View source for Bipolar disorder

'''Bipolar disorder''' or '''manic-depressive disorder''', also referred to as '''bipolar [[Affect (psychology)|affective]] disorder''' or '''manic depression''', is a [[Classification of mental disorders|psychiatric diagnosis]] that describes a category of [[mood disorders]] defined by the presence of one or more episodes of abnormally elevated energy levels, [[cognition]], and [[Mood (psychology)|mood]] with or without one or more depressive episodes. The elevated moods are clinically referred to as [[mania]] or, if milder, [[hypomania]]. Individuals who experience manic episodes also commonly experience [[major depressive episode|depressive]] episodes, or symptoms, or [[mixed episodes]] in which features of both mania and depression are present at the same time.<ref>Basco, Monica Ramirez. (2006). ''The Bipolar Workbook: Tools for Controlling Your Mood Swings''.  NY: The Guilford Press, p. viii.</ref> These episodes are usually separated by periods of "normal" [[mood (psychology)|mood]]; but, in some individuals, depression and mania may rapidly alternate, which is known as [[rapid cycling]]. Extreme manic episodes can sometimes lead to such [[psychotic]] symptoms as [[delusions]] and [[hallucinations]]. The disorder has been subdivided into [[bipolar I]], [[bipolar II]], [[cyclothymia]], and other types, based on the nature and severity of mood episodes experienced; the range is often described as the [[bipolar spectrum]].

Data from the United States on [[lifetime prevalence]] varies; but it indicates a rate of around 1% for bipolar I, 0.5%–1% for bipolar II or [[cyclothymia]], and 2%–5% for subthreshold cases meeting some, but not all, criteria.{{Citation needed|date=December 2010}} The onset of full [[symptom]]s generally occurs in late adolescence or young adulthood. Diagnosis is based on the person's self-reported experiences, as well as observed behavior. Episodes of abnormality are associated with distress and disruption and an elevated risk of [[suicide]], especially during depressive episodes. In some cases, it can be a devastating long-lasting disorder. In others, it has also been associated with creativity, goal striving, and positive achievements. There is significant evidence to suggest that [[list of people affected by bipolar disorder|many people]] with creative talents have also suffered from some form of bipolar disorder.<ref>{{cite doi|10.1016/S0165-0327(02)00462-7}}</ref>

[[Genetics|Genetic factors]] contribute substantially to the likelihood of developing bipolar disorder, and environmental factors are also implicated. Bipolar disorder is often treated with [[mood stabilizing medication]]s and, sometimes, other psychiatric drugs. [[Psychotherapy]] also has a role, often when there has been some recovery of the subject's stability. In serious cases, in which there is a risk of harm to oneself or others, [[involuntary commitment]] may be used. These cases generally involve severe manic episodes with dangerous behavior or depressive episodes with suicidal ideation. There are widespread problems with [[social stigma]], [[stereotypes]], and [[prejudice]] against individuals with a diagnosis of bipolar disorder.<ref>{{cite web|url=http://bipolar.about.com/od/stigma/Stigma.htm|publisher=NIMH|title=Stigma and Bipolar Disorder|date=February 21, 2009|accessdate=2010-11-08}}</ref> People with bipolar disorder exhibiting psychotic symptoms can sometimes be misdiagnosed as having [[schizophrenia]], another serious mental illness.<ref>{{cite web|url=http://www.nimh.nih.gov/health/publications/bipolar-disorder/what-are-the-symptoms-of-bipolar-disorder.shtml|publisher=NIMH|title=What are the symptoms of bipolar disorder?|date=April 15, 2009|accessdate=2010-09-19}}</ref>

The current term "bipolar disorder" is of fairly recent origin and refers to the cycling between high and low episodes (poles). A relationship between mania and [[melancholia]] had long been observed, although the basis of the current conceptualisation can be traced back to French psychiatrists in the 1850s. The term "manic-depressive illness" or psychosis was coined by German psychiatrist [[Emil Kraepelin]] in the late nineteenth century, originally referring to all kinds of mood disorder. German psychiatrist [[Karl Leonhard]] split the classification again in 1957, employing the terms [[unipolar disorder]] ([[major depressive disorder]]) and bipolar disorder.

==Signs and symptoms==
Bipolar disorder is a condition in which people experience abnormally elevated (manic or hypomanic) and, in many cases, abnormally depressed states for periods of time in a way that interferes with functioning. Not everyone's symptoms are the same, and there is no simple physiological test to confirm the disorder. Bipolar disorder can appear to be [[unipolar depression]].  Diagnosing bipolar disorder is often difficult, even for mental health professionals.  What distinguishes bipolar disorder from unipolar depression is that the affected person experiences states of mania and depression. Often bipolar is inconsistent among patients because some people feel depressed more often than not and experience little mania whereas others experience predominantly manic symptoms.  Additionally, the younger the age of onset—bipolar disorder starts in childhood or early adulthood in most patients—the more likely the first few episodes are to be depression.<ref name="Bowden">{{cite web|url=http://www.ps.psychiatryonline.org/cgi/content/full/52/1/51|title=Strategies to Reduce Misdiagnosis of Bipolar Depression|last=Bowden|first=Charles L., M.D.|publisher=[[American Psychiatric Association]]|date=January 2001|accessdate=2010-12-06}}</ref> Because a bipolar diagnosis requires a manic or hypomanic episode, many patients are initially diagnosed and treated as having major depression.

===Depressive episode===
{{Main|Major depressive episode}}
Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of [[sadness]], [[anxiety]], [[guilt]], [[anger]], [[isolation]], or [[hopelessness]]; disturbances in sleep and appetite; fatigue  and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; [[depersonalization]]; loss of interest in sexual activity; shyness or [[social anxiety]]; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal ideation.<ref name="Mayo-dsection2">{{cite web|url=http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=2 |title=Bipolar Disorder: Signs and symptoms |publisher=Mayo Clinic |accessdate= |work= }}{{dead link|date=January 2011}}</ref> In severe cases, the individual may become [[psychotic]], a condition also known as severe bipolar depression with psychotic features. These symptoms include [[delusion]]s or, less commonly, [[hallucination]]s, usually unpleasant.<ref>{{Harvnb |American Psychiatric Association|2000a| p=412}}</ref>  A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.<ref name=APA349>{{Harvnb |American Psychiatric Association|2000a| p=349}}</ref>

===Manic episode===
{{Main|Mania}}
Mania is the signature characteristic of bipolar disorder and, depending on its severity, is how the disorder is classified. Mania is generally characterized by a distinct period of an elevated mood, which can take the form of euphoria. People commonly experience an increase in energy and a decreased need for sleep, with many often getting as little as 3 or 4 hours of sleep per night, while others can go days without sleeping.<ref>American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC. pp357</ref> A person may exhibit [[pressured speech]], with [[racing thoughts|thoughts experienced as racing]].<ref>{{cite web|url=http://bipolar.about.com/od/maniahypomani1/a/mania.htm|title=Warning Signs of Mania|last=Read|first=Kimberly|publisher=About.com|date=2010-02-27|accessdate=2010-12-06}}</ref> Attention span is low, and a person in a manic state may be easily distracted. Judgment may become impaired, and sufferers may go on spending sprees or engage in behavior that is quite abnormal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive, intolerant, or intrusive. People may feel out of control or unstoppable, or as if they have been "chosen" and are "on a special mission" or have other grandiose or delusional ideas. Sexual drive may increase. At more extreme phases of bipolar I, a person in a manic state can begin to experience [[psychosis]], or a break with reality, where thinking is affected along with mood.<ref name="NIHpublication08-3679">{{cite web|url=http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-publication.shtml |title=NIMH · Bipolar Disorder: NIH Publication 08-3679, Revised 2008 |publisher=Nimh.nih.gov |date= |accessdate=2011-01-15}}</ref> Some people in a manic state experience severe [[anxiety]] and are very irritable (to the point of rage), while others are [[euphoria (emotion)|euphoric]] and grandiose.

To be diagnosed with mania according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a person must experience this state of elevated or irritable mood, as well as other symptoms, for at least one week, less if hospitalization is required.<ref>{{cite web
| title = Bipolar disorder: Tests and diagnosis
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Severity of manic symptoms can be measured by rating scales such as self-reported  [[Altman Self-Rating Mania Scale]] <ref>Altman EG., Hedeker D., Perterson JL., Davis J.M.  The Altman Self-Rating Mania Scale. Biol Psychiatry. 1997 Nov 15;42(10):948-55. PMID 9359982</ref> and clinician-based  [[Young Mania Rating Scale]]  <ref name="YMRS_paper">{{cite journal |author=Young RC, Biggs JT, Ziegler VE, Meyer DA |title=A rating scale for mania: reliability, validity and sensitivity |journal=Br J Psychiatry |volume=133 |pages=429–35 |year=1978 |month=Nov |pmid=728692 |url=http://bjp.rcpsych.org/cgi/content/abstract/133/5/429 |doi=10.1192/bjp.133.5.429}}</ref>. 

