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Chapter 10:
Bipolar Disorders
David J. Miklowitz
Sheri L. Johnson
Diagnosis: Diagnostic Features
 Severe changes in mood, thinking, and behavior, from
extreme highs to lows
 Distinctive “episodes” lasting a few days to a year or more.
 Depressive episode: ≥ Five of the following for 2
weeks or longer with significant distress and/or decline
in functioning
 Intense sadness and/or loss of interest must be present
• Insomnia or hypersomnia
• Difficulty concentrating or
• Psychomotor agitation or
making decisions
• Feelings of worthlessness or
guilt
• Suicidal ideation or behavior
retardation,
• Changes in weight or appetite
• Loss of energy
Diagnosis: Manic and Hypomanic
Episodes
 Manic episode: Notably different elated, expansive, or
irritable mood with ≥ 3 (≥ 4 if irritable) of the following
lasting for at least 1 week and causing significant
distress or impairment:
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Inflated self-esteem (grandiosity)
Decreased need for sleep
Racing thoughts or flight of ideas
Rapid or pressured speech
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Reckless and impulsive behavior
Enhanced energy
Increased goal-directed activity
Distractibility
 Hypomanic episode: Same symptom criteria, but…
 Shorter (4 days instead of 1 week)
 Not severe enough to cause marked impairment
in functioning (no psychotic features and no
hospitalization)
Diagnosis: Diagnostic Criteria
 Bipolar I (BD-I)
 Criteria met for at least 1 manic episode
 Not better explained by a schizophrenia spectrum
disorder (e.g., schizophrenia)
 Bipolar II (BD-II)
 Criteria met for at least one hypomanic episode and one
depressive episode
 Criteria never met for manic episode
 Not better explained by schizophrenia spectrum disorder
Diagnosis: Related Conditions
 Bipolar disorder not elsewhere classified
 Patients with brief and recurrent manic or hypomanic
phases that fall short of the duration criteria
 Cyclothymia
 2 or more years of switching between hypomanic and
depressive symptoms that do not meet the full DSM-5
criteria for a hypomanic or a major depressive episode
Diagnosis: Some Potential
Specifiers
 With mixed features: Features of depressive
episode present during manic episode or vice
versa
 More debilitating course of illness, earlier onset, and
greater comorbidity with anxiety and substance use
disorders
 Rapid cycling: Four or more episodes of
depression, mania, or hypomania in 1 year
 10%–20% of cases, more common in bipolar II and
women
Diagnosis: Changes in DSM-5
 Increased activity is now a cardinal (Criterion A)
symptom
 Helps diagnose people who can describe behavior well
but not internal experience
 Mixed episode specifier no longer requires meeting
full criteria for mania and depression
simultaneously
Diagnosis: Comorbid Disorders
 Virtually all bipolar patients have a lifetime history
of other psychiatric disorders
 Anxiety disorders (62.9%)
 ADHD and/or oppositional defiant disorder (44.8%)
 Substance use disorders (36.8%)
 In children, comorbidity of BD with ADHD is
between 60% and 90%
Symptoms: Presentation
Differences
 Patients with bipolar II disorder spend the majority
of their ill weeks depressed, not hypomanic (ratio
of 37 to 1)
 Bipolar I ratio is about 3:1
 80% of youths show irritability and grandiosity,
whereas 70% have elated mood, decreased need
for sleep, or racing thoughts
 Less frequent symptoms: hypersexuality and psychotic
symptoms
Symptoms: Suicidality
 Among those hospitalized for BD, 15x greater risk for
completed suicide than the general population
 4x greater risk than patients with major depressive disorder
 Risk factors:
 Comorbid alcohol or
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substance abuse
Younger age
Recent illness onset
Male gender
Prior suicide attempts
 Family history of suicide
 Rapid cycling course
 Social isolation
 Anxious mood
 Recent severe depression
 “Impulsive aggression”
Prognosis
 Majority of patients with BD experience significant
impairment in work, social, and family functioning
during and after illness episodes
 One third work full time outside of the home
 More than half unable to work or work only in sheltered
settings
 Negative predictors: subsyndromal depressive symptoms
following a manic episode and cognitive dysfunction
 1 in 10 BD-II patients eventually develop a full manic or
mixed episode and are then diagnosed with BD-I
Epidemiology
 1% meet lifetime criteria for BD-I; 1.1% for BD-II
 2.4% meet criteria for subthreshold BD; 4.2% cyclothymia
 Mean age at onset
 18.4 years BD-I
 20.0 years BD-II
 21.9 years subthreshold BD
 Between 50% and 67% of BD-I and BD-II have onset before
age 18
• 15% and 28% before age 13
 In community studies, 25% to -33% of bipolar I patients
have unipolar mania
Etiology: Expressed Emotion
 Expressed emotion attitudes (EE) - criticism,
hostility, or emotional overinvolvement
 Affective negativity (AE): Criticism, hostility, or guilt
induction
 BD patients who return home to high EE or AE
families are at ~94% risk for relapse within 9
months
 ~17% returning to low EE and AE families
Etiology: Unipolar Depression
Overlap
 Predictors of recurrent and severe symptoms in both
disorders include low social support, family EE, and
neuroticism
 Negative life events equally predictive of relapse
 Heritability for unipolar depression and mania modestly
correlated, but 71% of genetic liability to mania is
distinct from depression
 Variables that influence the course of unipolar
depression also influence BD depression
Etiology: Stress
 BD patients with high levels of stressful life events are
at 4.5x greater risk for relapse within 2 years
 Number of prior episodes of illness does not interact
with life events stress in predicting recurrences
 Contrary to kindling model
 Patients with severe early adversity (e.g., parental
