorsolateralprefrontalcortexduringthemanicphaseofbipolardisorder,andreturnstonormallevelsoncethephaseisover.[78] Medicationsusedtotreatbipolarmayexerttheireffectbymodulatingintracellularsignaling,suchasthroughdepletingmyo-inositollevels,inhibitionofcAMPsignaling,andthroughalteringsubunitsofthedopamine-associatedG-protein.[79]Consistentwiththis,elevatedlevelsofGαi,Gαs,andGαq/11havebeenreportedinbrainandbloodsamples,alongwithincreasedproteinkinaseA(PKA)expressionandsensitivity;[80]typically,PKAactivatesaspartoftheintracellularsignallingcascadedownstreamfromthedetachmentofGαssubunitfromtheGproteincomplex. Decreasedlevelsof5-hydroxyindoleaceticacid,abyproductofserotonin,arepresentinthecerebrospinalfluidofpersonswithbipolardisorderduringboththedepressedandmanicphases.Increaseddopaminergicactivityhasbeenhypothesizedinmanicstatesduetotheabilityofdopamineagoniststostimulatemaniainpeoplewithbipolardisorder.Decreasedsensitivityofregulatoryα2adrenergicreceptorsaswellasincreasedcellcountsinthelocuscoeruleusindicatedincreasednoradrenergicactivityinmanicpeople.LowplasmaGABAlevelsonbothsidesofthemoodspectrumhavebeenfound.[81]Onereviewfoundnodifferenceinmonoaminelevels,butfoundabnormalnorepinephrineturnoverinpeoplewithbipolardisorder.[82]Tyrosinedepletionwasfoundtoreducetheeffectsofmethamphetamineinpeoplewithbipolardisorderaswellassymptomsofmania,implicatingdopamineinmania.VMAT2bindingwasfoundtobeincreasedinonestudyofpeoplewithbipolarmania.[83] Diagnosis Bipolardisorderiscommonlydiagnosedduringadolescenceorearlyadulthood,butonsetcanoccurthroughoutlife.[5][84]Itsdiagnosisisbasedontheself-reportedexperiencesoftheindividual,abnormalbehaviorreportedbyfamilymembers,friendsorco-workers,observablesignsofillnessasassessedbyaclinician,andideallyamedicalwork-uptoruleoutothercauses.Caregiver-scoredratingscales,specificallyfromthemother,haveshowntobemoreaccuratethanteacherandyouth-scoredreportsinidentifyingyouthswithbipolardisorder.[85]Assessmentisusuallydoneonanoutpatientbasis;admissiontoaninpatientfacilityisconsideredifthereisarisktooneselforothers. ThemostwidelyusedcriteriafordiagnosingbipolardisorderarefromtheAmericanPsychiatricAssociation's(APA)DiagnosticandStatisticalManualofMentalDisorders,FifthEdition(DSM-5)andtheWorldHealthOrganization's(WHO)InternationalStatisticalClassificationofDiseasesandRelatedHealthProblems,10thEdition(ICD-10).TheICD-10criteriaareusedmoreofteninclinicalsettingsoutsideoftheU.S.whiletheDSMcriteriaareusedwithintheU.S.andaretheprevailingcriteriausedinternationallyinresearchstudies.TheDSM-5,publishedin2013,includesfurtherandmoreaccuratespecifierscomparedtoitspredecessor,theDSM-IV-TR.[86]ThisworkhasinfluencedtheupcomingeleventhrevisionoftheICD,whichincludesthevariousdiagnoseswithinthebipolarspectrumoftheDSM-V.[87] Severalratingscalesforthescreeningandevaluationofbipolardisorderexist,[88]includingtheBipolarspectrumdiagnosticscale,MoodDisorderQuestionnaire,theGeneralBehaviorInventoryandtheHypomaniaChecklist.[89]Theuseofevaluationscalescannotsubstituteafullclinicalinterviewbuttheyservetosystematizetherecollectionofsymptoms.[89]Ontheotherhand,instrumentsforscreeningbipolardisordertendtohavelowersensitivity.[88] Differentialdiagnosis BipolardisorderisclassifiedbytheInternationalClassificationofDiseasesasamentalandbehaviouraldisorder.[90]Mentaldisordersthatcanhavesymptomssimilartothoseseeninbipolardisorderincludeschizophrenia,majordepressivedisorder,[91]attentiondeficithyperactivitydisorder(ADHD),andcertainpersonalitydisorders,suchasborderlinepersonalitydisorder.[92][93][94]Akeydifferencebetweenbipolardisorderandborderlinepersonalitydisorderisthenatureofthemoodswings;incontrasttothesustainedchangestomoodoverdaystoweeksorlonger,thoseofthelattercondition(moreaccuratelycalledemotionaldysregulation)aresuddenandoftenshort-lived,andsecondarytosocialstressors.[95] Althoughtherearenobiologicalteststhatarediagnosticofbipolardisorder,[50]bloodtestsand/orimagingarecarriedouttoinvestigatewhethermedicalillnesseswithclinicalpresentationssimilartothatofbipolardisorderarepresentbeforemakingadefinitivediagnosis.Neurologicdiseasessuchasmultiplesclerosis,complexpartialseizures,strokes,braintumors,Wilson'sdisease,traumaticbraininjury,Huntington'sdisease,andcomplexmigrainescanmimicfeaturesofbipolardisorder.[84]AnEEGmaybeusedtoexcludeneurologicaldisorderssuchasepilepsy,andaCTscanorMRIoftheheadmaybeusedtoexcludebrainlesions.[84]Additionally,disordersoftheendocrinesystemsuchashypothyroidism,hyperthyroidism,andCushing'sdiseaseareinthedifferentialasistheconnectivetissuediseasesystemiclupuserythematosus.Infectiouscausesofmaniathatmayappearsimilartobipolarmaniaincludeherpesencephalitis,HIV,influenza,orneurosyphilis.[84]Certainvitamindeficienciessuchaspellagra(niacindeficiency),VitaminB12deficiency,folatedeficiency,andWernickeKorsakoffsyndrome(thiaminedeficiency)canalsoleadtomania.[84]Commonmedicationsthatcancausemanicsymptomsincludeantidepressants,prednisone,Parkinson'sdiseasemedications,thyroidhormone,stimulants(includingcocaineandmethamphetamine),andcertainantibiotics.[96] Bipolarspectrum SinceEmilKraepelin'sdistinctionbetweenbipolardisorderandschizophreniainthe19thcentury,researchershavedefinedaspectrumofdifferenttypesofbipolardisorder. Bipolarspectrumdisordersinclude:bipolarIdisorder,bipolarIIdisorder,cyclothymicdisorderandcaseswheresubthresholdsymptomsarefoundtocauseclinicallysignificantimpairmentordistress.