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Module 1: Overview of Bipolar Disorder
Overview of Bipolar Disorder
Keeping Your Balance
Module 1
Overview of Bipolar Disorder
2
5
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Stress-Vulnerability Worksheet
Module Summary
6
8
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Keeping Your Balance
The information provided in this document is for information purposes only. Please refer to the full
disclaimer and copyright statements available at www.cci.health.gov.au regarding the information on
this website before making use of such information.
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Overview of Bipolar Disorder
OVERVIEW OF BIPOLAR DISORDER
Introduction
Bipolar Disorder or Manic Depression is a mood disorder, and is the name given to the experience of
abnormal moods or exaggerated mood swings. This illness is characterised by the experience of extremely
“high” moods where one becomes extremely euphoric or elated, and the experience of extremely “low”
moods where one becomes extremely sad and finds it difficult to experience pleasure. The high moods are
called manic episodes and the low moods are called depressive episodes. These episodes can range from
mild to severe and affect how a person thinks, feels, and acts. However, it is important to remember that
some people may experience different patterns associated with their disorder. For example, some people
may experience only one episode of mania but more frequent episodes of depression.
Bipolar Disorder occurs in approximately 1% of the population, that is, about 1 in every 100 will experience
an episode that will probably require hospital care. This illness affects men and women equally, and
typically begins in their early to late 20s.
Features of Bipolar Disorder
Manic Episodes
Mania is an extreme mood state of this disorder. It describes an abnormally elevated,
euphoric, driven and/or irritable mood state. Hypomania is the term given to the more
moderate form of elevated mood. It can be managed often without the need for
hospitalisation as the person remains in contact with reality. However, it is very easy to move
rapidly from hypomania into a manic episode. Symptoms of mania include:
Irritability
Irritability as described in the Oxford dictionary means “quick to anger, touchy.” Many people, when in an
elevated mood state, experience a rapid flow of ideas and thoughts. They often find that they are way
ahead of other people in their thinking processes, already onto another idea before people around them
have grasped the first concept. Because of this rapid thought process, they become easily angered when
people don’t seem to comprehend their ideas or enthusiasm for some new scheme.
Decreased need for sleep
One of the most common symptoms of mania and often an early warning sign is the increased experience
of energy and lack of need for sleep. This is often because the rapid flow of thoughts and ideas tends to
keep people awake, exploring new schemes and plans.
Rapid flow of ideas
People who are becoming manic experience an increase in the speed at which they think. They move more
quickly from one subject to another. Sometimes thoughts can become so rapid that they begin to make no
sense, developing into a jumbled, incoherent message that the listener can no longer understand.
Grandiose ideas
It is common for people who are manic to think that they are more talented than others, or have unique
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gifts. As the person’s mood becomes more elevated, these beliefs can become delusional in nature, with
people often believing they are famous people, or that they have been put on this planet for a special
purpose (often religious beliefs can become very intense, and take more significance that usual).
Uncharacteristically poor judgement
A person’s ability to make rational decisions can become impaired and they may make inappropriate
decisions or decisions that are out of character.
Increased sexual drive
People when they become manic often experience increased libido, and may make less well-judged
decisions about the sexual partners.
Depressive Episodes
Depression is a mood state that is characterised by a significantly lowered mood. Its
severity, persistence, duration, and the presence of characteristic symptoms can distinguish a
major depressive episode, the other extreme mood state of bipolar disorder, from a milder
episode of depression. The most common symptoms of depression include:
Persistent sad, anxious, or empty mood
People often describe depression as an overwhelming feeling of sadness and hopelessness. They may lose
the motivation to eat and experience a loss of enjoyment in the activities of everyday life that they used to
take a lot of pleasure in.
Poor or disrupted sleep
A person when they are depressed often experiences sleep disturbances, and this can be due to increased
anxiety. They then find it difficult to fall asleep, or wake up frequently during the night worrying about day-
to-day events or wake early in the morning and are unable to get back to sleep.