===Hypomanic episode===
{{Main|Hypomanic episode}}
Hypomania is generally a mild to moderate level of mania, characterized by optimism, pressure of speech and activity, and decreased need for sleep. Generally, hypomania does not inhibit functioning like mania.<ref>{{cite web|url=http://www.webmd.com/bipolar-disorder/guide/hypomania-mania-symptoms|title=Hypomania and Mania Symptoms in Bipolar Disorder|publisher=WebMD.com|date=January 10, 2010}}</ref> Many people with hypomania are actually in fact more productive than usual, while manic individuals have difficulty completing tasks due to a shortened attention span. Some people have increased creativity while others demonstrate poor judgment and irritability. Many people experience signature [[hypersexuality]]. These persons generally have increased energy and tend to become more active than usual. They do not, however, have [[delusions]] or hallucinations. Hypomania can be difficult to diagnose because it may masquerade as mere happiness, though it carries the same risks as mania.

Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong.<ref>{{cite web|url=http://www.pueblo.gsa.gov/cic_text/health/bipolar/bipolar.htm |title=Bipolar Disorder: NIH Publication No. 95-3679|publisher=U.S. National Institutes of Health|date=September 1995 |archiveurl = http://web.archive.org/web/20080429204140/http://www.pueblo.gsa.gov/cic_text/health/bipolar/bipolar.htm |archivedate = 2008-04-29}}</ref>  Also, the individual may not be able to recall the events that took place while they were experiencing hypomania.<ref name="Bowden"/> What might be called a "hypomanic event", if not accompanied by complementary depressive episodes ("downs", etc.), is not typically deemed as problematic: The "problem" arises when mood changes are uncontrollable and, more importantly, volatile or "mercurial". If unaccompanied by depressive counterpart episodes or otherwise general [[irritability]], this behavior is typically called [[hyperthymia]], or [[happiness]], which is, of course, perfectly normal. Indeed, the most elementary definition of bipolar disorder is an often "violent" or "jarring" state of essentially uncontrollable [[oscillation]] between [[hyperthymia]] and [[dysthymia]].  If left untreated, an episode of hypomania can last anywhere from a few days to several years. Most commonly, symptoms continue for a few weeks to a few months.<ref>{{cite web|url=http://www.webmd.com/bipolar-disorder/guide/bipolar-2-disorder|title=Bipolar II Disorder Symptoms and Signs|publisher=[[Web M.D.]]|accessdate=2010-12-06}}</ref>

===Mixed affective episode===
{{Main|Mixed state (psychiatry)}}
In the context of bipolar disorder, a mixed state is a condition during which symptoms of [[mania]] and [[clinical depression]] occur simultaneously.<ref>{{cite web|url=http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=7 |title=Bipolar Disorder: Complications |accessdate= |publisher=Mayo Clinic}}{{dead link|date=January 2011}}</ref>  Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. Individuals may also feel incredibly frustrated in this state, since one may feel like a failure and at the same time have a [[flight of ideas]]. Mixed states are often the most dangerous period of mood disorders, during which [[substance abuse]], [[panic disorder]], [[suicide]] attempts, and other complications increase greatly.<ref>Goldman, E. (1999). Severe Anxiety, Agitation are Warning Signals of Suicide in Bipolar Patients. ''Clin Psychiatr News''. pg 25.</ref>

===Associated features===
{{Main|Associated features of bipolar disorder}}
Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria for the disorder. There are several childhood precursors in children who later receive a diagnosis of bipolar disorder. They may show subtle early traits such as mood abnormalities, full major depressive episodes, and [[ADHD]].<ref name="pmid2504732">{{cite journal |author=Andreoli TE |title=Molecular aspects of endocrinology |journal=Hosp. Pract. (Off. Ed.) |volume=24 |issue=8 |pages=11–2 |year=1989 |month=August |pmid=2504732 |doi= |url=}}</ref> BD is also accompanied by changes in [[Cognition|cognitive]] processes and abilities. This include reduced [[attention|attentional]] and [[Executive functions|executive]] capabilities and impaired [[memory]]. How the individual processes the world also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states.<ref name="Mansell2008">{{cite journal | pmid = 17825463 | doi=10.1016/j.cpr.2007.07.010 | volume=28 | issue=3 | journal = Clinical Psychology Review | year=2008 | title = The ascent into mania: A review of psychological processes associated with the development of manic symptoms | month=March | pages=494–520 | author=Mansell W, Pedley R | ref = harv}}</ref> Some studies have found a significant association between bipolar disorder and [[creativity]].<ref name="pmid20936438">{{cite journal |author=Srivastava S, Ketter TA |title=The link between bipolar disorders and creativity: evidence from personality and temperament studies |journal=Curr Psychiatry Rep |volume=12 |issue=6 |pages=522–30 |year=2010 |month=December |pmid=20936438 |doi=10.1007/s11920-010-0159-x |url=}}</ref>

==Causes==
The causes of bipolar disorder likely vary between individuals. [[Twin studies]] have been limited by relatively small sample sizes but have indicated a substantial genetic contribution, as well as environmental influence. For bipolar I, the (probandwise) [[concordance (genetics)|concordance]] rates in modern studies have been consistently put at around 40% in [[monozygotic]] twins (same genes), compared to 0 to 10% in [[dizygotic]] twins.<ref name="Kieseppa_2004">{{Cite journal|author=Kieseppä T, Partonen T, Haukka J, Kaprio J, Lönnqvist J |title=High concordance of bipolar I disorder in a nationwide sample of twins |journal=Am J Psychiatry |volume=161 |issue=10 |pages=1814–21 |year=2004 |month=October |pmid=15465978 |doi=10.1176/appi.ajp.161.10.1814 |url=|ref=harv}}</ref> A combination of bipolar I, II and [[cyclothymia]] produced concordance rates of 42% vs 11%, with a relatively lower ratio for bipolar II that likely reflects heterogeneity. The overall [[heritability]] of the [[bipolar spectrum]] has been put at 0.71.<ref name="Edvardsen2008">{{cite journal | pmid = 17692389 | doi=10.1016/j.jad.2007.07.001 | volume=106 | issue=3 | journal = Journal of Affective Disorders | year=2008 | title = Heritability of bipolar spectrum disorders. Unity or heterogeneity | month=March | pages=229–40 | author=Edvardsen J, Torgersen S, Røysamb E, ''et al.'' | ref = harv}}</ref> There is overlap with [[unipolar depression]] and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67% in monozigotic twins and 19% in dizigotic.<ref>{{Cite journal| last = McGuffin | first = P | last2 = Rijsdijk | first2 = F | last3 = Andrew | first3 = M | last4 = Sham | first4 = P | last5 = Katz | first5 = R | last6 = Cardno | first6 = A | title = The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression | journal = Archives of General Psychiatry | volume = 60 | issue = 5 | pages = 497–502 | year = 2003 | url = http://archpsyc.ama-assn.org/cgi/content/abstract/60/5/497 | doi = 10.1001/archpsyc.60.5.497 | pmid = 12742871| ref = harv}}</ref> The relatively low concordance between dizygotic twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes.<ref name="Edvardsen2008" />

===Genetic===
Genetic studies have suggested many [[chromosomal]] regions and [[candidate gene]]s appearing to relate to the development of bipolar disorder, but the results are not consistent and often not replicated.<ref>{{cite journal | pmid = 17239033 | doi=10.1111/j.1440-1819.2007.01604.x | volume=61 | issue=1 | journal = Psychiatry and Clinical Neurosciences | year=2007 | title = Molecular genetics of bipolar disorder and depression | month=February | pages=3–19 | author=Kato T | ref = harv}}</ref> 

Although the first [[genetic linkage]] finding for mania was in 1969,<ref>Reich, T., P. J. Clayton and G. Winokur (1969). "Family history studies-V  The genetics of Mania." American Journal of Psychiatry l25: l358–1369.</ref> the linkage studies have been inconsistent.<ref name="Burmeister2008" />. Meta-analyses of linkage studies detected either no significant genome-wide findings or, using a different methodology, only two genome-wide significant peaks, on chromosome 6q and on 8q21.{{fact|date=January 2011}} Genome-wide [[genetic association|association]] studies neither brought a consistent focus&nbsp;— each has identified new loci.<ref name="Burmeister2008">Margit Burmeister, Melvin G. McInnis, & Sebastian Zöllner [http://www.nature.com/nrg/journal/v9/n7/abs/nrg2381.html Psychiatric genetics: progress amid controversy] Nature Reviews Genetics 9, 527–540 (July 2008) | doi:10.1038/nrg2381</ref>

Findings point strongly to heterogeneity, with different genes being implicated in different families.<ref>{{cite journal | author = Segurado R, Detera-Wadleigh SD, Levinson DF, Lewis CM, Gill M, Nurnberger JI Jr, Craddock N ''et al.'' | year = 2003 | title = Genome Scan Meta-Analysis of Schizophrenia and Bipolar Disorder, Part III: Bipolar Disorder | url = | journal = Am J Hum Genet | volume = 73 | issue = 1| pages = 49–62 | pmid = 12802785 | pmc = 1180589 | doi=10.1086/376547 | ref = harv}}</ref> A review seeking to identify the more consistent findings suggested several genes related to [[serotonin]] (SLC6A4 and TPH2), [[dopamine]] (DRD4 and SLC6A3), [[glutamate]] (DAOA and DTNBP1), and cell growth and/or maintenance pathways (NRG1, DISC1 and [[BDNF]]), although noting a high risk of false positives in the published literature. It was also suggested that individual genes are likely to have only a small effect and to be involved in some aspect related to the disorder (and a broad range of "normal" human behavior) rather than the disorder per se.<ref name="Serretti" />