[5][84][87]Thesedisordersinvolvemajordepressiveepisodesthatalternatewithmanicorhypomanicepisodes,orwithmixedepisodesthatfeaturesymptomsofbothmoodstates.[5]TheconceptofthebipolarspectrumissimilartothatofEmilKraepelin'soriginalconceptofmanicdepressiveillness.[97]BipolarIIdisorderwasestablishedasadiagnosisin1994withinDSMIV;thoughdebatecontinuesoverwhetheritisadistinctentity,partofaspectrum,orexistsatall.[98] Criteriaandsubtypes SimplifiedgraphicalcomparisonofbipolarI,bipolarIIandcyclothymia[99][100]: 267  TheDSMandtheICDcharacterizebipolardisorderasaspectrumofdisordersoccurringonacontinuum.TheDSM-5andICD-11liststhreespecificsubtypes:[5][87] BipolarIdisorder:Atleastonemanicepisodeisnecessarytomakethediagnosis;[101]depressiveepisodesarecommoninthevastmajorityofcaseswithbipolardisorderI,butareunnecessaryforthediagnosis.[25]Specifierssuchas"mild,moderate,moderate-severe,severe"and"withpsychoticfeatures"shouldbeaddedasapplicabletoindicatethepresentationandcourseofthedisorder.[5] BipolarIIdisorder:Nomanicepisodesandoneormorehypomanicepisodesandoneormoremajordepressiveepisodes.[101]Hypomanicepisodesdonotgotothefullextremesofmania(i.e.,donotusuallycauseseveresocialoroccupationalimpairment,andarewithoutpsychosis),andthiscanmakebipolarIImoredifficulttodiagnose,sincethehypomanicepisodesmaysimplyappearasperiodsofsuccessfulhighproductivityandarereportedlessfrequentlythanadistressing,cripplingdepression. Cyclothymia:Ahistoryofhypomanicepisodeswithperiodsofdepressionthatdonotmeetcriteriaformajordepressiveepisodes.[10] Whenrelevant,specifiersforperipartumonsetandwithrapidcyclingshouldbeusedwithanysubtype.Individualswhohavesubthresholdsymptomsthatcauseclinicallysignificantdistressorimpairment,butdonotmeetfullcriteriaforoneofthethreesubtypesmaybediagnosedwithotherspecifiedorunspecifiedbipolardisorder.Otherspecifiedbipolardisorderisusedwhenaclinicianchoosestoexplainwhythefullcriteriawerenotmet(e.g.,hypomaniawithoutapriormajordepressiveepisode).[5]Iftheconditionisthoughttohaveanon-psychiatricmedicalcause,thediagnosisofbipolarandrelateddisorderduetoanothermedicalconditionismade,whilesubstance/medication-inducedbipolarandrelateddisorderisusedifamedicationisthoughttohavetriggeredthecondition.[102] Rapidcycling Mostpeoplewhomeetcriteriaforbipolardisorderexperienceanumberofepisodes,onaverage0.4to0.7peryear,lastingthreetosixmonths.[103]Rapidcycling,however,isacoursespecifierthatmaybeappliedtoanybipolarsubtype.Itisdefinedashavingfourormoremooddisturbanceepisodeswithinaone-yearspan.Rapidcyclingisusuallytemporarybutiscommonamongstpeoplewithbipolardisorderandaffectsbetween25.8and45.3%ofthematsomepointintheirlife.[37][104]Theseepisodesareseparatedfromeachotherbyaremission(partialorfull)foratleasttwomonthsoraswitchinmoodpolarity(i.e.,fromadepressiveepisodetoamanicepisodeorviceversa).[25]Thedefinitionofrapidcyclingmostfrequentlycitedintheliterature(includingtheDSM-VandICD-11)isthatofDunnerandFieve:atleastfourmajordepressive,manic,hypomanicormixedepisodesduringa12-monthperiod.[105]Theliteratureexaminingthepharmacologicaltreatmentofrapidcyclingissparseandthereisnoclearconsensuswithrespecttoitsoptimalpharmacologicalmanagement.[106]Peoplewiththerapidcyclingorultradiansubtypesofbipolardisordertendtobemoredifficulttotreatandlessresponsivetomedicationsthanotherpeoplewithbipolardisorder.[107] Coexistingpsychiatricconditions Thediagnosisofbipolardisordercanbecomplicatedbycoexisting(comorbid)psychiatricconditionsincludingobsessive–compulsivedisorder,substance-usedisorder,eatingdisorders,attentiondeficithyperactivitydisorder,socialphobia,premenstrualsyndrome(includingpremenstrualdysphoricdisorder),orpanicdisorder.[32][37][47][108]Athoroughlongitudinalanalysisofsymptomsandepisodes,assistedifpossiblebydiscussionswithfriendsandfamilymembers,iscrucialtoestablishingatreatmentplanwherethesecomorbiditiesexist.[109]Childrenofparentswithbipolardisordermorefrequentlyhaveothermentalhealthproblems.[needsupdate][110] Children Mainarticle:Bipolardisorderinchildren LithiumistheonlymedicationapprovedbytheFDAfortreatingmaniainchildren. Inthe1920s,Kraepelinnotedthatmanicepisodesarerarebeforepuberty.[111]Ingeneral,bipolardisorderinchildrenwasnotrecognizedinthefirsthalfofthetwentiethcentury.ThisissuediminishedwithanincreasedfollowingoftheDSMcriteriainthelastpartofthetwentiethcentury.[111][112]Thediagnosisofchildhoodbipolardisorder,whileformerlycontroversial,[113]hasgainedgreateracceptanceamongchildhoodandadolescentpsychiatrists.[114]Americanchildrenandadolescentsdiagnosedwithbipolardisorderincommunityhospitalsincreased4-foldreachingratesofupto40%in10yearsaroundthebeginningofthe21stcentury,whileinoutpatientclinicsitdoubledreaching6%.[113]StudiesusingDSMcriteriashowthatupto1%ofyouthmayhavebipolardisorder.[111]TheDSM-5hasestablishedadiagnosis—disruptivemooddysregulationdisorder—thatcoverschildrenwithlong-term,persistentirritabilitythathadattimesbeenmisdiagnosedashavingbipolardisorder,[115]distinctfromirritabilityinbipolardisorderthatisrestrictedtodiscretemoodepisodes.