Feelings of worthlessness or hopelessness
Sometimes people become overwhelmed with a sense of their own inability to be of use to anyone, and can
become convinced that they are useless and worthless. Thoughts may revolve around the hopelessness of
the situation and the future.
Decreased interest in sex
As the person becomes more depressed, they gradually become less interested in social activities and sex.
Poor concentration
Thinking can become slowed and the person can have difficulty in making decisions. They find it difficult to
concentrate on reading a book or on the day to day tasks such as shopping. This can often create anxiety
or agitation in a person.
Thoughts of suicide, or suicide attempts
When a person becomes overwhelmed by their feelings of hopelessness and despair, they may have
thoughts of ending their lives or make plans to commit suicide.
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Mixed Episodes
A mixed episode is characterised by the experience of both depressive and manic symptoms nearly every
day for a period of time. The person experiences rapidly alternating moods, eg, irritability, euphoria,
sadness, and there may be insomnia, agitation, hallucinations and delusions, suicidal thoughts, etc.
Recording Your Symptoms
What sorts of symptoms do you experience? On the next page is a Symptom Record worksheet. Take a
few minutes to write down what you experience when you are feeling well, that is, when you are neither
depressed nor hypomanic or manic. Then think of how you feel, what you think, and what you do or don’t
do when you are depressed or hypomanic or manic and write these symptoms down. The purpose of
recording you symptoms is so that you can learn to become more aware of them and are ultimately able to
recognise any early warning symptoms. We will discuss more about early warning symptoms in Module 3.
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Symptom Record
To help you fill out this worksheet, you may want to ask yourself the following questions:
• What am I like when I’m in a “normal”, non-symptomatic state?
• How does my life change when I’m depressed or manic?
• How, if at all, does my view of myself, others, and the future change when I’m depressed, manic,
and when feeling fine?
• What do other people notice about me when I’m symptomatic?
• What sorts of comments do I hear from others?
Depression
Normal
Mania
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Overview of Bipolar Disorder
The Diagnosis of Bipolar Disorder
Correctly identifying an illness can help you begin to explore the various treatment options available to you
so that you can better manage your illness. As such, having an accurate diagnosis is the beginning of
becoming well. Remember that a proper diagnosis should only be made by your general practitioner or
psychiatrist, or a trained mental health practitioner. The information provided below is not enough for an
accurate diagnosis to be made by anyone who is not a trained mental health professional or physician.
The following diagnoses are based on the definitions and criteria used in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) by the American Psychiatric Association, 1994.
Bipolar I Disorder is the most common and prevalent of the different bipolar mood disorders. It is
characterised by the experience of full-blown manic episodes and severe depressive episodes. The patterns
of abnormal mood states are very varied and different individuals may experience a different course of the
illness. Many physicians refer to bipolar I disorder as a relapsing and remitting illness, where symptoms
come and go. It is therefore, important to ensure that treatment is continued even if the symptoms are no
longer present, to prevent an episode relapse.
Bipolar II Disorder is characterised by the experience of full-blown episodes of depression and episodes
of hypomania (i.e., with mild manic symptoms) that almost never developed into full-fledged mania.
Cyclothymic Disorder is characterised by frequent short periods of mild depressive symptoms and
hypomania, mixed in with short periods of normal mood. Though a patient with cyclothymic disorder does
not experience major depression or mania, they may go on to develop bipolar I or II disorder.
Patients with bipolar I or bipolar II may experience frequent mood cycling. Patients who experience more
than four episodes of hypomania, mania, and/or depression in a year are said to experience Rapid Cycling.
These patients tend to alternate between extreme mood states separated by short periods of being well, if
at all.
What Causes Bipolar Disorder?