[[Paternal age effect|Advanced paternal age]] has been linked to a somewhat increased chance of bipolar disorder in offspring, consistent with a hypothesis of increased new [[genetic mutations]].<ref>Frans, E., Sandin, S., Reichenberg, A., Lichtenstein, P., Langstrom, N., Hultman, C. (2008) [http://archpsyc.ama-assn.org/cgi/content/short/65/9/1034 Advancing Paternal Age and Bipolar Disorder] Arch Gen Psychiatry. 2008;65(9):1034–1040.</ref>

===Physiological===
Abnormalities in the structure and/or function of certain brain circuits could underlie bipolar. A general reduction of brain volume and anatomically specific differences in areas such as the [[prefrontal cortex]] and the [[globus pallidus]] are most commonly found.<ref name="pmid19721106">{{cite journal |author=Arnone D, Cavanagh J, Gerber D, Lawrie SM, Ebmeier KP, McIntosh AM |title=Magnetic resonance imaging studies in bipolar disorder and schizophrenia: meta-analysis |journal=Br J Psychiatry |volume=195 |issue=3 |pages=194–201 |year=2009 |month=September |pmid=19721106 |doi=10.1192/bjp.bp.108.059717 |url=http://bjp.rcpsych.org/cgi/content/full/195/3/194}}</ref>

The "kindling" theory asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events,<ref name="kindling">[http://www.bpinfo.net/kindling_theory.htm Link and reference involving kindling theory]</ref> each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and become recurrent) by itself. There is evidence of [[hypothalamic-pituitary-adrenal axis]] (HPA axis) abnormalities in bipolar disorder due to [[stress (biological)|stress]].<ref>Brian Koehler, Ph.D., The International Society for the Psychological Treatment Of Schizophrenia and Other Psychoses, [http://www.isps-us.org/koehler/bipolar_stress.htm Bipolar Disorder, Stress, and the HPA Axis], 2005.</ref>

Other brain components which have been proposed to play a role are the [[mitochondria]],<ref name="pmid16027739">{{cite journal |author=Stork C, Renshaw PF |title=Mitochondrial dysfunction in bipolar disorder: evidence from magnetic resonance spectroscopy research |journal=Mol. Psychiatry |volume=10 |issue=10 |pages=900–19 |year=2005 |month=October |pmid=16027739 |doi=10.1038/sj.mp.4001711 |url=}}</ref> and a sodium ATPase pump,<ref>{{Cite book|title=Focus on Bipolar Disorder Research|author=Malcomb R. Brown|coauthors=Michael R. Basso|page=16|year=2004|publisher=[[Nova Science Publishers]]|isbn=978-1594540592}}</ref> causing cyclical periods of poor neuron firing (depression) and hyper sensitive neuron firing (mania). This may only apply for type one, but type two apparently results from a large confluence of factors.{{Citation needed|date=February 2009}} [[Circadian rhythm]]s and melatonin activity also seem to be altered.<ref name="pmid19909672">{{cite journal |author=Dallaspezia S, Benedetti F |title=Melatonin, circadian rhythms, and the clock genes in bipolar disorder |journal=Curr Psychiatry Rep |volume=11 |issue=6 |pages=488–93 |year=2009 |month=December |pmid=19909672 |doi= |url=}}</ref>

===Environmental===
Evidence suggests that environmental factors play a significant role in the development and course of bipolar disorder, and that individual psychosocial variables may interact with genetic dispositions.<ref name="Serretti">{{cite journal | pmid = 18332878 | doi=10.1038/mp.2008.29 | volume=13 | issue=8 | journal = Molecular Psychiatry | year=2008 | title = The genetics of bipolar disorder: genome ‘hot regions,’ genes, new potential candidates and future directions | month=August | pages=742–71 | author=Serretti A, Mandelli L | ref = harv}}</ref> There is fairly consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for onsets and recurrences of unipolar depression.<ref name="Alloy2005">{{cite journal | pmid = 16140445 | doi=10.1016/j.cpr.2005.06.006 | volume=25 | issue=8 | journal = Clinical Psychology Review | year=2005 | title = The psychosocial context of bipolar disorder: Environmental, cognitive, and developmental risk factors | month=December | pages=1043–75 | author=Alloy LB, Abramson LY, Urosevic S, Walshaw PD, Nusslock R, Neeren AM | ref = harv}}</ref> There have been repeated findings that between a third and a half of adults diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a worse course, and more co-occurring disorders such as [[PTSD]].<ref>Gabriele S Leverich a, Robert M Post [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68450-X/fulltext Course of bipolar illness after history of childhood trauma] The Lancet, Volume 367, Issue 9516, Pages 1040–1042, April 1, 2006 doi:10.1016/S0140-6736(06)68450-XCite</ref> The total number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior.<ref>Louisa D. Grandin, Lauren B. Alloy, Lyn Y. Abramson (2007) [http://www.atypon-link.com/GPI/doi/abs/10.1521/jscp.2007.26.4.460 Childhood Stressful Life Events and Bipolar Spectrum Disorders] Journal of Social and Clinical Psychology, 26 (4) pp460–478 doi: 10.1521/jscp.2007.26.4.460</ref> Early experiences of adversity and conflict are likely to make subsequent [[developmental psychology|developmental challenges]] in adolescence more difficult, and are likely a potentiating factor in those at risk of developing bipolar disorder.<ref name="Miklowitz2008">David J. Miklowitz and Kiki D. Chan [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2504732 Prevention of Bipolar Disorder in At-Risk Children: Theoretical Assumptions and Empirical Foundations] Dev Psychopathol. Dev Psychopathol. 2008; 20(3): 881–897. doi: 10.1017/S0954579408000424.</ref>

==Diagnosis==
Diagnosis is based on the self-reported experiences of an individual as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a [[psychiatrist]], [[nurse]], [[social worker]], [[clinical psychologist]] or other clinician in a clinical assessment.  There are lists of criteria for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms. Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's [[Diagnostic and Statistical Manual of Mental Disorders]], the current version being DSM-IV-TR, and the [[World Health Organization|World Health Organization's]] [[ICD|International Statistical Classification of Diseases and Related Health Problems]], currently the ICD-10. The latter criteria are typically used in Europe and other regions while the DSM criteria are used in the USA and other regions, as well as prevailing in research studies.

An initial assessment may include a physical exam by a physician. Although there are no biological tests which confirm bipolar disorder, tests may be carried out to exclude medical illnesses such as [[hypothyroidism|hypo-]] or [[hyperthyroidism]], metabolic disturbance, a systemic infection or chronic disease, and [[syphilis]] or [[HIV]] infection. An [[Electroencephalography|EEG]] may be used to exclude [[epilepsy]], and a [[Computed tomography|CT scan]] of the head to exclude brain lesions. Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication.

Several [[rating scale]]s for the [[Screening (medicine)|screening]] and evaluation of BD exist, such as the [[Bipolar spectrum diagnostic scale]].<ref name="pmid19122534"/> The use of evaluation scales can not substitute a full clinical interview but they serve to systematize the recollection of symptoms.<ref name="pmid19122534"/>  On the other hand instruments for the screening of BD have low [[sensitivity]] and limited diagnostic [[Validity (statistics)|validity]].<ref name="pmid19122534">{{cite journal |author=Picardi A |title=Rating scales in bipolar disorder |journal=Curr Opin Psychiatry |volume=22 |issue=1 |pages=42–9 |year=2009 |month=January |pmid=19122534 |doi=10.1097/YCO.0b013e328315a4d2 |url=}}</ref>

===Criteria and subtypes===
There is no clear consensus as to how many types of bipolar disorder exist.<ref>{{Cite journal|author=Akiskal HS, Benazzi F | year = 2006 | month = May | title = The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum | journal = J Affect Disord. | volume = 92 | issue = 1 | pages = 45–54 | pmid = 16488021 | doi = 10.1016/j.jad.2005.12.035|ref=harv}}</ref> In [[DSM-IV-TR]] and [[ICD-10]], bipolar disorder is conceptualized as a [[Bipolar spectrum|spectrum of disorders]] occurring on a continuum. The DSM-IV-TR lists three specific subtypes and one for non-specified:<ref>{{vcite book |title=Diagnostic and Statistical Manual of Mental Disorders |edition=4th, text revision ([[DSM-IV-TR]]) |author=American Psychiatric Association |year=2000 |isbn=0-89042-025-4 |ref=DSM-IV-TR |publisher=<!-- pacify Citation bot --> |location=<!-- pacify Citation bot --> }} {{vcite book |chapter=Bipolar Disorder |chapterurl=http://www.behavenet.com/capsules/disorders/bipdis.htm }}</ref>

