Bipolar I disorder

Bipolar I disorder is defined by the presence of a manic episode.   In Australia, a diagnosis of bipolar disorder is usually made by a psychiatrist using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria.

An abbreviated list of the manic episode criteria according to the DSM-5-TR is below:

A.      A period of elevated or expansive, irritable mood and increased activity and energy, lasting at least 1 week or longer (this can be less if hospitalisation is needed).

B.      The presence of 3 or more of the following symptoms:

1.      Inflated self-esteem

This can look like: thinking that you have great talents or other abilities,

feeling very attractive to others, being on top of the world and wanting to share this with others.

2.      Decreased need for sleep

This can look like: feeling rested after only a few hours of sleep with this lasting for many days, being busy and active when you are usually asleep, having so many ideas that you don’t want to rest.

3.      Flight of ideas or racing thoughts

This can look like: having too many thoughts that are hard to follow, having difficulty identifying thoughts as they are moving so quickly from one to the other, having many new ideas (eg new projects, business plans and activities).

4.      More talkative than usual

This can look like: talking very quickly to keep up with the racing thoughts, people having a hard time following what you are saying, communicating more often with others and with greater intensity (eg. posting more on social media than usual).

5.      Distractibility

This can look like: having trouble staying on one task, having so many thoughts and ideas that it’s difficult to follow them all, jumping from one idea to the next to try to keep up.

6.       Increase in goal-directed activity or psychomotor agitation

This can look like: not being able to sit still, feeling the need to move all the time, following through with ideas and plans (eg starting a new business).

7.      Excessive involvement in activities that have a high potential for painful consequences. 

This can look like:  taking drugs, excessive shopping, driving dangerously, engaging in sexual activity that is out of character.

C.     The episode causes impairment, hospitalisatiation is needed or there are psychotic symptoms.

D.     The episode is not caused by drugs or another medical condition.

Usually for people living with Bipolar I disorder, they will experience all the symptoms above in a manic episode.  It is not unusual for people to require hospitalisation for their episodes and sometimes this can happen quickly.

People living with Bipolar I disorder can also experience hypomanic episodes.  The symptoms of a hypomanic episode are similar to those of a manic episode, but the symptoms are not as severe and do not require hospitalisation.

Depression symptoms in Bipolar I disorder

Although a Bipolar I disorder diagnosis does not require an episode of depression, depression is the most common type of symptom experienced for most people with Bipolar I disorder.  It is also the type of episode that usually occurs first, with many people reporting several recurrent episodes of depression prior to their first manic episode.

An abbreviated list of the Major Depressive Disorder episode criteria according to the DSM-5-TR is below:

A. Five or more of the following symptoms for 2 weeks of longer (must include depressed mood or loss of interest or pleasure).

1.      Depressed mood most of the day nearly every day.

2.      Loss of interest in activities most of the day nearly every day.

3.      Weight loss/loss of appetite or weight gain/increase in appetite nearly every day.

4.      Insomnia or hypersomnia (sleeping more than usual) nearly every day.

5.      Psychomotor agitation or retardation nearly every day.

6.      Fatigue and loss of energy nearly every day.

7.      Feelings of worthlessness or excessive guilt nearly every day.

8.      Difficulty thinking or concentrating and making decisions nearly every day.

9.      Recurrent thoughts of death or dying, suicidal ideation or suicide attempt.

B.  The symptoms cause impairment or significant distress.

C. The episode is not caused by drugs or another medical condition.

Many people living with bipolar disorder also report depression symptoms outside of a full episode.  Hypersomnia (eg sleeping more than 10 hours a day) and loss of energy are some of the symptoms that are often reported frequently.

Psychotic symptoms in Bipolar I disorder

These can be common in both depression and mania for people living with Bipolar I disorder.  Common symptoms can be:

1.      Delusions

2.      Hallucinations

Delusions are the most reported psychotic symptom in bipolar disorder.  This can include delusions relating to mania (eg grandiose delusions) or in depression (eg delusions relating to excessive guilt).  Less common symptoms of psychosis for Bipolar I disorder include unusual smells or bodily sensations (eg skin crawling). 

Treatment

Medication is usually required for the ongoing management of Bipolar I disorder.  This will often include the use of mood stabilisers (such as lithium), anti-depressants and anti-psychotic medications. 

Guidelines for the treatment of bipolar disorder are published by the Royal Australians and New Zealand College of Psychiatrists (https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/mood-disorders-cpg).

These guidelines cover a range of areas and treatment types.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Chakrabarti, S., & Singh, N. (2022). Psychotic symptoms in bipolar disorder and their impact on the illness: a systematic review. World journal of psychiatry, 12(9), 1204.