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Understanding Bipolar Disorder

Bipolar disorder, formerly termed "manic-depressive illness," is meant to characterize the fluctuations in mood from one end or "pole" to the other-severe depression to mania. Unlike schizophrenia, bipolar illness might have little effect on the client's ability to think; that is, it does not necessarily include the symptoms of a "thought disorder," whereas schizophrenia at some point always shows disturbances of thought (such as delusions, bizarre beliefs, or loose associations).

The lifetime prevalence of bipolar disorder also is roughly 1 percent of the general U.S. population (APA 2000), so both schizophrenia and bipolar disorder are relatively rare compared to major depressive illness, which has lifetime incidences in the general population of 10 to 25 percent for women and 5 to 12 percent for men (APA 2000). People with bipolar disorder also are subject to high rates of co-occurring substance abuse and dependence, with even higher rates in specific populations. In the ECA study, nearly 90 percent of those with bipolar disorder in a prison population had a co-occurring substance use disorder (Regier et al. 1990).

Depressive phases in bipolar clients are similar to those in clients who are severely depressed -- that is, the person feels sad; might feel life is not worthwhile; gets little or no enjoyment from anything, even from involvement with children or family/friends; and has altered appetite and sleep needs, for example, waking up early in the morning almost 2 hours before normal or oversleeping. Similarly, the client may overeat or have little or no appetite. The person might experience lethargy; fatigue easily; have feelings of guilt or worthlessness (sometimes for seemingly trivial things) or show strong feelings disproportional to the acts or thoughts involved; and experience recurrent thoughts of death, illness, or manifest suicidal thoughts, plans, or attempts.

Manic episodes for someone with bipolar disorder also vary in intensity. Full-blown, intense mania (during which a client might, for example, take off all his or her clothes and run to a church to declare that the secrets of the universe have been revealed) is relatively rare and, especially with medication, usually short-lived. An evolving manic episode might be hard to detect, especially in someone who is drinking and/or using drugs; some people with mania can get by on a day-to-day basis, partying and barely sleeping, telling tall tales others might ignore, and even being intact enough to persuade others that their delusion of vast wealth is true. People in a manic state have been known to get yachts to take to sea for a trial run or to run up thousands in bills at expensive hotels before anyone recognizes that the individual has not changed clothes in 6 days and cannot carry on a conversation without stating outlandish impossibilities (such as owning Nebraska or being married to the queen of England).

In between the extremes of elation and depression, some clients with bipolar disorder are likely to struggle almost all the time with mild-to-moderate depression and, on occasion, with "hypomanic" (mildly elevated) states that can carry deterioration in judgment, leading to legal trouble, financial loss, or relapse to abusing substances. For the 20 to 30 percent of people with bipolar illness who are not fully functional between episodes of mania and/or depression, the residual phase is usually characterized by mood instability, interpersonal problems, and/or occupational difficulties (APA 2000). However, clients with bipolar disorder who are successfully treated frequently return to positive and productive lives without any future disruption.

Adapted from Substance Abuse Treatment for Persons with Co-Occurring Disorders
Treatment Improvement Protocol 42
US Department of Health and Human Services
DHHS Publication No. (SMA) 2005-3992

Reviewed by athealth on February 8, 2014.