[114] Elderly Bipolardisorderisuncommoninolderpatients,withameasuredlifetimeprevalenceof1%inover60sanda12-monthprevalenceof0.1to0.5%inpeopleover65.Despitethis,itisoverrepresentedinpsychiatricadmissions,makingup4to8%ofinpatientadmissiontoagedcarepsychiatryunits,andtheincidenceofmooddisordersisincreasingoverallwiththeagingpopulation.Depressiveepisodesmorecommonlypresentwithsleepdisturbance,fatigue,hopelessnessaboutthefuture,slowedthinking,andpoorconcentrationandmemory;thelastthreesymptomsareseeninwhatisknownaspseudodementia.Clinicalfeaturesalsodifferbetweenthosewithlate-onsetbipolardisorderandthosewhodevelopeditearlyinlife;theformergrouppresentwithmildermanicepisodes,moreprominentcognitivechangesandhaveabackgroundofworsepsychosocialfunctioning,whilethelatterpresentmorecommonlywithmixedaffectiveepisodes,[116]andhaveastrongerfamilyhistoryofillness.[117]Olderpeoplewithbipolardisorderexperiencecognitivechanges,particularlyinexecutivefunctionssuchasabstractthinkingandswitchingcognitivesets,aswellasconcentratingforlongperiodsanddecision-making.[116] Prevention Attemptsatpreventionofbipolardisorderhavefocusedonstress(suchaschildhoodadversityorhighlyconflictualfamilies)which,althoughnotadiagnosticallyspecificcausalagentforbipolar,doesplacegeneticallyandbiologicallyvulnerableindividualsatriskforamoreseverecourseofillness.[118]Longitudinalstudieshaveindicatedthatfull-blownmanicstagesareoftenprecededbyavarietyofprodromalclinicalfeatures,providingsupportfortheoccurrenceofanat-riskstateofthedisorderwhenanearlyinterventionmightpreventitsfurtherdevelopmentand/orimproveitsoutcome.[119][120] Management Mainarticle:Treatmentofbipolardisorder Theaimofmanagementistotreatacuteepisodessafelywithmedicationandworkwiththepatientinlong-termmaintenancetopreventfurtherepisodesandoptimisefunctionusingacombinationofpharmacologicalandpsychotherapeutictechniques.[12]HospitalizationmayberequiredespeciallywiththemanicepisodespresentinbipolarI.Thiscanbevoluntaryor(locallegislationpermitting)involuntary.Long-terminpatientstaysarenowlesscommonduetodeinstitutionalization,althoughthesecanstilloccur.[121]Following(orinlieuof)ahospitaladmission,supportservicesavailablecanincludedrop-incenters,visitsfrommembersofacommunitymentalhealthteamoranAssertiveCommunityTreatmentteam,supportedemployment,patient-ledsupportgroups,andintensiveoutpatientprograms.Thesearesometimesreferredtoaspartial-inpatientprograms.[122] Psychosocial Psychotherapyaimstoassistapersonwithbipolardisorderinacceptingandunderstandingtheirdiagnosis,copingwithvarioustypesofstress,improvingtheirinterpersonalrelationships,andrecognizingprodromalsymptomsbeforefull-blownrecurrence.[9]Cognitivebehavioraltherapy,family-focusedtherapy,andpsychoeducationhavethemostevidenceforefficacyinregardtorelapseprevention,whileinterpersonalandsocialrhythmtherapyandcognitive-behavioraltherapyappearthemosteffectiveinregardtoresidualdepressivesymptoms.MoststudieshavebeenbasedonlyonbipolarI,however,andtreatmentduringtheacutephasecanbeaparticularchallenge.[123]Somecliniciansemphasizetheneedtotalkwithindividualsexperiencingmania,todevelopatherapeuticallianceinsupportofrecovery.[124] Medication Lithiumisoftenusedtotreatbipolardisorderandhasthebestevidenceforreducingsuicide. Medicationsareoftenprescribedtohelpimprovesymptomsofbipolardisorder.Medicationsapprovedfortreatingbipolardisorderincludingmoodstabilizers,antipsychotics,andantidepressants.Sometimesacombinationofmedicationsmayalsobesuggested.[12]Thechoiceofmedicationsmaydifferdependingonthebipolardisorderepisodetypeorifthepersonisexperiencingunipolarorbipolardepression.[12][125]Otherfactorstoconsiderwhendecidingonanappropriatetreatmentapproachincludesifthepersonhasanycomorbidities,theirresponsetoprevioustherapies,adverseeffects,andthedesireofthepersontobetreated.[12] Moodstabilizers Lithiumandtheanticonvulsantscarbamazepine,lamotrigine,andvalproicacidareclassedasmoodstabilizersduetotheireffectonthemoodstatesinbipolardisorder.[107]Lithiumhasthebestoverallevidenceandisconsideredaneffectivetreatmentforacutemanicepisodes,preventingrelapses,andbipolardepression.[126][127]Lithiumreducestheriskofsuicide,self-harm,anddeathinpeoplewithbipolardisorder.[128]Lithiumispreferredforlong-termmoodstabilization.[58]Lithiumtreatmentisalsoassociatedwithadverseeffectsandithasbeenshowntoerodekidneyandthyroidfunctionoverextendedperiods.[12]Valproatehasbecomeacommonlyprescribedtreatmentandeffectivelytreatsmanicepisodes.[129]Carbamazepineislesseffectiveinpreventingrelapsethanlithiumorvalproate.[130][131]Lamotriginehassomeefficacyintreatingdepression,andthisbenefitisgreatestinmoreseveredepression.[132]Ithasalsobeenshowntohavesomebenefitinpreventingbipolardisorderrelapses,thoughthereareconcernsaboutthestudiesdone,andisofnobenefitinrapidcyclingsubtypeofbipolardisorder.[133]Valproateandcarbamazepineareteratogenicandshouldbeavoidedasatreatmentinwomenofchildbearingage,butdiscontinuationofthesemedicationsduringpregnancyisassociatedwithahighriskofrelapse.[17]Theeffectivenessoftopiramateisunknown.[134]Carbamazepineeffectivelytreatsmanicepisodes,withsomeevidenceithasgreaterbenefitinrapid-cyclingbipolardisorder,orthosewithmorepsychoticsymptomsormoresymptomssimilartothatofschizoaffectivedisorder. Moodstabilizersareusedforlong-termmaintenancebuthavenotdemonstratedtheabilitytoquicklytreatacutebipolardepression.