neglect or sexual/physical abuse) report less stress
prior to illness recurrences and earlier age at onset
 Supports stress sensitization model
Etiology: Reward Sensitivity and
Goal Setting
 People with a history of mania describe themselves as
more likely to react with strong emotions to reward
cues (reward sensitive)
 Elevated reward sensitivity predicts BD onset and a
more severe course of mania among BD-I patients
 Goal-attainment-type life events predict increases in
manic symptoms but not depressive symptoms
 Highly ambitious life goals/goal setting associated with
more severe course of mania and onset of BD
Etiology: Brain Systems
 Abnormally strong activity in the dopaminergic
pathways involved in reward sensitivity
 Nucleus accumbens and the ventral tegmentum
 Reduced connectivity between limbic (emotion-
related) brain regions and prefrontal regions
 May explain why patients with bipolar disorder have
unstable mood and hyperreactivity to events
 Diminished activity of the PFC might interfere with the
ability to inhibit emotions and to conduct effective
planning and goal pursuit
Biological Etiology: Heritability
 Genetic studies show bipolar disorder is among
the most heritable of disorders. Heritability
estimates from twin studies are as high as .85 to
.93
 Risk of bipolar disorder among first-degree relatives
between 5% and 12%
 Risk of all forms of mood disorder between 20% and 25%
 Monozygotic twins of BD-I patients are at an
increased risk for schizophrenia (13.6%) and
mania (36.4%)
Biological Etiology:
Neurotransmitters
 Research emphasis has shifted from absolute levels of
neurotransmitters to the overall functioning of systems
 Neural plasticity and disturbed intracellular signaling cascades
rather than the amount of dopamine or serotonin
 Dopamine theory: Dopamine function is enhanced
during mania and diminished during depression
 Dopamine precursors, such as l-dopa, can trigger mania
 Mood disorders generally associated with decreased
serotonin receptor sensitivity
Treatment- Lithium Medication
and Nonadherence
 Lithium: A mood stabilizer
 60% to 70% improve on lithium during a manic episode
 Also helps prevent relapse
 Significant side effects: sedation, weight gain, tremors of the
hands, stomach irritation, thirst, and kidney problems
 40% to 60% of patients are fully or partially
nonadherent with stabilizer regimens in the year after a
manic episode
 In community, patients take lithium for an average of only 2 to
3 months
 Rapid discontinuation of lithium places patients at higher risk
for recurrence and suicide
Treatment: Pharmacological:
Anticonvulsants/Mood Stabilizers
 Divalproex sodium (Depakote) is as effective as
lithium in controlling manic episodes
 Generally more benign side effects: stomach pain,
nausea, weight gain, elevated liver enzymes, and
lowering of blood platelet counts
 Combination therapy and lithium alone both more
effective than divalproex alone in preventing relapse
 Other anticonvulsants/mood stabilizers
 Carbamazepine (Tegretol), lamotrigine (Lamictal), and
oxcarbazepine (Trileptal)
Treatment: Pharmacological:
Suicide Prevention
 Patients treated with lithium, antipsychotics, or
antidepressants (especially in combination
regimens) have lower suicide rate
 Lithium was more effective than divalproex sodium
in reducing suicide attempts and completions
Treatment: Pharmacological
Other Medications
 Olanzapine (atypical antipsychotic medication)
 Prevention of recurrences of mania or mixed episodes is
as good or better than lithium or divalproex
 Concerns about side effects: weight gain and metabolic
syndrome
 Quetiapine, risperidone, aripiprazole, and ziprasidone are
alternatives with lower side-effect risk
 Not clear that combinations of SSRI and mood
stabilizer are effective for treating BD depression
 Risk of more frequent mood cycles
Treatment: Group Psychotherapy
 Structured group psychoeducation
 Education about BD, relapse, and importance of medication
 After 2 years, relapse is 67% vs. 92% in controls, and fewer
hospitalized
 More likely to maintain lithium levels within the therapeutic
range
 Group treatment is most cost-effective form of psychotherapy
 Integrated CBT group treatment for bipolar adults
with comorbid substance dependence
 Focuses on the overlap between the cognitions and behaviors
of both conditions during recovery and relapse
 About half as many days of substance use as those receiving
only drug counseling
Treatment: Individual
Psychotherapy
 Interpersonal and Social-Rhythm Therapy (IPSRT)
 Stabilize social rhythms and resolve interpersonal problems that
precede episodes
 Track daily routines and sleep/wake cycles and identify events that
change those routines
 Delays recurrence if begun during acute phase
 Individual psychoeducational treatment and medication
 7 to 12 sessions
 30% reduction in mania relapse, longer time before relapse, and
enhanced social functioning
Treatment: Family Focused
Treatment (FFT)
 Group therapy with patient and family
 Goal: Reduce high EE attitudes and enhance
communication
 Psychoeducation about BD and develop relapse prevention
drill
 Communication-enhancement training
 Problem-solving skills training
 Efficacy vs. standard care over 2 years
 Less likely to relapse (17% vs. 52%)
 Greater improvements over time in depression, manic
symptoms, and better adherence to medications
Treatment: Psychotherapy
Efficacy Comparison (STEP-BD)
 30 sessions of IPSRT, FFT, or CBT over 9 months
for BD-I and BD-II starting in depressed episode
 Control condition was three sessions of psychoeducation;
medication prescribed in all conditions
 Treatment conditions more likely to recover rapidly from
depression, remain well, better overall functioning,
relationship functioning, and life satisfaction
 One-year rates of recovery same across intensive
therapy groups