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In the latter half of the 19th century and the early part of the 20th century, the German psychiatrist Emil Krapelin developed a classification scheme for psychiatric/psychological disorders that serves as the foundation of the modern classification system used by the American Psychiatric Association (APA). His early classification considered two syndromes of disorders: dementia praecox (now referred to as schizophrenia) and manic depression (a broad category of issues with mood that eventually evolved into bipolar disorder).  Even though some individuals attempt to explain that there are differences between the older term manic depression and the new term bipolar disorder, the diagnosis of manic depressive disorder is essentially the same diagnosis as the current conceptualization of bipolar disorder.

What Is Bipolar Disorder?

In the current classification system bipolar, disorder is not a singular diagnosis; instead, it is a term that describes several different but related psychological/psychiatric conditions. In general, bipolar disorder is a severe psychological/psychiatric disorder that consists of very specific variations in an individual’s mood and affect.

  • Mood refers to an individual’s subjective appraisal of their emotional state, essentially how an individual describes how they feel.
  • Affect refers to behaviors that an outsider observes that are used to infer the person’s emotional state. For instance, if you see an individual who is crying, you might infer the individual is sad.
  • In bipolar disorder, the range of mood and affect alternates from feelings of depression to manic-like states.
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The Current Conceptualization of Bipolar Disorder

Up until 2013, APA included bipolar disorder under the category of mood disorders. Mood disorders are psychiatric/psychological disorders that primarily consist of dysfunctional states of an individual’s mood or their subjective emotional state. The term bipolar disorder was used to describe a specific set of disorders where there was a fluctuation between two poles of mood, mania, and depression.

As research continued to progress regarding the potential causes and manifestations of bipolar disorder, researchers began to conceptualize bipolar disorder as a bridge between major depressive disorder (severe clinical depression) and the psychotic disorders, such as schizophrenia. Bipolar disorder and related conditions were seen as a sort of middle ground between depression and psychosis as opposed to being a mood disorder. In the current version of the diagnostic manual used by APA that was released in 2013, the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), bipolar disorder was placed in a separate category (Bipolar and Related Disorders) and is no longer considered to be a mood disorder or a variation of depression.

Like the vast majority of the disorders listed in the DSM-5, there are no medical tests, brain scans, laboratory tests, etc., that can diagnose bipolar disorder. Instead, clinicians use a set of behavioral criteria to make the diagnosis.

Bipolar disorder is characterized by the presence of mania or hypomania. Mania is defined as a period of abnormally elevated, expansive, or irritable displays of mood or affect that last for at least one week; if the individual’s behavior results in them being hospitalized and medicated, it need not last for an entire week. Specific manifestations of mania include:

  • Extreme talkativeness
  • Grandiose behavior or extremely inflated self-esteem
  • A significant decrease in the need for sleep
  • Racing thoughts, often observed as very rapid and prolonged speech
  • Being very distractible
  • Significant hyperactivity
  • An increase in potentially dangerous behaviors that include gambling binges, shopping binges, having multiple sexual encounters, etc.
  • A significant increase in goal-directed behavior, such as housecleaning, pacing, work-related behaviors, etc.

An individual need not display all of the above symptoms to be diagnosed with mania. A less intense form of mania termed hypomania is characterized as lasting for four days or more as opposed to a minimum of one week, and it is associated with less functional impairment (often characterized by significant irritability).

It should be stressed that mania is not necessarily equated with “feeling good,” and individuals who are extremely distractible or hyperactive, and engaging in destructive behaviors may have feelings of elation, but these individuals often report that these experiences are not overtly positive even though they were caught up in them when they occurred. In addition, manic episodes are notoriously short-lived (often lasting only for hours or a few days) whereas depressive symptoms may occur for months.

The definitive symptom for diagnosing bipolar disorder is the presence of mania (or hypomania). Individuals with bipolar disorder also often experience alternating episodes of clinical depression. Like mania, clinical depression is diagnosed by a set of behavioral criteria. An individual must the display at least five of 11 symptoms consistently over a two-week period, and one of the symptoms must include significant feelings of sadness or a significant loss of interest or the ability to experience pleasure.

Bipolar Disorder Is Not One Disorder

There are numerous presentations that can occur in bipolar disorder. APA recognizes two primary types of bipolar disorder.

  • Bipolar I disorder is diagnosed when an individual meets the diagnostic criteria for at least one full episode of mania. The person may, or may not, have had episodes of depression or hypomania.
  • Bipolar II disorder is diagnosed when the individual has displayed at least one episode of hypomania. No manic episodes can be documented in the individual, and they may or may not have had depression.