[107] Antipsychotics Antipsychoticmedicationsareeffectiveforshort-termtreatmentofbipolarmanicepisodesandappeartobesuperiortolithiumandanticonvulsantsforthispurpose.[58]Atypicalantipsychoticsarealsoindicatedforbipolardepressionrefractorytotreatmentwithmoodstabilizers.[107]Olanzapineiseffectiveinpreventingrelapses,althoughthesupportingevidenceisweakerthantheevidenceforlithium.[135]A2006reviewfoundthathaloperidolwasaneffectivetreatmentforacutemania,limiteddatasupportednodifferenceinoverallefficacybetweenhaloperidol,olanzapineorrisperidone,andthatitcouldbelesseffectivethanaripiprazole.[136] Antidepressants Antidepressantsarenotrecommendedforusealoneinthetreatmentofbipolardisorderanddonotprovideanybenefitovermoodstabilizers.[12][137]Atypicalantipsychoticmedications(e.g.,aripiprazole)arepreferredoverantidepressantstoaugmenttheeffectsofmoodstabilizersduetothelackofefficacyofantidepressantsinbipolardisorder.[107]Treatmentofbipolardisorderusingantidepressantscarriesariskofaffectiveswitches;whereapersonswitchesfromdepressiontomanicorhypomanicphases.[17]TheriskofaffectiveswitchesishigherinbipolarIdepression;antidepressantsaregenerallyavoidedinbipolarIdisorderoronlyusedwithmoodstabilizerswhentheyaredeemednecessary.[17]Thereisalsoariskofacceleratingcyclingbetweenphaseswhenantidepressantsareusedinbipolardisorder.[17] Combinedtreatmentapproaches Antipsychoticsandmoodstabilizersusedtogetherarequickerandmoreeffectiveattreatingmaniathaneitherclassofdrugusedalone.Someanalysesindicateantipsychoticsalonearealsomoreeffectiveattreatingacutemania.[12]Afirst-linetreatmentfordepressioninbipolardisorderisacombinationofolanzapineandfluoxetine.[125] Otherdrugs Shortcoursesofbenzodiazepinesareusedinadditiontoothermedicationsforcalmingeffectuntilmoodstabilizingbecomeeffective.[138]Electroconvulsivetherapy(ECT)isaneffectiveformoftreatmentforacutemooddisturbancesinthosewithbipolardisorder,especiallywhenpsychoticorcatatonicfeaturesaredisplayed.ECTisalsorecommendedforuseinpregnantwomenwithbipolardisorder.[12]Itisunclearifketamine(acommongeneraldissociativeanestheticusedinsurgery)isusefulinbipolardisorder.[125] Children Treatingbipolardisorderinchildreninvolvesmedicationandpsychotherapy.[113]Theliteratureandresearchontheeffectsofpsychosocialtherapyonbipolarspectrumdisordersarescarce,makingitdifficulttodeterminetheefficacyofvarioustherapies.[139]Moodstabilizersandatypicalantipsychoticsarecommonlyprescribed.[113]Amongtheformer,lithiumistheonlycompoundapprovedbytheFDAforchildren.[111]Psychologicaltreatmentcombinesnormallyeducationonthedisease,grouptherapy,andcognitivebehavioraltherapy.[113]Long-termmedicationisoftenneeded.[113] Resistancetotreatment Theoccurrenceofpoorresponsetotreatmentinhasgivensupporttotheconceptofresistancetotreatmentinbipolardisorder.[140][141]Guidelinestothedefinitionofsuchtreatmentresistanceandevidence-basedoptionsforitsmanagementwerereviewedin2020.[142] Prognosis Alifelongconditionwithperiodsofpartialorfullrecoveryinbetweenrecurrentepisodesofrelapse,[37][143]bipolardisorderisconsideredtobeamajorhealthproblemworldwidebecauseoftheincreasedratesofdisabilityandprematuremortality.[143]Itisalsoassociatedwithco-occurringpsychiatricandmedicalproblems,higherratesofdeathfromnaturalcauses(e.g.,cardiovasculardisease),andhighratesofinitialunder-ormisdiagnosis,causingadelayinappropriatetreatmentandcontributingtopoorerprognoses.[4][38]Whencomparedtothegeneralpopulation,peoplewithbipolardisorderalsohavehigherratesofotherseriousmedicalcomorbiditiesincludingdiabetesmellitus,respiratorydiseases,HIV,andHepatitisCvirusinfection.[144]Afteradiagnosisismade,itremainsdifficulttoachievecompleteremissionofallsymptomswiththecurrentlyavailablepsychiatricmedicationsandsymptomsoftenbecomeprogressivelymoresevereovertime.[88][145] Compliancewithmedicationsisoneofthemostsignificantfactorsthatcandecreasetherateandseverityofrelapseandhaveapositiveimpactonoverallprognosis.[146]However,thetypesofmedicationsusedintreatingBDcommonlycausesideeffects[147]andmorethan75%ofindividualswithBDinconsistentlytaketheirmedicationsforvariousreasons.[146]Ofthevarioustypesofthedisorder,rapidcycling(fourormoreepisodesinoneyear)isassociatedwiththeworstprognosisduetohigherratesofself-harmandsuicide.[37]Individualsdiagnosedwithbipolarwhohaveafamilyhistoryofbipolardisorderareatagreaterriskformorefrequentmanic/hypomanicepisodes.[148]Earlyonsetandpsychoticfeaturesarealsoassociatedwithworseoutcomes,[149][150]aswellassubtypesthatarenonresponsivetolithium.[145] Earlyrecognitionandinterventionalsoimproveprognosisasthesymptomsinearlierstagesarelesssevereandmoreresponsivetotreatment.[145]Onsetafteradolescenceisconnectedtobetterprognosesforbothgenders,andbeingmaleisaprotectivefactoragainsthigherlevelsofdepression.Forwomen,bettersocialfunctioningbeforedevelopingbipolardisorderandbeingaparentareprotectivetowardssuicideattempts.[148] Functioning Changesincognitiveprocessesandabilitiesareseeninmooddisorders,withthoseofbipolardisorderbeinggreaterthanthoseinmajordepressivedisorder.[151]Theseincludereducedattentionalandexecutivecapabilitiesandimpairedmemory.