; [[Bipolar I disorder]]: One or more [[manic episodes]]. Subcategories specify whether there has been more than one episode, and the type of the most recent episode.<ref>{{vcite book |title=DSM-IV-TR |chapter=Bipolar I Disorder |chapterurl=http://www.behavenet.com/capsules/disorders/bip1dis.htm }}</ref> A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.
; [[Bipolar II disorder]]: No manic episodes, but one or more [[hypomanic]] episodes and one or more [[major depressive episode]].<ref>{{vcite book |title=DSM-IV-TR |chapter=Diagnostic criteria for 296.89 Bipolar II Disorder |chapterurl=http://www.behavenet.com/capsules/disorders/bip2dis.htm }}</ref> However, a bipolar II diagnosis is not a guarantee that they will not eventually suffer from such an episode in the future.{{Citation needed|date=March 2009}} Hypomanic episodes do not go to the full extremes of mania (''i.e.'', do not usually cause severe social or occupational impairment, and are without [[psychosis]]), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression.
; [[Cyclothymia]]: A history of hypomanic episodes with periods of [[Clinical depression|depression]] that do not meet criteria for [[major depressive episode]]s.<ref>{{vcite book |title=DSM-IV-TR |chapter=Diagnostic criteria for 301.13 Cyclothimic Disorder |chapterurl=http://www.behavenet.com/capsules/disorders/cclthymcdis.htm }}</ref> There is a low-grade cycling of mood which appears to the observer as a personality trait, and interferes with functioning.
; [[Bipolar NOS|Bipolar Disorder NOS]] (Not Otherwise Specified): This is a catchall category, diagnosed when the disorder does not fall within a specific subtype.<ref>{{vcite book |title=DSM-IV-TR |chapter=Not Otherwise Specified (NOS) |chapterurl=http://www.behavenet.com/capsules/disorders/nos.htm }}</ref> [[Bipolar NOS]] can still significantly impair and adversely affect the quality of life of the patient.

The bipolar I and II categories have specifiers that indicate the presentation and course of the disorder. For example, the "with full interepisode recovery" specifier applies if there was full remission between the two most recent episodes.<ref>{{vcite book |title=DSM-IV-TR |chapter=Longitudinal course specifiers for mood disorders |chapterurl=http://www.behavenet.com/capsules/disorders/clcs.htm }}</ref>

====Rapid cycling====
Most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months.<ref>{{Cite journal| last = Angst | first = J | last2 = Selloro | first2 = R | title = Historical perspectives and natural history of bipolar disorder | journal = Biological Psychiatry | volume = 48 | issue = 6 | pages = 445–457 | date = September 15, 2000 | doi = 10.1016/S0006-3223(00)00909-4 | pmid = 11018218| ref = harv}}</ref> ''Rapid cycling'', however, is a course specifier that may be applied to any of the above subtypes. It is defined as having four or more episodes per year and is found in a significant fraction of individuals with bipolar disorder. The definition of rapid cycling most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period.<ref>{{Cite journal| last = Mackin | first = P | last2 = Young | first2 = AH | title = Rapid cycling bipolar disorder: historical overview and focus on emerging treatments | journal = Bipolar Disorders | volume = 6 | issue = 6 | pages = 523–529 | year = 2004 | doi = 10.1111/j.1399-5618.2004.00156.x | pmid = 15541068| ref = harv}}</ref> Ultra-rapid (days) or ultra-ultra rapid or [[ultradian]] (within a day) cycling have also been described.<ref name="pmid14642014">{{cite journal |author=Tillman R, Geller B |title=Definitions of rapid, ultrarapid, and ultradian cycling and of episode duration in pediatric and adult bipolar disorders: a proposal to distinguish episodes from cycles |journal=J Child Adolesc Psychopharmacol |volume=13 |issue=3 |pages=267–71 |year=2003 |pmid=14642014 |doi=10.1089/104454603322572598 |url=}}</ref>

===Differential diagnosis===
There are several other mental disorders which may involve similar symptoms to bipolar disorder. These include [[schizophrenia]],<ref>{{Cite journal|author=Pope HG |year=1983 |title=Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports |journal=Hospital and Community Psychiatry |volume=34|pages=322–28|ref=harv}}</ref> [[schizoaffective disorder]], drug intoxication, brief drug-induced psychosis, [[schizophreniform disorder]] and [[borderline personality disorder]]. Both borderline personality and bipolar disorder can involve what are referred to as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months. The term in borderline personality refers to the marked [[Affective lability|lability]] and reactivity of mood, known as [[emotional dysregulation]], due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.<ref>Goodwin & Jamison. pp. 108–110.</ref> Some hold that borderline personality disorder represents a subthreshold form of mood disorder while others maintain the distinctness, though noting they often coexist.<ref name="pmid15453104">{{cite journal |author=Magill CA |title=The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges |journal=Can J Psychiatry |volume=49 |issue=8 |pages=551–6 |year=2004 |month=August |pmid=15453104 |doi= |url=}}</ref>

===Challenges===
The experiences and behaviors involved in bipolar disorder are often not understood by individuals or recognized by mental health professionals, so diagnosis may sometimes be delayed for over 10 years.<ref>{{cite web|url=http://www.familyaware.org/expertprofiles/drghaemi4.asp|title=Bipolar Disorder: How long does it usually take for someone to be diagnosed for bipolar disorder?|author=S. Nassir Ghaemi|year=2001|accessdate = February 20, 2007| archiveurl = http://web.archive.org/web/20061207224847/http://www.familyaware.org/expertprofiles/drghaemi4.asp| archivedate = December 7, 2006}}</ref> The treatment lag is apparently not decreasing, even though there is increased public awareness of the condition. 

Individuals are commonly misdiagnosed.<ref>{{Cite journal|title=Misdiagnosis of Bipolar Disorder|author=Roy H. Perlis|journal=American Journal of Managed Care|url=http://www.ajmc.com/Article.cfm?Menu=1&ID=2969|year=2005|accessdate = February 20, 2007|ref=harv}}</ref> An individual may appear simply depressed when they are seen by a health professional. This can result in misdiagnosis of [[Major Depressive Disorder]]. However, there is also a long-standing issue in the research literature as to whether a categorical classificatory divide between unipolar and bipolar depression is actually valid, or whether it is more accurate to talk of a continuum involving dimensions of depression and mania.<ref>Amy K. Cuellar, Sheri L. Johnson and Ray Winters (2005) Distinctions between bipolar and unipolar depression ''Clinical Psychology Review'', Vol 25, 3, May, P 307-339 {{PMID|15792852}} {{doi|10.1016/j.cpr.2004.12.002}}</ref><ref>Benazzi F. (2007) Is there a continuity between bipolar and depressive disorders? ''Psychother Psychosom'' 76(2):70-6. {{PMID|17230047}}</ref>

It has been noted that the bipolar disorder diagnosis is officially characterised in historical terms such that, technically, anyone with a history of (hypo)mania and depression has bipolar disorder whatever their current or future functioning and vulnerability. This has been described as "an ethical and methodological issue", as it means no one can be considered as being recovered (only "in [[remission (medicine)|remission]]") from bipolar disorder according to the official criteria. This is considered especially problematic given that brief hypomanic episodes are widespread among people generally and not necessarily associated with dysfunction.<ref name="Mansell2008" />

Flux is the fundamental nature of bipolar disorder.<ref>{{cite web|url=http://www.dbsalliance.org/site/PageServer?pagename=about_MDOverview |title=Depression and Bipolar Support Alliance: About Mood Disorders |publisher=Dbsalliance.org |date= |accessdate=2011-01-15}}</ref> Individuals with the illness have continual changes in energy, [[mood (psychology)|mood]], thought, sleep, and activity. The [[medical diagnosis|diagnostic]] [[subtypes]] of bipolar disorder are thus static descriptions—snapshots, perhaps—of an illness in continual flux, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness.<ref>Goodwin & Jamison, 1990.</ref> The [[DSM-V]], to be published in 2013, will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).

The diagnosis of bipolar disorder can be complicated by coexisting psychiatric conditions such as [[obsessive-compulsive disorder]], [[social anxiety disorder|social phobia]], [[panic disorder]], or [[attention-deficit/hyperactivity disorder]]. [[Substance abuse]] may predate the appearance of bipolar symptoms, further complicating the diagnosis. A careful longitudinal analysis of symptoms and episodes, enriched if possible by discussions with friends and family members, is crucial to establishing a treatment plan where these comorbidities exist.<ref>{{Cite journal|author=Sagman D and Tohen M |title=Comorbidity in Bipolar Disorder: The Complexity of Diagnosis and Treatment |journal=Psychiatric Times |volume= |issue= |year=2009 |url=http://www.psychiatrictimes.com/display/article/10168/1391541|ref=harv}}</ref>

==Management==
{{Main|Treatment of bipolar disorder}}
There are a number of [[pharmacological]] and [[psychotherapeutic]] techniques used to treat Bipolar Disorder. Individuals may use [[self-help groups for mental health|self-help]] and pursue a personal [[recovery model|recovery]] journey.