No one factor has been identified to cause bipolar disorder, that is, it is not caused by a person, event, or
experience. There are a number of factors that interact with each other that may contribute to the
development of this disorder in some people. In this section, we present to you a way of understanding
how all these factors come together to trigger the onset of this illness – called a stress vulnerability model.
First, we begin by looking at three key factors in this model, namely: genetic vulnerability, biological
vulnerability and socioenvironmental stress (or life stress).
Genetic Vulnerability
Bipolar disorder tends to run in families. First degree relatives of people with bipolar disorder have an
increased risk of developing bipolar disorder. Children of bipolar patients face an 8% risk of getting the
illness versus 1% in the population. Children of bipolar patients also face an increased risk (12%) of getting
unipolar depression (i.e., depression only, without mania). Identical twins are also more likely to both
develop this disorder than fraternal twins. While these results indicate to some extent that this disorder is
genetically inherited, they also suggest that there are other factors that may contribute to its development.
Biological Vulnerability
This refers to possible biochemical imbalances in the brain that makes a person vulnerable to experiencing
mood episodes. An imbalance of brain chemicals or an inability for them to function properly may lead to
episodes of “high” or “low” moods.
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Socioenvironmental Stress
Stressful events or circumstances in a person’s life, such as, family conflicts, employment difficulties,
bereavement, or even positive events, such as getting married, having children, moving house, etc, can place
extra demands on the person, leading to them feeling stressed, frustrated, anxious, sad, etc. The
occurrence of bipolar disorder can thus be explained as an interaction of the 3 above factors. A person
who is genetically and/or biologically vulnerable may not necessarily develop bipolar disorder. These
vulnerabilities are affected by how they cope with stressors in their life. For example, a person who has a
family history of diabetes may not develop diabetes if they are careful with they eat and have enough
exercise. This brings us to a discussion on protective and risk factors.
Protective and Risk Factors
A risk factor is something that will increase the chances of a person who is already vulnerable becoming ill.
Examples of risk factors are: poor or maladaptive coping strategies, alcohol or drug use, irregular daily
routines, interpersonal conflicts, stressful events, etc. Protective factors, on the other hand, are those that
can help to prevent a vulnerable person from becoming ill. Protective factors include good coping
strategies, good social support networks, effective communication and problem solving skills, etc. It is
when the risk factors outweigh the protective factors, that the chances of developing the disorder are high.
This principle applies when considering the risk of recurrence as well.
Course of Illness
While some patients may experience long periods of normal moods, most individuals with bipolar disorder
will experience repeated manic and/or depressive episodes throughout their lifetime. The ratio of manic
episodes to depressive episodes will vary from one individual to the next, as will the frequency of episodes.
Some individuals may experience only two or three episodes in their lifetime while others may experience
a rapid cycling pattern of four or more episodes of illness per year. Whatever the pattern, it is important
that bipolar patients learn effective ways of managing their illness and preventing the recurrence of further
episodes.
On the next page is a Stress-Vulnerability Worksheet. This is for you to record factors in your life that
might increase and decrease the risk of your experiencing an episode recurrence of depression, hypomania,
or mania. Being aware of all these factors is the first step towards learning how to minimise the risk factors
and maximise the protective factors so that ultimately you will be able to better manage your illness and
prevent episode recurrences.
Life Stress
Biological
Vulnerability
Genetic
Vulnerability
Stress Vulnerability
Risk Factors
• Noncompliance with
medication
• Alcohol/drug abuse
• Subsyndromal symptoms
• Irregular lifestyle
• Poor social support
• Psychosocial impairment
• Inappropriate coping
strategies
Risk of Recurrence
Protective Factors
• Compliance with
medication
• Regular/balanced lifestyle
• Good social support
• Appropriate coping
strategies
Risk of Recurrence
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Stress-Vulnerability Worksheet
Vulnerability Factors
: What factors do you think
might have increased your vulnerability to developing
bipolar disorder or a depressive, hypomanic, or manic
episode?