[152]Peoplewithbipolardisorderoftenexperienceadeclineincognitivefunctioningduring(orpossiblybefore)theirfirstepisode,afterwhichacertaindegreeofcognitivedysfunctiontypicallybecomespermanent,withmoresevereimpairmentduringacutephasesandmoderateimpairmentduringperiodsofremission.Asaresult,two-thirdsofpeoplewithBDcontinuetoexperienceimpairedpsychosocialfunctioninginbetweenepisodesevenwhentheirmoodsymptomsareinfullremission.AsimilarpatternisseeninbothBD-IandBD-II,butpeoplewithBD-IIexperiencealesserdegreeofimpairment.[147] Whenbipolardisorderoccursinchildren,itseverelyandadverselyaffectstheirpsychosocialdevelopment.[114]Childrenandadolescentswithbipolardisorderhavehigherratesofsignificantdifficultieswithsubstanceusedisorders,psychosis,academicdifficulties,behavioralproblems,socialdifficulties,andlegalproblems.[114]Cognitivedeficitstypicallyincreaseoverthecourseoftheillness.Higherdegreesofimpairmentcorrelatewiththenumberofpreviousmanicepisodesandhospitalizations,andwiththepresenceofpsychoticsymptoms.[153]Earlyinterventioncanslowtheprogressionofcognitiveimpairment,whiletreatmentatlaterstagescanhelpreducedistressandnegativeconsequencesrelatedtocognitivedysfunction.[145] Despitetheoverlyambitiousgoalsthatarefrequentlypartofmanicepisodes,symptomsofmaniaunderminetheabilitytoachievethesegoalsandofteninterferewithanindividual'ssocialandoccupationalfunctioning.One-thirdofpeoplewithBDremainunemployedforoneyearfollowingahospitalizationformania.[154]Depressivesymptomsduringandbetweenepisodes,whichoccurmuchmorefrequentlyformostpeoplethanhypomanicormanicsymptomsoverthecourseofillness,areassociatedwithlowerfunctionalrecoveryinbetweenepisodes,includingunemploymentorunderemploymentforbothBD-IandBD-II.[5][155]However,thecourseofillness(duration,ageofonset,numberofhospitalizations,andthepresenceornotofrapidcycling)andcognitiveperformancearethebestpredictorsofemploymentoutcomesinindividualswithbipolardisorder,followedbysymptomsofdepressionandyearsofeducation.[155] Recoveryandrecurrence Anaturalisticstudyin2003byTohenandcoworkersfromthefirstadmissionformaniaormixedepisode(representingthehospitalizedandthereforemostseverecases)foundthat50%achievedsyndromalrecovery(nolongermeetingcriteriaforthediagnosis)withinsixweeksand98%withintwoyears.Withintwoyears,72%achievedsymptomaticrecovery(nosymptomsatall)and43%achievedfunctionalrecovery(regainingofprioroccupationalandresidentialstatus).However,40%wentontoexperienceanewepisodeofmaniaordepressionwithin2yearsofsyndromalrecovery,and19%switchedphaseswithoutrecovery.[156] Symptomsprecedingarelapse(prodromal),especiallythoserelatedtomania,canbereliablyidentifiedbypeoplewithbipolardisorder.[157]Therehavebeenintentstoteachpatientscopingstrategieswhennoticingsuchsymptomswithencouragingresults.[158] Suicide Bipolardisordercancausesuicidalideationthatleadstosuicideattempts.Individualswhosebipolardisorderbeginswithadepressiveormixedaffectiveepisodeseemtohaveapoorerprognosisandanincreasedriskofsuicide.[91]Oneoutoftwopeoplewithbipolardisorderattemptsuicideatleastonceduringtheirlifetimeandmanyattemptsaresuccessfullycompleted.[47]Theannualaveragesuiciderateis0.4%,whichis10–20timesthatofthegeneralpopulation.[159]Thenumberofdeathsfromsuicideinbipolardisorderisbetween18and25timeshigherthanwouldbeexpectedinsimilarlyagedpeoplewithoutbipolardisorder.[160]Thelifetimeriskofsuicidehasbeenestimatedtobeashighas20%inthosewithbipolardisorder.[25] Riskfactorsforsuicideattemptsanddeathfromsuicideinpeoplewithbipolardisorderincludeolderage,priorsuicideattempts,adepressiveormixedindexepisode(firstepisode),amanicindexepisodewithpsychoticsymptoms,hopelessnessorpsychomotoragitationpresentduringtheepisodes,co-existinganxietydisorder,afirstdegreerelativewithamooddisorderorsuicide,interpersonalconflicts,occupationalproblems,bereavementorsocialisolation.[17] Epidemiology Burdenofbipolardisorderaroundtheworld:disability-adjustedlifeyearsper100,000 inhabitantsin2004.  <180  180–185  185–190  190–195  195–200  200–205  205–210  210–215  215–220  220–225  225–230  >230 Bipolardisorderisthesixthleadingcauseofdisabilityworldwideandhasalifetimeprevalenceofabout1to3%inthegeneralpopulation.[6][161][162]However,areanalysisofdatafromtheNationalEpidemiologicalCatchmentAreasurveyintheUnitedStatessuggestedthat0.8%ofthepopulationexperienceamanicepisodeatleastonce(thediagnosticthresholdforbipolarI)andafurther0.5%haveahypomanicepisode(thediagnosticthresholdforbipolarIIorcyclothymia).Includingsub-thresholddiagnosticcriteria,suchasoneortwosymptomsoverashorttime-period,anadditional5.1%ofthepopulation,addinguptoatotalof6.4%,wereclassifiedashavingabipolarspectrumdisorder.[163]AmorerecentanalysisofdatafromasecondUSNationalComorbiditySurveyfoundthat1%metlifetimeprevalencecriteriaforbipolarI,1.1%forbipolarII,and2.4%forsubthresholdsymptoms.[164]Estimatesvaryabouthowmanychildrenandyoungadultshavebipolardisorder.[114]Theseestimatesrangefrom0.6to15%dependingondifferingsettings,methods,andreferralsettings,raisingsuspicionsofoverdiagnosis.[114]Onemeta-analysisofbipolardisorderinyoungpeopleworldwideestimatedthatabout1.8%ofpeoplebetweentheagesofsevenand21havebipolardisorder.[114]Similartoadults,bipolardisorderinchildrenandadolescentsisthoughttooccuratasimilarfrequencyinboysandgirls.