Hospitalization may be required especially with the manic episodes present in bipolar I. This can be voluntary or (if mental health legislation allows and varying state-to-state regulations in the USA) involuntary (called civil or [[involuntary commitment]]). Long-term inpatient stays are now less common due to [[deinstitutionalization]], although these can still occur.<ref name="BeckerKilian2006">{{cite journal | author = Becker T, Kilian R | year = 2006 | title = Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? | url = | journal = [[Acta Psychiatrica Scandinavica]] Supplement | volume = 429 | issue = 429| pages = 9–16 | pmid = 16445476 | doi=10.1111/j.1600-0447.2005.00711.x | ref = harv}}</ref> Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or [[Assertive Community Treatment]] team, supported employment and patient-led support groups, intensive outpatient programs.  These are sometimes referred to partial-inpatient programs.<ref>{{cite journal | pmid = 17329468 | doi=10.1176/appi.ajp.164.3.437 | volume=164 | issue=3 | journal = American Journal of Psychiatry | year=2007 | title = Cognitive Training for Supported Employment: 2-3 Year Outcomes of a Randomized Controlled Trial | month=March | pages=437–41 | author=McGurk SR, Mueser KT, Feldman K, Wolfe R, Pascaris A | ref = harv}}</ref>

===Psychosocial===
[[Psychotherapy]] is aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing [[prodromal]] symptoms before full-blown recurrence, and, practicing the factors that lead to maintenance of [[remission (medicine)|remission]]<ref>(Lam et al., 1999; Johnson & Leahy, 2004; Basco & Rush, 2005; Miklowitz & Goldstein, 1997; Frank, 2005.</ref> [[Cognitive behavioural therapy]], [[family therapy|family-focused therapy]], and [[psychoeducation]] have the most evidence for efficacy in regard to relapse prevention, while [[interpersonal and social rhythm therapy]] and cognitive-behavioural therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge.<ref>Zaretsky AE, Rizvi S, & Parikh SV. (2007). [http://publications.cpa-apc.org/media.php?mid=343 How well do psychosocial interventions work in bipolar disorder?] Can J Psychiatry, January;52(1):14–21.</ref> Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a [[therapeutic alliance]] in support of [[recovery model|recovery]].<ref>{{cite journal | pmid = 16170918 | volume=59 | journal = American journal of psychotherapy | issue=2 | title = Existential despair and bipolar disorder: the therapeutic alliance as a mood stabilizer. | year=2005 | pages=137–47 | author=Havens LL, Ghaemi SN | ref = harv}}</ref>

===Medication===
The mainstay of treatment is a mood stabilizer medication such as [[lithium carbonate]] or [[lamotrigine]].<ref>{{Cite journal|author=Geddes JR, Burgess S, Hawton K, Jamison K, Goodwin GM |title=Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials |journal=Am J Psychiatry |volume=161 |issue=2 |pages=217–22 |year=2004 |month=February |pmid=14754766 |doi= 10.1176/appi.ajp.161.2.217|url=|ref=harv}}</ref><ref>{{Cite journal|author=Bauer MS, Mitchner L |title=What is a "mood stabilizer"? An evidence-based response |journal=Am J Psychiatry |volume=161 |issue=1 |pages=3–18 |year=2004 |month=January |pmid=14702242 |doi= 10.1176/appi.ajp.161.1.3|url=|ref=harv}}</ref> Lamotrigine has been found to be best for preventing depressions, while lithium is the only drug proven to reduce suicide in bipolar patients. These two drugs comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is [[lithium pharmacology|lithium]],<ref>{{cite journal | doi = 10.1046/j.1365-2710.2000.00278.x | author = Poolsup N, Li Wan Po A, de Oliveira IR | year = 2000 | title = Systematic overview of lithium treatment in acute mania | url = | journal = J Clin Pharm Ther | volume = 25 | issue = 2| pages = 139–156 | pmid = 10849192 | ref = harv }}</ref> while almost as widely used is [[sodium valproate]],<ref name="Macr02">{{Cite journal| author = Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G. | title = Valproate for acute mood episodes in bipolar disorder| journal = The Cochrane Database of Systematic Reviews | volume = | issue = 2 | pages = CD004052| publisher = John Wiley and Sons, Ltd. | year= 2002 | url = http://www.cochrane.org/reviews/en/ab004052.html (abstract) | doi = 10.1002/14651858.CD004052| id = ISSN 1464-780X | pmid = 12535506| ref = harv}}</ref> also used as an [[anticonvulsant]]. Other anticonvulsants used in bipolar disorder include [[carbamazepine]], reportedly more effective in rapid cycling bipolar disorder, and [[lamotrigine]], which is the first anticonvulsant shown to be of benefit in bipolar depression.<ref>{{Cite journal|author=Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD |title=A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group |journal=J Clin Psychiatry |volume=60 |issue=2 |pages=79–88 |year=1999 |month=February |pmid=10084633 |doi= 10.4088/JCP.v60n0203|url=|ref=harv}}</ref> Depending on the severity of the case, anti-convulsants may be used in combination with lithium-based products or on their own.<ref>Barker, P. ed. 2003. Psychiatric and mental health nursing: the craft and caring. London: Arnold. pp284-285.</ref>

Treatment of the agitation in acute manic episodes has often required the use of [[antipsychotic]] medications, such as [[chlorpromazine]] and the [[atypical antipsychotic]]s [[quetiapine]] and [[olanzapine]]. More recently, olanzapine and quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder.<ref name="Olanzapine_maintenance_therapy">{{cite web | title = FDA Approves Zyprexa for Schizophrenia, Bipolar Disorder in Teens | url = http://psychcentral.com/news/2009/12/05/fda-approves-zyprexa-for-schizophrenia-bipolar-disorder-in-teens/9974.html | last = Grohol | first = John | date = 12-7-1009 | accessdate = 2010-12-30 | ref = harv | postscript = <!-- Bot inserted parameter. Either remove it; or change its value to "." for the cite to end in a ".", as necessary. -->{{inconsistent citations}}}}</ref> A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in [[prophylaxis]].<ref name="Tohen_et_al_2005">{{Cite journal|author=Tohen M, Greil W, Calabrese JR |title=Olanzapine versus lithium in the maintenance treatment of bipolar disorder: a 12-month, randomized, double-blind, controlled clinical trial |journal=Am J Psychiatry |volume=162 |issue=7 |pages=1281–90 |year=2005 |month=July |pmid=15994710 |doi=10.1176/appi.ajp.162.7.1281 |url=|ref=harv}}</ref>

The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes, especially if no mood stabiliser is used. However, most mood stabilizers are of limited effectiveness in depressive episodes. Rapid cycling can be induced or made worse by [[antidepressant]]s, unless there is adjunctive treatment with a mood stabilizer.<ref>{{cite web|url=http://www.wpic.pitt.edu/stanley/1stbipconf/bipolar2.htm#trtref|title=Treatment of refractory and rapid-cycling bipolar disorder}}</ref><ref>Sachs, GS, MD, et al. (2007) [http://content.nejm.org/cgi/content/abstract/356/17/1711 Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression] ''New England Journal of Medicine'', Volume 356:1711–1722 (Abstract).</ref> One large-scale study found that depression in bipolar disorder responds no better to an antidepressant with mood stabilizer than it does to a mood stabilizer alone.<ref>[http://goliath.ecnext.com/coms2/gi_0199-6442678/Bipolar-surprise-mood-disorder-endures.html Bipolar surprise: mood disorder endures antidepressant setback.] Science News, March 31, 2007, vol. 171, #13, p.196</ref> [[Omega 3 fatty acids]], in addition to normal pharmacological treatment, may have beneficial effects on depressive symptoms, although studies have been scarce and of variable quality.<ref name="pmid18425912">{{cite journal |author=Montgomery P, Richardson AJ |title=Omega-3 fatty acids for bipolar disorder |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD005169 |year=2008 |pmid=18425912 |doi=10.1002/14651858.CD005169.pub2 |url=}}</ref> [[Topiramate]] is an anticonvulsant sometimes prescribed as a mood stabilizer. However its efficay is unproven.<ref name="pmid16437453">{{cite journal |author=Vasudev K, Macritchie K, Geddes J, Watson S, Young A |title=Topiramate for acute affective episodes in bipolar disorder |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD003384 |year=2006 |pmid=16437453 |doi=10.1002/14651858.CD003384.pub2 |url=}}</ref>

==Prognosis==
For many individuals with bipolar disorder a good [[prognosis]] results from good treatment, which, in turn, results from an accurate [[medical diagnosis|diagnosis]]. Because bipolar disorder can have a high rate of both under-diagnosis and [[misdiagnosis]],<ref name="Bowden"/> it is often difficult for individuals with the condition to receive timely and competent treatment.