Numerous other presentations occur that are often described as different types of bipolar disorder, such as bipolar disorder with rapid cycling (displaying four or more episodes of mania, hypomania, or depression within a 12-month period), bipolar disorder with psychotic features (the presence of hallucinations and/or delusions), bipolar disorder with seasonal pattern (some symptoms of the disorder regularly occurring during specific times of the year), etc. However, all of these other presentations must include either mania or hypomania.

Manic-like behavior can be the result of a medical condition, such as a stroke, brain injury, or metabolic condition, or it can result from the use of drugs or alcohol. Depressive symptoms can also occur as a result of a medical condition or the use of drugs or alcohol. APA designates specific diagnostic categories for individuals who display these behaviors as a result of these other conditions. True bipolar disorder does not have a known cause and is most likely the result of the interaction between heredity and environment.

Bipolar Disorder and Alcohol Abuse

According to APA, individuals with a diagnosis of bipolar disorder are very often also diagnosed with other mental health disorders (comorbidity). One of the most common dual diagnoses is a diagnosis of bipolar disorder and a substance use disorder. APA reports that alcohol is the most commonly abused substance in individuals with bipolar disorder.

The research that describes the prevalence of co-occurring bipolar disorder and alcohol use disorder often combines both bipolar I and bipolar II disorders.

  • The 12-month prevalence for bipolar I disorder in the United States is reported as being 0.6 percent, with equivalent prevalence rates between males and females.
  • The 12-month prevalence for bipolar II disorder in the United States is reported as being 0.8 percent.

Research studies investigating the relationship between bipolar disorder and substance use disorders report that 33-61 percent of individuals with a diagnosis of bipolar disorder also have a co-occurring alcohol use disorder, depending on the study. In general, sources report that about 50 percent of individuals who receive a diagnosis of bipolar disorder will also qualify for a diagnosis of alcohol use disorder.

The reasons for the strong relationship between bipolar disorder and substance abuse are not well defined. Explanations range from the common “self-medication” hypothesis (people use alcohol to deaden their emotional symptoms) to more sophisticated notions of genetic contributions and environmental interactions with an individual’s genes. No explanation for this relationship has been definitively demonstrated, although the most popular notion among professional researchers and clinicians is that individuals who develop one form of psychiatric/psychological disorder are at an increased risk to develop numerous other psychological/psychiatric disorders. The increased risk is due to a combination of family history, genetics, and experiences all interacting in unique ways in different individuals.

Treatment for Co-Occurring Disorders

Individuals who have a dual diagnosis of an alcohol use disorder and bipolar disorder present with very complicated issues when these disorders are being treated. In addition, APA reports that bipolar disorder is comorbid with numerous other mental health disorders that can complicate the situation further. The initial treatment approach for bipolar disorder is the use of medications to control issues with mania and hypomania. Numerous medications can be used to treat individuals with manic or hypomanic behaviors, including:

  • Lithium
  • Anticonvulsant medications or mood stabilizers
  • Antipsychotic medications
  • Antidepressant medications, particularly selective serotonin reuptake inhibitors (primarily used in the treatment of depression)

The use of psychotherapy is not considered appropriate for the treatment of mania or hypomania as a sole treatment approach. Therapy can be useful for adjustment issues and treatment compliance, as individuals with bipolar disorder are notoriously noncompliant with their treatment.

When an individual has a dual diagnosis of bipolar disorder and an alcohol use disorder, it is imperative that both disorders be treated concurrently. Attempting to address only the bipolar disorder or the alcohol use disorder, and not treating the other disorder, will not be successful.

Treatment programs for individuals with co-occurring disorders are often described as integrated treatment approaches. These programs utilize a team of treatment professionals who work together to treat issues associated with both disorders. An individual with bipolar disorder and a co-occurring alcohol use disorder would be thoroughly evaluated by several physicians and therapists. They would, most likely, initially be placed on medication for bipolar disorder and in a physician-assisted withdrawal management program for their alcohol abuse (sometimes referred to as medical detox).

Initial treatment would most likely be performed on an inpatient basis. Once the individual has completed the withdrawal management program, they would continue on their medication for bipolar disorder and with any other medically assisted treatments for other co-occurring issues, including depression.

The individual would be expected to attend substance use disorder therapy, other forms of psychotherapy as needed in the individual case, group therapy, and social support groups for both bipolar disorder and for alcohol abuse. Other treatment providers would provide other supports as deemed necessary in the specific case, such as vocational rehabilitation, job training, childcare, parenting instruction, etc. Case management and other supports would also be put into place.

Medical treatment for bipolar disorder would be ongoing over the course of the person’s life. Treatment for the individual’s alcohol use disorder should also be extensive, and the individual should continue to participate in treatment-related activities, such as social support groups (e.g., Alcoholics Anonymous), for many years. An individual who stops taking their medication or experiences a relapse of their bipolar disorder would automatically be assumed to relapse in regard to their use of alcohol, and vice versa.