[114] Thereareconceptualandmethodologicallimitationsandvariationsinthefindings.Prevalencestudiesofbipolardisorderaretypicallycarriedoutbylayinterviewerswhofollowfullystructured/fixedinterviewschemes;responsestosingleitemsfromsuchinterviewsmayhavelimitedvalidity.Inaddition,diagnoses(andthereforeestimatesofprevalence)varydependingonwhetheracategoricalorspectrumapproachisused.Thisconsiderationhasledtoconcernsaboutthepotentialforbothunderdiagnosisandoverdiagnosis.[165] Theincidenceofbipolardisorderissimilarinmenandwomen[166]aswellasacrossdifferentculturesandethnicgroups.[167]A2000studybytheWorldHealthOrganizationfoundthatprevalenceandincidenceofbipolardisorderareverysimilaracrosstheworld.Age-standardizedprevalenceper100,000rangedfrom421.0inSouthAsiato481.7inAfricaandEuropeformenandfrom450.3inAfricaandEuropeto491.6inOceaniaforwomen.However,severitymaydifferwidelyacrosstheglobe.Disability-adjustedlifeyearrates,forexample,appeartobehigherindevelopingcountries,wheremedicalcoveragemaybepoorerandmedicationlessavailable.[168]WithintheUnitedStates,AsianAmericanshavesignificantlylowerratesthantheirAfricanAmericanandEuropeanAmericancounterparts.[169]In2017,theGlobalBurdenofDiseaseStudyestimatedtherewere4.5millionnewcasesandatotalof45.5millioncasesglobally.[170] History Mainarticle:Historyofbipolardisorder GermanpsychiatristEmilKraepelinfirstdistinguishedbetweenmanic–depressiveillnessand"dementiapraecox"(nowknownasschizophrenia)inthelate19thcentury. Intheearly1800s,FrenchpsychiatristJean-ÉtienneDominiqueEsquirol'slypemania,oneofhisaffectivemonomanias,wasthefirstelaborationonwhatwastobecomemoderndepression.[171]Thebasisofthecurrentconceptualizationofbipolarillnesscanbetracedbacktothe1850s.In1850,Jean-PierreFalretdescribed"circularinsanity"(lafoliecirculaire,Frenchpronunciation: ​[lafɔlisiʁ.ky.lɛʁ]);thelecturewassummarizedin1851inthe"Gazettedeshôpitaux"("HospitalGazette").[2]Threeyearslater,in1854,Jules-Gabriel-FrançoisBaillarger(1809–1890)describedtotheFrenchImperialAcadémieNationaledeMédecineabiphasicmentalillnesscausingrecurrentoscillationsbetweenmaniaandmelancholia,whichhetermedfolieàdoubleforme(Frenchpronunciation: ​[fɔliadublfɔʀm],"madnessindoubleform").[2][172]Baillarger'soriginalpaper,"Delafolieàdoubleforme,"appearedinthemedicaljournalAnnalesmédico-psychologiques(Medico-psychologicalannals)in1854.[2] TheseconceptsweredevelopedbytheGermanpsychiatristEmilKraepelin(1856–1926),who,usingKahlbaum'sconceptofcyclothymia,[173]categorizedandstudiedthenaturalcourseofuntreatedbipolarpatients.Hecoinedthetermmanicdepressivepsychosis,afternotingthatperiodsofacuteillness,manicordepressive,weregenerallypunctuatedbyrelativelysymptom-freeintervalswherethepatientwasabletofunctionnormally.[174] Theterm"manic–depressivereaction"appearedinthefirstversionoftheDSMin1952,influencedbythelegacyofAdolfMeyer.[175]Subtypinginto"unipolar"depressivedisordersandbipolardisordershasitsorigininKarlKleist'sconcept–since1911–ofunipolarandbipolaraffectivedisorders,whichwasusedbyKarlLeonhardin1957todifferentiatebetweenunipolarandbipolardisorderindepression.[176]ThesesubtypeshavebeenregardedasseparateconditionssincepublicationoftheDSM-III.ThesubtypesbipolarIIandrapidcyclinghavebeenincludedsincetheDSM-IV,basedonworkfromthe1970sbyDavidDunner,ElliotGershon,FrederickGoodwin,RonaldFieve,andJosephFleiss.[177][178][179] Societyandculture Seealso:Listofpeoplewithbipolardisorder,Category:Booksaboutbipolardisorder,andCategory:Filmsaboutbipolardisorder SingerRosemaryClooney'spublicrevelationofbipolardisordermadeheranearlycelebrityspokespersonformentalillness.[180] Cost TheUnitedStatesspentapproximately$202.1billiononpeoplediagnosedwithbipolarIdisorder(excludingothersubtypesofbipolardisorderandundiagnosedpeople)in2015.[144]OneanalysisestimatedthattheUnitedKingdomspentapproximately£5.2billiononthedisorderin2007.[181][182]Inadditiontotheeconomiccosts,bipolardisorderisaleadingcauseofdisabilityandlostproductivityworldwide.[19]Peoplewithbipolardisorderaregenerallymoredisabled,havealowerleveloffunctioning,longerdurationofillness,andincreasedratesofworkabsenteeismanddecreasedproductivitywhencomparedtopeopleexperiencingothermentalhealthdisorders.[183]Thedecreaseintheproductivityseeninthosewhocareforpeoplewithbipolardisorderalsosignificantlycontributestothesecosts.[184] Advocacy Therearewidespreadissueswithsocialstigma,stereotypes,andprejudiceagainstindividualswithadiagnosisofbipolardisorder.[185]In2000,actressCarrieFisherwentpublicwithherbipolardisorderdiagnosis.Shebecameoneofthemostwell-recognizedadvocatesforpeoplewithbipolardisorderinthepubliceyeandfiercelyadvocatedtoeliminatethestigmasurroundingmentalillnesses,includingbipolardisorder.[186]StephenFried,whohaswrittenextensivelyonthetopic,notedthatFisherhelpedtodrawattentiontothedisorder'schronicity,relapsingnature,andthatbipolardisorderrelapsesdonotindicatealackofdisciplineormoralshortcomings.[186]Sincebeingdiagnosedatage37,actorStephenFryhaspushedtoraiseawarenessofthecondition,withhis2006documentaryStephenFry:TheSecretLifeoftheManicDepressive.[187][188]Inanefforttoeasethesocialstigmaassociatedwithbipolardisorder,theorchestraconductorRonaldBraunsteincofoundedtheME/2OrchestrawithhiswifeCarolineWhiddonin2011.Braunsteinwasdiagnosedwithbipolardisorderin1985andhisconcertswiththeME/2Orchestrawereconceivedinordertocreateawelcomingperformanceenvironmentforhismusicalcolleagues,whilealsoraisingpublicawarenessaboutmentalillness.