Bipolar disorder can be a severely disabling medical condition. However, many individuals with bipolar disorder can live full and satisfying lives. Quite often, medication is needed to enable this. Persons with bipolar disorder may have periods of normal or near normal functioning between episodes.<ref>{{Cite book|title=Riding the Roller Coaster: Living with Mood Disorders |author=Bergen M |year=1999 |publisher=Wood Lake Publishing Inc.|url=http://books.google.com/?id=s4dVLeND9l0C&lpg=PP1&dq=riding%20the%20roller%20coaster%2C%20living%20with%20mood&pg=PA26#v=onepage&q= |isbn=9781896836317}}</ref>

Prognosis depends on many factors such as the right medicines and dosage, comprehensive knowledge of the disease and its effects; a positive relationship with a competent medical doctor and therapist; and good physical health, which includes exercise, nutrition, and a regulated stress level. There are other factors that lead to a good prognosis, such as being very aware of small changes in a person's energy, mood, sleep and eating behaviors.<ref>{{cite web|title=Introduction|url=http://www.cs.umd.edu/class/spring2004/cmsc434/teams/rise/Introduction.htm|publisher=cs.umd.edu|accessdate=February 16, 2008}}</ref>

===Functioning===
A recent 20-year prospective study on bipolar I and II found that functioning varied over time along a spectrum from good to fair to poor. During periods of [[major depression]] or mania (in BPI), functioning was on average poor, with depression being more persistently associated with disability than mania. Functioning between episodes was on average good&nbsp;— more or less normal. Subthreshold symptoms were generally still substantially impairing, however, except for hypomania (below or above threshold) which was associated with improved functioning.<ref>Judd Lewis L.; Aksikal Hagop S.; Schettler Pamela J. ; Endicott Jean; Leon Andrew C.; Solomon David A.; Coryell William; Maser Jack D.; Keller Martin B. (2005) [http://archpsyc.ama-assn.org/cgi/reprint/62/12/1322.pdf Psychosocial disability in the course of bipolar I and II disorders : A prospective, comparative, longitudinal study] Archives of General Psychiatry, vol. 62, no12, pp. 1322–1330</ref>

Another study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately two-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States." Episodes of abnormality are associated with distress and disruption, and an elevated risk of [[suicide]], especially during depressive episodes.<ref>{{Cite journal| last = Ösby | first = U | last2 = Brandt | first2 = L | last3 = Correia | first3 = N | last4 = Ekbom | first4 = A | last5 = Sparén | first5 = P | title = Excess Mortality in Bipolar and Unipolar Disorder in Sweden | journal = Archives of General Psychiatry | volume = 58 | issue = 9 | pages = 844–850 | year = 2001 | url = http://archpsyc.ama-assn.org/cgi/content/abstract/58/9/844 | doi = 10.1001/archpsyc.58.9.844 | pmid = 11545667| ref = harv}}</ref>

===Recovery and recurrence===
A naturalistic study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.<ref>Tohen M, Zarate CA Jr, Hennen J, Khalsa HM, Strakowski SM, Gebre-Medhin P, Salvatore P, Baldessarini RJ. (2003) [http://ajp.psychiatryonline.org/cgi/content/full/160/12/2099 The McLean-Harvard First-Episode Mania Study: prediction of recovery and first recurrence] Am J Psychiatry. 2003 December;160(12):2099-107.</ref>

Symptoms precceding a relapse ([[prodromal]]), specially those related to mania, can be reliably identified by people with BD.<ref name="pmid12738039">{{cite journal |author=Jackson A, Cavanagh J, Scott J |title=A systematic review of manic and depressive prodromes |journal=J Affect Disord |volume=74 |issue=3 |pages=209–17 |year=2003 |month=May |pmid=12738039 |doi= |url=}}</ref> There have been intents to teach patients [[coping strategies]] when noticing such symptoms with encouraging results.<ref name="pmid16125292">{{cite journal |author=Lam D, Wong G |title=Prodromes, coping strategies and psychological interventions in bipolar disorders |journal=Clin Psychol Rev |volume=25 |issue=8 |pages=1028–42 |year=2005 |month=December |pmid=16125292 |doi=10.1016/j.cpr.2005.06.005 |url=}}</ref>

===Mortality===
Bipolar disorder can cause suicidal ideation that leads to [[suicidal]] attempts. One out of 3 people with bipolar disorder report past attempts of suicide or complete it,<ref name="pmid20148862">{{cite journal |author=Novick DM, Swartz HA, Frank E |title=Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence |journal=Bipolar Disord |volume=12 |issue=1 |pages=1–9 |year=2010 |month=February |pmid=20148862 |doi=10.1111/j.1399-5618.2009.00786.x |url=}}</ref> and the annual average suicide rate is 0.4%, which is 10 to 20 times that of the general population.<ref>{{Cite book | title = Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical ... |url = http://books.google.com/?id=u-ohbTtxCeYC&pg=PA1268&lpg=PA1268&dq=bipolar+%2220+times%22#v=snippet&q=20%20times&f=false | last = Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock | page = 388 | year = 2007 | accessdate = 2010-12-30 | isbn = 9780781773270 | ref = harv | postscript = <!-- Bot inserted parameter. Either remove it; or change its value to "." for the cite to end in a ".", as necessary. -->{{inconsistent citations}}}}</ref>  The [[standardized mortality ratio]] from [[suicide]] in BD is between 18 and 25.<ref name="MortBio_2006">{{cite web|title=Bipolar Disorder: Defining Remission and Selecting Treatment| author=Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski|publisher=Psychiatric Times, October 2006, Vol. XXIII, No. 11|url=http://www.psychiatrictimes.com/article/showArticle.jhtml?articleId=193400986}}</ref>

==Epidemiology==
[[Image:Bipolar disorder world map - DALY - WHO2002.svg|thumb|[[Disability-adjusted life year]] for bipolar disorder per 100,000&nbsp;inhabitants in 2002.<div class="references-small" style="-moz-column-count:3; column-count:3;">
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|less than 180}}
{{legend|#fff200|180–186}}
{{legend|#ffdc00|186–190}}
{{legend|#ffc600|190–195}}
{{legend|#ffb000|195–200}}
{{legend|#ff9a00|200–205}}
{{legend|#ff8400|205–210}}
{{legend|#ff6e00|210–215}}
{{legend|#ff5800|215–220}}
{{legend|#ff4200|220–225}}
{{legend|#ff2c00|225–230}}
{{legend|#cb0000|230–235}}
</div>]]

When broadly defined 4% of people experience bipolar at some point in their life.<ref>{{cite journal |author=Ketter TA |title=Diagnostic features, prevalence, and impact of bipolar disorder |journal=J Clin Psychiatry |volume=71 |issue=6 |pages=e14 |year=2010 |month=June |pmid=20573324 |doi=10.4088/JCP.8125tx11c |url= |ref=harv}}</ref> The lifetime prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, has generally been estimated at 2%.<ref name="Soldani2005">{{Cite journal| first = Federico | last = Soldani | month = April | year = 2005 | title = Mania in the Swedish Twin Registry: criterion validity and prevalence | journal = Australian and New Zealand of Psychiatry | volume = 39 | issue = 4 | pages = 235–43 | pmid=15777359 | doi = 10.1111/j.1440-1614.2005.01559.x | last2 = Sullivan | first2 = PF | last3 = Pedersen | first3 = NL| ref = harv }}</ref> It is equally prevalent in men and women and is found across all cultures and ethnic groups.<ref>Frederick K Goodwin and Kay R Jamison.''Manic-Depressive Illness'' Chapter 7, "Epidemiology". Oxford University Press, 1990. ISBN 0-19-503934-3.</ref>  

A reanalysis of data from the National Epidemiological Catchment Area survey in the United States, however, suggested that 0.8 percent experience a [[manic episode]] at least once (the diagnostic threshold for [[bipolar I]]) and 0.5 a [[hypomanic]] episode (the diagnostic threshold for bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1 percent of the population, adding up to a total of 6.4 percent, were classed as having a bipolar spectrum disorder.<ref name="Judd_and_Akiskal_2003">{{Cite journal| first = Lewis L. | last = Judd | month = January | year = 2003 | title = The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases | journal = Journal of Affective Disorders | volume = 73 | issue = 1–2 | pages = 123–31 | doi = 10.1016/S0165-0327(02)00332-4 |pmid=12507745 |url=http://linkinghub.elsevier.com/retrieve/pii/S0165032702003324 | last2 = Akiskal | first2 = HS| ref = harv}}</ref> A more recent analysis of data from a second US [[National Comorbidity Survey]] found that 1% met lifetime prevalence criteria for bipolar 1, 1.1% for bipolar II, and 2.4% for subthreshold symptoms.<ref>Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, Kessler RC. (2007) [http://archpsyc.ama-assn.org/cgi/content/full/64/5/543#REF-YOA60082-2 Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication] Arch Gen Psychiatry. May;64(5):543–52.</ref> There are conceptual and methodological limitations and variations in the findings. Prevalence studies of bipolar disorder are typically carried out by lay interviewers who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity. In addition, diagnosis and prevalence rates are dependent on whether a categorical or spectrum approach is used. Concerns have arisen about the potential for both underdiagnosis and overdiagnosis.<ref>Phelps, J. (2006) [http://www.psychiatrictimes.com/print.jhtml?articleID=191504355&url_prefix= Bipolar Disorder: Particle or Wave? DSM Categories or Spectrum Dimensions?] Psychiatric Times</ref>

Late adolescence and early adulthood are peak years for the onset of bipolar disorder.<ref name="Christie88">{{Cite journal|author=Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ |year=1988 |title=Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults |journal=Am J Psychiatry |volume=145 |pages=971–975 |id= |url=http://www.ajp.psychiatryonline.org/cgi/content/abstract/145/8/971 |accessdate = July 1, 2007 |pmid=3394882 |issue=8|ref=harv }}</ref><ref>Goodwin & Jamison. p. 121.</ref>{{Which?|date=December 2010}} One study also found that in 10% of bi-polar cases, the onset of mania had happened after the patient had turned 50.<ref>{{cite pmid|21188315}}</ref>