Stress Checklist:
Were you stressed by anything
happening in your life before you had a depressive,
hypomanic, or manic episode?
Risk Factors
: What things might increase your risk
of experiencing a depressive, hypomanic, or manic
episode?
Protective Factors
: What are some of the
resources and strengths you might have that might
decrease the risk of your experiencing a depressive,
hypomanic, or manic episode?
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Module Summary
• About 1% of the population suffers from bipolar disorder
• Bipolar disorder is the experience of exaggerated mood swings, where one can become extremely
euphoric, i.e., a hypomanic/manic episode, or extremely sad, i.e., a depressive episode
• Sufferers of bipolar disorder can be diagnosed with Bipolar 1 Disorder (severe depression and full-
blown mania), Bipolar 11 Disorder (severe depression and hypomania), or Cyclothymic Disorder
(brief periods of mild depression and hypomania)
• Frequent mood cycling, ie, more than 4 episodes a year, is known as Rapid Cycling
• Bipolar disorder is not caused by any one factor, but an interaction of factors that may contribute
to its development in some people – the three common factors are genetic vulnerability, biological
vulnerability, and life stress
• The risk of developing the illness and the risk of developing another episode after recovery from
one are affected by risk and protective factors
• Risk factors include: poor coping strategies, low level of social support, alcohol/drug use, irregular
daily routines, interpersonal conflicts, etc
• Protective factors include: good coping skills, good social support networks, effective
communication and problem-solving skills
• The ultimate aim is to minimise risk factors and maximise protective factors so that episode
recurrence can be prevented
Keep Going ...
In the next module, we will discuss the
various types of treatments for bipolar
disorder, and briefly evaluate the
effectiveness of each of those
treatment options.
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About The Modules
Contributors
Laura Smith (MPsych
1
)
Centre for Clinical Interventions
Dr Louella Lim (DPsych
2
)
Centre for Clinical Interventions
1
Masters of Psychology (Clinical Psychology)
2
Doctor of Psychology (Clinical Psychology)
Background
The concepts and strategies in these modules have been developed from evidence based psychological
practice, primarily Cognitive Behaviour Therapy. CBT for bipolar disorder is based on the approach that
adjunctive psychological treatment is helpful to improve understanding of the illness, medication adherence,
awareness of early warning signs of mood episodes, quality of life and to reduce symptoms.
References
These are some of the professional references that informed the development of modules in this
information package.
Basco, M.R., & Rush, A.J. (2005) Cognitive Behavioral Therapy for Bipolar Disorder (Second Edition). New
York: The Guildford Press
Bauer, M.S. & McBride, L. (2003) Structured Group Psychotherapy for Bipolar Disorder: The Life Goals
Program (Second Edition). New York: Springer Publishing Company
Goodwin, F.K. & Jamison K.R. (1990) Manic Depressive Illness. Oxford; Oxford University Press
Johnson, S.L. & Leahy, R.L. (2004) Psychological Treatment of Bipolar Disorder. New York: The Guildford
Press
Lam, D.H., Jones, S.H., Hayward, P., & Bright, J.A. (1999) Cognitive Therapy for Bipolar Disorder: A
therapist’s guide to concepts, methods and practice. Chichester: John Wiley & Sons Ltd
Miklowitz, D.J. (2001) Bipolar disorder. In David H. Barlow (Ed.) Clinical Handbook of Psychological
Disorders – Third Edition (pp 523-561). New York: Guilford Press
Newman, C.F., Leahy, R.L., Beck, A.T., Reilly-Harrington, N.A., & Gyulai, L. (2002) Bipolar Disorder: A
cognitive therapy approach. Washington: American Psychological Association
“KEEPING YOUR BALANCE”
This module forms part of:
Lim, L., & Smith, L. (2003). Keeping your Balance: Coping with Bipolar Disorder. Perth, Western Australia:
Centre for Clinical Interventions.
ISBN: 9780975198520 Created: March 2003
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