[189][190] Notablecases Numerousauthorshavewrittenaboutbipolardisorderandmanysuccessfulpeoplehaveopenlydiscussedtheirexperiencewithit.KayRedfieldJamison,aclinicalpsychologistandprofessorofpsychiatryattheJohnsHopkinsUniversitySchoolofMedicine,profiledherownbipolardisorderinhermemoirAnUnquietMind(1995).[191]Severalcelebritieshavealsopubliclysharedthattheyhavebipolardisorder;inadditiontoCarrieFisherandStephenFrytheseincludeCatherineZeta-Jones,MariahCarey,KanyeWest,[192]JanePauley,DemiLovato,[186]SelenaGomez,[193]andRussellBrand.[194] Mediaportrayals Severaldramaticworkshaveportrayedcharacterswithtraitssuggestiveofthediagnosiswhichhavebeenthesubjectofdiscussionbypsychiatristsandfilmexpertsalike. InMr.Jones(1993),(RichardGere)swingsfromamanicepisodeintoadepressivephaseandbackagain,spendingtimeinapsychiatrichospitalanddisplayingmanyofthefeaturesofthesyndrome.[195]InTheMosquitoCoast(1986),AllieFox(HarrisonFord)displayssomefeaturesincludingrecklessness,grandiosity,increasedgoal-directedactivityandmoodlability,aswellassomeparanoia.[196]PsychiatristshavesuggestedthatWillyLoman,themaincharacterinArthurMiller'sclassicplayDeathofaSalesman,hasbipolardisorder.[197] The2009drama90210featuredacharacter,Silver,whowasdiagnosedwithbipolardisorder.[198]StaceySlater,acharacterfromtheBBCsoapEastEnders,hasbeendiagnosedwiththedisorder.ThestorylinewasdevelopedaspartoftheBBC'sHeadroomcampaign.[199]TheChannel4soapBrooksidehadearlierfeaturedastoryaboutbipolardisorderwhenthecharacterJimmyCorkhillwasdiagnosedwiththecondition.[200]2011Showtime'spoliticalthrillerdramaHomelandprotagonistCarrieMathisonhasbipolardisorder,whichshehaskeptsecretsinceherschooldays.[201]The2014ABCmedicaldrama,BlackBox,featuredaworld-renownedneuroscientistwithbipolardisorder.[202] IntheTVseriesDave,theeponymousmaincharacter,playedbyLilDickyasafictionalizedversionofhimself,isanaspiringrapper.LilDicky'sreal-lifehypemanGaTaalsoplayshimself.Inoneepisode,afterbeingoffhismedicationandhavinganepisode,GaTatearfullyconfessestohavingbipolardisorder.GaTahasbipolardisorderinreallifebut,likehischaracterintheshow,heisabletomanageitwithmedication.[203] Creativity Mainarticle:Creativityandmentalillness§ Bipolardisorder Alinkbetweenmentalillnessandprofessionalsuccessorcreativityhasbeensuggested,includinginaccountsbySocrates,SenecatheYounger,andCesareLombroso.Despiteprominenceinpopularculture,thelinkbetweencreativityandbipolarhasnotbeenrigorouslystudied.Thisareaofstudyalsoislikelyaffectedbyconfirmationbias.Someevidencesuggeststhatsomeheritablecomponentofbipolardisorderoverlapswithheritablecomponentsofcreativity.Probandsofpeoplewithbipolardisorderaremorelikelytobeprofessionallysuccessful,aswellastodemonstratetemperamentaltraitssimilartobipolardisorder.Furthermore,whilestudiesofthefrequencyofbipolardisorderincreativepopulationsampleshavebeenconflicting,full-blownbipolardisorderincreativesamplesisrare.[204] Research Researchdirectionsforbipolardisorderinchildrenincludeoptimizingtreatments,increasingtheknowledgeofthegeneticandneurobiologicalbasisofthepediatricdisorderandimprovingdiagnosticcriteria.[113]Sometreatmentresearchsuggeststhatpsychosocialinterventionsthatinvolvethefamily,psychoeducation,andskillsbuilding(throughtherapiessuchasCBT,DBT,andIPSRT)canbenefitinadditiontopharmocotherapy.[139] Seealso Psychiatryportal Psychologyportal Medicineportal Listofpeoplewithbipolardisorder Outlineofbipolardisorder BipolarIdisorder BipolarIIdisorder BipolarNOS Cyclothymia Bipolardisordersresearch Borderlinepersonalitydisorder Emotionaldysregulation Mood(psychology) Moodswing Ultradianbipolardisorder InternationalSocietyforBipolarDisorders Explanatorynotes ^Catatoniaisasyndromecharacterizedbyprofoundunresponsivenessorstuporwithabnormalmovementsinapersonwhoisotherwiseawake.[15] Citations 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Citedtexts BascoMR,RushAJ(2005).Cognitive-BehavioralTherapyforBipolarDisorder(Second ed.).NewYork:TheGuilfordPress.ISBN 978-1-59385-168-2.OCLC 300306925. BrownMR,BassoMR(2004).FocusonBipolarDisorderResearch.NovaSciencePublishers.ISBN 978-1-59454-059-2. JosephC(2008).Manicdotes:There'sMadnessinHisMethod.London:Austin &Macauley.ISBN 978-1-905609-07-9. GoodwinFK,JamisonKR(2007).Manic–depressiveillness:bipolardisordersandrecurrentdepression(2nd. ed.).OxfordUniversityPress.ISBN 978-0-19-513579-4.OCLC 70929267.RetrievedApril2,2016. JamisonKR(1995).AnUnquietMind:AMemoirofMoodsandMadness.NewYork:Knopf.ISBN 978-0-330-34651-1. LeahyRL,JohnsonSL(2003).PsychologicalTreatmentofBipolarDisorder.NewYork:TheGuilfordPress.ISBN 978-1-57230-924-1.OCLC 52714775. LiddellHG,ScottR(1980).AGreek-EnglishLexicon(Abridged ed.).OxfordUniversityPress.ISBN 978-0-19-910207-5. MillonT(1996).DisordersofPersonality:DSM-IV-TMandBeyond.NewYork:JohnWileyandSons.ISBN 978-0-471-01186-6. RobinsonDJ(2003).ReelPsychiatry:MoviePortrayalsofPsychiatricConditions.PortHuron,Michigan:RapidPsychlerPress.ISBN 978-1-894328-07-4. SadockBJ,KaplanHI,SadockVA(2007).Kaplan &Sadock'sSynopsisofPsychiatry:BehavioralSciences/ClinicalPsychiatry(Tenth ed.).ISBN 978-0-7817-7327-0.RetrievedApril2,2016. Furtherreading LibraryresourcesaboutBipolardisorder Resourcesinyourlibrary Resourcesinotherlibraries HealyD(2011).Mania:AShortHistoryofBipolarDisorder.Baltimore:JohnsHopkinsUniversityPress.ISBN 