==History==
{{Main|History of bipolar disorder}}
Variations in moods and energy levels have been observed as part of the human experience since time immemorial. The words "[[melancholia]]" (an old word for [[depression (mood)|depression]]) and "mania" have their [[etymologies]] in [[Ancient Greek]]. The word melancholia is derived from ''melas''/μελας, meaning "black", and ''chole''/χολη, meaning "bile" or "gall",<ref name="Liddell 1980">{{Cite book| author = [[Henry George Liddell|Liddell, Henry George]] and [[Robert Scott (philologist)|Robert Scott]] | year = 1980 | title = [[A Greek-English Lexicon]] (Abridged Edition) | publisher = [[Oxford University Press]] | location = United Kingdom | isbn = 0-19-910207-4}}</ref> indicative of the term's origins in pre-[[Hippocrates|Hippocratic]] [[humoral]] theories. Within the humoral theories, mania was viewed as arising from an excess of [[yellow bile]], or a mixture of black and yellow bile. The [[linguistics|linguistic]] origins of mania, however, are not so clear-cut. Several etymologies are proposed by the [[Ancient Rome|Roman]] physician [[Caelius Aurelianus]], including the Greek word ‘ania’, meaning to produce great mental anguish, and ‘manos’, meaning relaxed or loose, which would contextually approximate to an excessive relaxing of the mind or soul (Angst and Marneros 2001). There are at least five other candidates, and part of the confusion surrounding the exact etymology of the word mania is its varied usage in the pre-Hippocratic [[poetry]] and [[mythology|mythologies]] (Angst and Marneros 2001).

The basis of the current conceptualisation of manic-depressive illness can be traced back to the 1850s; on January 31, 1854, [[Jules Baillarger]] described to the French Imperial [[Academy of Medicine]] a [[biphasic]] [[mental illness]] causing recurrent oscillations between mania and depression, which he termed ''folie à double forme'' (‘dual-form insanity’).<ref>{{cite web|url=http://www.ncbi.nlm.nih.gov/pubmed/15506718 |title=Circular insanity, 150 years on |accessdate=2008-04-12}}</ref> Two weeks later, on February 14, 1854, [[Jean-Pierre Falret]] presented a description to the Academy on what was essentially the same disorder, and designated ''folie circulaire'' (‘circular [[insanity]]’) by him.(Sedler 1983) The two bitterly disputed as to who had been the first to conceptualise the condition.

These concepts were developed by the German [[psychiatrist]] [[Emil Kraepelin]] (1856–1926), who, using [[Karl Ludwig Kahlbaum|Kahlbaum]]'s concept of [[cyclothymia]],<ref name="millon">{{Cite book
| first = Theordore
| last = Millon
| year = 1996
| title = Disorders of Personality: DSM-IV-TM and Beyond
| edition =
| publisher = John Wiley and Sons
| location = New York
| page = 290
| isbn=  0-471-01186-X }}</ref> categorized and studied the natural course of untreated bipolar patients. He coined the term ''manic depressive [[psychosis]]'', after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally.<ref>[[Emil Kraepelin|Kraepelin, Emil]] (1921) ''Manic-depressive Insanity and Paranoia'' ISBN 0-405-07441-7</ref>

The term "manic-depressive ''reaction''" appeared in the first [[American Psychiatric Association]] Diagnostic Manual in 1952, influenced by the legacy of [[Adolf Meyer (psychiatrist)|Adolf Meyer]] who had introduced the paradigm illness as a reaction of biogenetic factors to psychological and social influences.<ref>Goodwin & Jamison. pp. 60–61.</ref> Subclassification of bipolar disorder was first proposed by German psychiatrist [[Karl Leonhard]] in 1957; he was also the first to introduce the terms ''bipolar'' (for those with mania) and ''unipolar'' (for those with depressive episodes only).<ref>Goodwin & Jamison. p62</ref>

==Society and culture==
===Stigma===
There are widespread problems with [[social stigma]], [[stereotypes]], and [[prejudice]] against individuals with a diagnosis of bipolar disorder.<ref>{{cite web|url=http://bipolar.about.com/od/stigma/Stigma.htm|publisher=NIMH|title=Stigma and Bipolar Disorder|date=February 21, 2009|accessdate=2010-11-08}}</ref>
===Cultural references===
{{See also|List of people affected by bipolar disorder}}

[[Andy Behrman]], a former art dealer and spokesperson for Bristol Myers-Squibb, wrote ''Electroboy'', detailing his struggles with bipolar disorder.

[[Carrie Fisher]], who is diagnosed with bipolar type-two, has a memoir about her struggles entitled ''Wishful Drinking''.

[[Kay Redfield Jamison]], a clinical psychologist and Professor of Psychiatry at the [[Johns Hopkins University School of Medicine]], profiled her own bipolar disorder in her memoir ''[[An Unquiet Mind]]'' (1995).<ref name="unquiet">{{Cite book|last=Jamison|first=Kay Redfield|title=An Unquiet Mind: A Memoir of Moods and Madness|publisher=Knopf.|location=New York|year=1995|isbn=0-330-34651-2}}</ref> In her book, ''[[Touched with Fire]]'' (1993), she argued for a connection between bipolar disorder and artistic creativity.<ref>{{Cite book|last=Jamison |first=Kay Redfield|title=Touched With Fire: Manic-Depressive Illness and the Artistic Temperament|publisher=The Free Press: Macmillian, Inc.|location=New York|year=1996|isbn=0-684-83183-X}}</ref>

Several films have portrayed characters with traits suggestive of the diagnosis that has been the subject of discussion by psychiatrists and film experts alike. A notable example is ''[[Mr. Jones (film)|Mr. Jones]]'' (1993), in which Mr. Jones ([[Richard Gere]]) swings from a manic episode into a depressive phase and back again, spending time in a psychiatric hospital and displaying many of the features of the syndrome.<ref>{{Cite book|title=Reel Psychiatry:Movie Portrayals of Psychiatric Conditions|author=Robinson DJ |year= 2003|publisher=Rapid Psychler Press |location=Port Huron, Michigan |isbn=1-894328-07-8|pages=78–81}}</ref> In ''[[The Mosquito Coast]]'' (1986), Allie Fox ([[Harrison Ford]]) displays some features including recklessness, grandiosity, increased goal-directed activity and mood lability, as well as some paranoia.<ref>Robinson (''Reel Psychiatry:Movie Portrayals of Psychiatric Conditions''), p. 84–85</ref>

In the Australian TV drama ''Stingers'', Detective Luke Harris (Gary Sweet) is portrayed as having bipolar disorder and shows how his paranoia interfered with his work. As research for the role, Sweet visited a psychiatrist to learn about manic-depressive illness. He said that he left the sessions convinced he had the condition.
[[TV special]]s, for example the [[BBC]]'s ''[[The Secret Life of the Manic Depressive]]'',<ref>{{cite web|url=http://www.bbc.co.uk/health/tv_and_radio/secretlife_index.shtml|title=The Secret Life of the Manic Depressive|publisher=BBC|year=2006|accessdate = February 20, 2007}}</ref> MTV's ''[[True Life]]: I'm Bipolar'', talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions, thereby, raising public awareness.

On April 7, 2009, the nighttime drama ''[[90210 (TV series)|90210]]'' on the [[The CW|CW]] network, aired a [[very special episode|special episode]] where the character Silver was diagnosed with bipolar disorder.  A public service announcement ([[Public service announcement|PSA]]) aired after the episode, directing teens and young adults to the Child and Adolescent Bipolar Foundation website for information and to chat with other teens.<ref>{{cite web|url=http://www.bpkids.org/90210|title=Child and Adolescent Bipolar Foundation special 90210 website|publisher=CABF|year=2009|accessdate=April 7, 2009}}{{dead link|date=January 2011}}</ref>

[[Stacey Slater]], a character from the popular BBC soap [[EastEnders]], has been diagnosed with the disorder. After losing her friend Danielle Jones, Stacey began acting strangely; and the character had to come to terms with the prospect that, like her mother, [[Jean Slater]], she suffers from bipolar disorder. The high-profile storyline was developed as part of the BBC's Headroom campaign.<ref>{{cite web|url=http://www.bbc.co.uk/pressoffice/pressreleases/stories/2009/05_may/14/stacey.shtml|title=EastEnders' Stacey faces bipolar disorder|publisher=BBC Press Office|date=May 14, 2009|accessdate=May 28, 2009}}</ref> The [[Channel 4]] soap ''[[Brookside]]'' had earlier featured a story about bipolar disorder when the character [[Jimmy Corkhill]] was diagnosed with the condition.<ref name=Echo14May2003>{{Cite news|title= The Brookie boys who shone at soap awards show|publisher= Mirror Group Newspapers|work= Liverpool Echo|first= Rachael|last= Tinniswood|date= May 14, 2003}}</ref> [[Dean Sullivan]], the actor who played Jimmy, was presented with a Special Achievement Award at the 2003 [[British Soap Awards]] for the role.<ref name=Echo14May2003/>