978-1-4214-0397-7. MondimoreFM(2014).BipolarDisorder:AGuideforPatientsandFamilies(3rd ed.).Baltimore:JohnsHopkinsUniversityPress.ISBN 978-1-4214-1206-1. YathamL(2010).BipolarDisorder.NewYork:Wiley.ISBN 978-0-470-72198-8. Externallinks BipolardisorderatWikipedia'ssisterprojects DefinitionsfromWiktionaryMediafromCommonsNewsfromWikinewsTextbooksfromWikibooksDatafromWikidata InternationalSocietyforBipolarDisordersTaskForcereportoncurrentknowledgeinpediatricbipolardisorderandfuturedirections ClassificationDICD-10:F31ICD-9-CM:296.0,296.1,296.4,296.5,296.6,296.7,296.8OMIM:125480309200MeSH:D001714DiseasesDB:7812SNOMEDCT:13746004ExternalresourcesMedlinePlus:000926eMedicine:med/229PatientUK:Bipolardisorder vteMentaldisorders (Classification)AdultpersonalityandbehaviorSexual Ego-dystonicsexualorientation Paraphilia Fetishism Voyeurism Sexualmaturationdisorder Sexualrelationshipdisorder Other Factitiousdisorder Munchausensyndrome Genderdysphoria Intermittentexplosivedisorder Dermatillomania Kleptomania Pyromania Trichotillomania Personalitydisorder ChildhoodandlearningEmotionalandbehavioral ADHD Conductdisorder ODD Emotionalandbehavioraldisorders Separationanxietydisorder Movementdisorders Stereotypic Socialfunctioning DAD RAD Selectivemutism Speech Cluttering Stuttering Ticdisorder Tourettesyndrome Intellectualdisability X-linkedintellectualdisability Lujan–Frynssyndrome Psychologicaldevelopment(developmentaldisabilities) Pervasive Specific Mood(affective) Bipolar BipolarI BipolarII BipolarNOS Cyclothymia Depression Atypicaldepression Dysthymia Majordepressivedisorder Melancholicdepression Seasonalaffectivedisorder Mania NeurologicalandsymptomaticAutismspectrum Autism Aspergersyndrome High-functioningautism PDD-NOS Savantsyndrome Dementia AIDSdementiacomplex Alzheimer'sdisease Creutzfeldt–Jakobdisease Frontotemporaldementia Huntington'sdisease Mildcognitiveimpairment Parkinson'sdisease Pick'sdisease Sundowning Vasculardementia Wandering Other Delirium Organicbrainsyndrome Post-concussionsyndrome Neurotic,stress-relatedandsomatoformAdjustment Adjustmentdisorderwithdepressedmood AnxietyPhobia Agoraphobia Socialanxiety Socialphobia Anthropophobia Specificsocialphobia Specificphobia Claustrophobia Other Generalizedanxietydisorder OCD Panicattack Panicdisorder Stress Acutestressdisorder PTSD Dissociative Depersonalization-derealizationdisorder Dissociativeidentitydisorder Fuguestate Psychogenicamnesia Somaticsymptom Bodydysmorphicdisorder Conversiondisorder Gansersyndrome Globuspharyngis Psychogenicnon-epilepticseizures Falsepregnancy Hypochondriasis Masspsychogenicillness Nosophobia Psychogenicpain Somatizationdisorder PhysiologicalandphysicalbehaviorEating Anorexianervosa Bulimianervosa Ruminationsyndrome Otherspecifiedfeedingoreatingdisorder Nonorganicsleep Hypersomnia Insomnia Parasomnia Nightterror Nightmare REMsleepbehaviordisorder Postnatal Postpartumdepression Postpartumpsychosis SexualdysfunctionArousal Erectiledysfunction Femalesexualarousaldisorder Desire Hypersexuality Hypoactivesexualdesiredisorder Orgasm Anorgasmia Delayedejaculation Prematureejaculation Sexualanhedonia Spontaneousorgasm Pain Nonorganicdyspareunia Nonorganicvaginismus Psychoactivesubstances,substanceabuseandsubstance-related Drugoverdose Intoxication Physicaldependence Reboundeffect Stimulantpsychosis Substancedependence Withdrawal Schizophrenia,schizotypalanddelusionalDelusional Delusionaldisorder Folieàdeux Psychosisandschizophrenia-like Briefreactivepsychosis Schizoaffectivedisorder Schizophreniformdisorder Schizophrenia Childhoodschizophrenia Disorganized(hebephrenic)schizophrenia Paranoidschizophrenia Pseudoneuroticschizophrenia Simple-typeschizophrenia Other Catatonia Symptomsanduncategorized Impulse-controldisorder Klüver–Bucysyndrome Psychomotoragitation Stereotypy vteMooddisorderSpectrumBipolardisorder BipolarI BipolarII Cyclothymia BipolarNOS Childhood Hypomania Mania Mixedaffectivestate Rapidcycling Depression Majordepressivedisorder Dysthymia Seasonalaffectivedisorder Atypicaldepression Melancholicdepression Majordepressiveepisode Comorbidities Schizoaffectivedisorder Symptoms Delusion Depression(differentialdiagnoses) Emotionaldysregulation Anhedonia Dysphoria Suicidalideation Hallucination Moodswing Sleepdisorder Hypersomnia Insomnia Psychosis Psychoticdepression Racingthoughts Reducedaffectdisplay Diagnosis BipolarSpectrumDiagnosticScale ChildManiaRatingScale GeneralBehaviorInventory HypomaniaChecklist MoodDisorderQuestionnaire Ratingscalesfordepression YoungManiaRatingScale TreatmentAnticonvulsants Carbamazepine Lamotrigine Oxcarbazepine Valproate Sodiumvalproate Valproatesemisodium Sympathomimetics,SSRIsandsimilar Bupropion Dextroamphetamine Escitalopram Fluoxetine Methylphenidate Sertraline Othermoodstabilizers Antipsychotics Atypicalantipsychotics Lithium Lithiumcarbonate Lithiumcitrate Lithiumsulfate Lithiumtoxicity Non-pharmaceutical Clinicalpsychology Cognitivebehavioraltherapy Dialecticalbehaviortherapy Electroconvulsivetherapy Involuntarycommitment Lighttherapy Psychotherapy Transcranialmagneticstimulation History EmilKraepelin FrederickK.Goodwin JohnCade KarlLeonhard KayRedfieldJamison 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