==Specific populations==
===In children===
{{Main|Bipolar disorder in children}}
[[File:Lithium carbonate.jpg|thumb| [[Lithium carbonate]]. Lithium is the only drug approved for children with BD by the FDA]]

[[Emil Kraepelin]] in the 1920s noted that mania episodes were rare before puberty.<ref name="pmid17195735"/> In general BD in children was not recognized in the first half of the XX century this issue diminishing with an increased following of the DSM criteria in the last part of the XXth century.<ref name="pmid17195735"/><ref>{{Cite journal | doi = 10.1111/j.1469-7610.1960.tb01979.x | last1 = Anthony | first1 =  James| last2 = Scott | first2 =  Peter| year = 1960 | title = Manic-depressive psychosis in childhood | url = | journal = Journal of Child Psychology and Psychiatry | volume = 1 | issue = | pages = 53–72 }}</ref>

While in adults the course of BD is characterized by discrete episodes of depression and mania with no clear symptomatology between them, in chidren and adolescents very fast mood changes or even chronic symptoms are the norm.<ref name="pmid17716034"/> On the other hand pediactric BD instead of [[euphoria|euphoric]] [[mania]] commonly develops with outbursts of anger, irritability and [[psychosis]], less common in adults.<ref name="pmid17716034"/><ref name="pmid17195735"/>

The diagnosis of childhood BD is controversial,<ref name="pmid17716034"/> although it is not under discussion that BD typical symptoms have negative consequences for minors suffering them.<ref name="pmid17195735"/> Main discussion is centered on whether what is called BD in children refers to the same disorder than when diagnosing adults,<ref name="pmid17195735"/> and the related question on whether adults criteria for diagnosis are useful and accurate when applied to children.<ref name="pmid17716034"/> Regarding diagnosis of children some experts recommend to follow the DSM criteria.<ref name="pmid17716034"/> Others believe that these criteria do not separate correctly children with BD from other problems such as ADHD, and emphasize fast mood cycles.<ref name="pmid17716034"/> Still others argue that what accurately differentiates children with BD is irritability.<ref name="pmid17716034"/> The practice parameters of the [[American Academy of Child and Adolescent Psychiatry|AACAP]] encourage the first strategy.<ref name="pmid17716034"/><ref name="pmid17195735"/> American children and adolescents diagnosed of BD in community hospitals increased 4-fold reaching rates of up to 40% in 10 years around the beginning of the current century, while in [[outpatient]] clinics it doubled reaching the 6%.<ref name="pmid17716034"/> The data suggest that doctors had been more aggressively applying the [[medical diagnosis|diagnosis]] to children.{{Citation needed|date=January 2011}} The reasons for this increase are unclear. Consensus regarding the diagnosis in the pediatric age seems to apply only to the USA.{{Citation needed|date=January 2011}} Studies using DSM criteria show that up to 1% of youth may have BD.<ref name="pmid17195735"/>

Treatment involves medication and psychotherapy.<ref name="pmid17716034">{{cite journal |author=Leibenluft E, Rich BA |title=Pediatric bipolar disorder |journal=Annu Rev Clin Psychol |volume=4 |issue= |pages=163–87 |year=2008 |pmid=17716034 |doi=10.1146/annurev.clinpsy.4.022007.141216 |url=}}</ref> Drug prescription usually consists in [[mood stabilizer]]s and [[atypical antipsychotic]]s.<ref name="pmid17716034"/> Among the formers [[Lithium pharmacology|lithium]] is the only compound approved by the [[Food and Drug Administration|FDA]] for children.<ref name="pmid17195735">{{cite journal |author=McClellan J, Kowatch R, Findling RL |title=Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder |journal=J Am Acad Child Adolesc Psychiatry |volume=46 |issue=1 |pages=107–25 |year=2007 |month=January |pmid=17195735 |doi=10.1097/01.chi.0000242240.69678.c4 |url=}}</ref> Psychological treatment combines normally [[Psychoeducation|education on the disease]], [[Group psychotherapy|group therapy]] and [[cognitive behavioral therapy]].<ref name="pmid17716034"/> [[Chronic]] medication is often needed.<ref name="pmid17716034"/>

Current research directions for BD in children include optimizing treatments, increasing the knowledge of the genetic and neurobiological basis of the pediatric disorder and improving diagnostic criteria.<ref name="pmid17716034"/> The [[DSM-V]] has proposed a new diagnosis which is considered to cover some presentations currently thought of as childhood-onset bipolar.<ref>http://www.dsm5.org/Proposed%20Revision%20Attachments/Justification%20for%20Temper%20Dysregulation%20Disorder%20with%20Dysphoria.pdf</ref><ref>http://www.dsm5.org/Newsroom/Documents/Diag%20%20Criteria%20General%20FINAL%202.05.pdf</ref>

===In the elderly===
There is a relative lack of knowledge about bipolar disorder in late life. There is evidence that it becomes less prevalent with age but nevertheless accounts for a similar percentage of psychiatric admissions; that older bipolar patients had first experienced symptoms at a later age; that later onset of mania is associated with more neurologic impairment; that substance abuse is considerably less common in older groups; and that there is probably a greater degree of variation in presentation and course, for instance individuals may develop new-onset mania associated with vascular changes, or become manic only after recurrent depressive episodes, or may have been diagnosed with bipolar disorder at an early age and still meet criteria. There is also some weak evidence that mania is less intense and there is a higher prevalence of mixed episodes, although there may be a reduced response to treatment. Overall there are likely more similarities than differences from younger adults.<ref name="pmid15383127">{{cite journal |author=Depp CA, Jeste DV |title=Bipolar disorder in older adults: a critical review |journal=Bipolar Disord |volume=6 |issue=5 |pages=343–67 |year=2004 |month=October |pmid=15383127 |doi=10.1111/j.1399-5618.2004.00139.x |url=}}</ref> In the elderly, recognition and treatment of bipolar disorder may be complicated by the presence of [[dementia]] or the side effects of medications being taken for other conditions.<ref>{{Cite journal|author=Trinh NH, Forester B|title=Bipolar Disorder in the Elderly: Differential Diagnosis and Treatment |journal=Psychiatric Times|volume=24 |issue=14 |year=2007 |url=http://www.psychiatrictimes.com/bipolar-disorder/article/10168/54481|ref=harv}}</ref>


==References==

<references/>

===Cited texts===
*{{Cite book|author= Goodwin FK, Jamison KR|title= Manic-Depressive Illness |year= 1990|publisher= Oxford University Press|location=New York |isbn=0-19-503934-3}}
*{{Cite book|author= Goodwin FK, Jamison KR|title= Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition |year= 2007|publisher=Oxford University Press|location=New York |isbn= 0-19-513579-2}}

==Further reading==
;Contemporary first-person accounts:
*Simon, Lizzie. 2002. ''Detour: My Bipolar Road Trip in 4-D''. New York: Simon and Schuster. ISBN 0-7434-4659-3.
*Behrman, Andy. 2002. ''Electroboy: A Memoir of Mania''. New York: Random House, 2002. ISBN 0-375-50358-7.
*Lovelace, David. 2008. ''[[Scattershot (book)|Scattershot: My Bipolar Family]]''. New York: Dutton Adult, 2008. ISBN 0-525-95078-8.

;Managing bipolar disorder:
* {{Cite book| date  = March 5, 2009 | title = Living with Bipolar | last = Berk | first = Lesley | publisher = [[Vermilion]] | isbn = 9780091924256}}

;Bipolar disorder in children:
*Greenberg, Rosalie. 2008.  ''Bipolar Kids: Helping Your Child Find Calm in the Mood Storm''.  ISBN 978-0-7382-1113-8
*Papolos, Demetri, and Papolos, Janice. 2007. ''The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder -- Third Edition''.  ISBN 978-0-7679-2860-1
*Raeburn, Paul. 2004. ''Acquainted with the Night: A Parent's Quest to Understand Depression and Bipolar Disorder in His Children''.
*Earley, Pete. ''Crazy''. 2006. New York: G. P. Putnam's Sons. ISBN 0-399-15313-6. A father's account of his son's bipolar disorder.

;Classic works on bipolar disorder
*[[Emil Kraepelin|Kraepelin, Emil]]. 1921. ''Manic-depressive Insanity and Paranoia'' ISBN 0-405-07441-7 (English translation of the original German from the earlier eighth edition of Kraepelin's textbook&nbsp;— now outdated, but a work of major historical importance).
*''Mind Over Mood: Cognitive Treatment Therapy Manual for Clients'' by Christine Padesky, Dennis Greenberger. ISBN 0-89862-128-3

==External links==
*[http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml Bipolar Disorder overview] from the U.S. [[National Institute of Mental Health]] website
*[http://www.nice.org.uk/Guidance/CG38 NICE Bipolar Disorder clinical guidelines] from the U.K. [[National Institute for Health and Clinical Excellence]] website
*{{dmoz|Health/Mental_Health/Disorders/Mood/Bipolar_Disorder|Bipolar Disorder}}