People with a bipolar disorder experience both the lows of depression and the highs of mania. Many describe their life as an emotional roller coaster, as they shift back and forth between extreme moods. A number of sufferers eventually become suicidal. Their roller coaster ride also has a dramatic impact on relatives and friends (Barron et al., 2014).

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Unlike people sunk in the gloom of depression, those in a state of mania typically experience dramatic and inappropriate rises in mood. The symptoms of mania span the same areas of functioning—emotional, motivational, behavioral, cognitive, and physical—as those of depression, but mania affects those areas in an opposite way.

A person in the throes of mania has powerful emotions in search of an outlet. The mood of euphoric joy and well-being is out of all proportion to the actual happenings in the person’s life. Not every person with mania is a picture of happiness, however. Some instead become very irritable and angry, especially when others get in the way of their exaggerated ambitions.

In the motivational realm, people with mania seem to want constant excitement, involvement, and companionship. They enthusiastically seek out new friends and old, new interests and old, and have little awareness that their social style is overwhelming, domineering, and excessive.

The behavior of people with mania is usually very active. They move quickly, as though there were not enough time to do everything they want to do. They may talk rapidly and loudly, their conversations filled with jokes and efforts to be clever or, conversely, with complaints and verbal outbursts. Flamboyance is not uncommon: dressing in flashy clothes, giving large sums of money to strangers, or even getting involved in dangerous activities.

In the cognitive realm, people with mania usually show poor judgment and planning, as if they feel too good or move too fast to consider possible pitfalls. Filled with optimism, they rarely listen when others try to slow them down. They may also hold an inflated opinion of themselves, and sometimes their self-esteem approaches grandiosity. During severe episodes of mania, some have trouble remaining coherent or in touch with reality.

Finally, in the physical realm, people with mania feel remarkably energetic. They typically get little sleep yet feel and act wide awake (Armitage & Arnedt, 2011). Even if they miss a night or two of sleep, their energy level may remain high.

People are considered to be in a full manic episode when for at least one week they display an abnormally high or irritable mood, increased activity or energy, and at least three other symptoms of mania (see Table 6.4). The episode may even include psychotic features such as delusions or hallucinations. When the symptoms of mania are less severe (causing little impairment), the person is said to be having a hypomanic episode (APA, 2013).

DSM-5 distinguishes two kinds of bipolar disorders—bipolar I and bipolar II. People with bipolar I disorder have full manic and major depressive episodes. Most of them experience an alternation of the episodes; for example, weeks of mania followed by a period of wellness, followed in turn by an episode of depression. Some, however, have mixed features, in which they display both manic and depressive symptoms within the same episode—for example, having racing thoughts amidst feelings of extreme sadness. In bipolar II disorder, hypomanic—that is, mildly manic—episodes alternate with major depressive episodes over the course of time. Some people with this pattern accomplish huge amounts of work during their mild manic periods (see PsychWatch on page 214).

Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder. If a person has four or more episodes within a one-year period, his or her disorder is considered to be rapid cycling. A woman describes her rapid cycling in the following excerpt, taken from a journal article she wrote anonymously several years ago.

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Surveys from around the world indicate that between 1 and 2.6 percent of all adults are suffering from a bipolar disorder at any given time (Kessler et al., 2012; Merikangas et al., 2011). As many as 4 percent experience one of the bipolar disorders at some time in their life. The bipolar disorders are equally common in women and men, but they are more common among people with low incomes than those with higher incomes (Sareen et al., 2011). Onset usually occurs between the ages of 15 and 44 years. In most untreated cases, the manic and depressive episodes eventually subside, only to recur at a later time.

Some people have numerous periods of hypomanic symptoms and mild depressive symptoms, a pattern that is called cyclothymic disorder in DSM-5. The symptoms of this milder form of bipolar disorder continue for two or more years, interrupted occasionally by normal moods that may last for only days or weeks. This disorder, like bipolar I and bipolar II disorders, usually begins in adolescence or early adulthood and is equally common among women and men. At least 0.4 percent of the population develops cyclothymic disorder. In some cases, the milder symptoms eventually blossom into a bipolar I or II disorder (Zeschel et al., 2015; Goto et al., 2011).

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Throughout the first half of the twentieth century, the search for the causes of bipolar disorders made little progress. More recently, biological research has produced some promising clues. The biological insights have come from research into neurotransmitter activity, ion activity, brain structure, and genetic factors.

Neurotransmitters Could overactivity of norepinephrine be related to mania? This was the expectation of clinicians back in the 1960s after investigators first found a relationship between low norepinephrine activity and unipolar depression. Indeed, some research did find the norepinephrine activity of people with mania to be higher than that of control participants (Post et al., 1980, 1978; Schildkraut, 1965).

Because serotonin activity often parallels norepinephrine activity in unipolar depression, theorists at first expected that mania would also be related to high serotonin activity, but no such relationship has been found. Instead, research suggests that mania, like depression, may be linked to low serotonin activity (Hsu et al., 2014; Nugent et al., 2013). Perhaps low activity of serotonin opens the door to a mood disorder and permits the activity of norepinephrine (or perhaps other neurotransmitters) to define the particular form the disorder will take. That is, low serotonin activity accompanied by low norepinephrine activity may lead to depression; low serotonin activity accompanied by high norepinephrine activity may lead to mania.

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Ion Activity While neurotransmitters play a significant role in the communication between neurons, electrically charged ions seem to play a critical role in relaying messages within a neuron. When a neuron receives an incoming message, its sodium ions (Na⁺) and potassium ions (K+) flow back and forth between the outside and inside of the neuron’s membrane, producing a wave of electrical activity that travels down the length of the neuron (the axon) and results in its “firing.”

If messages are to travel effectively down the axon, the ions must be able to move easily between the outside and the inside of the neural membrane. Some studies suggest that, among bipolar individuals, irregularities in the transport of these ions may cause neurons to fire too easily (resulting in mania) or to stubbornly resist firing (resulting in depression) (Manji & Zarate, 2011; Li & El-Mallakh, 2004).

Brain Structure Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorders (Eker et al., 2014; Chen et al., 2011; Savitz & Drevets, 2011). For example, the basal ganglia and cerebellum of these people tend to be smaller than those of other people, and their dorsal raphe nucleus, striatum, amygdala, hippocampus, and prefrontal cortex each have structural abnormalities. It is not clear what role such structural abnormalities play in bipolar disorders.

Genetic Factors Many theorists believe that people inherit a biological predisposition to develop bipolar disorders (Wiste et al., 2014; Gershon & Nurnberger, 1995). Family pedigree studies support this idea. Identical twins of those with a bipolar disorder have a 40 percent likelihood of developing the same disorder, and fraternal twins, siblings, and other close relatives of such persons have a 5 to 10 percent likelihood, compared with the 1 to 2.6 percent prevalence rate in the general population.

Researchers have also used techniques from molecular biology to more directly examine possible genetic factors. These various undertakings have linked bipolar disorders to genes on chromosomes 1, 4, 6, 10, 11, 12, 13, 15, 18, 20, 21, and 22 (Sinkus et al., 2015; Green et al., 2013; Bigdeli et al., 2013). Such wide-ranging findings suggest that a number of genetic abnormalities probably combine to help bring about bipolar disorders.

Until the latter part of the twentieth century, people with bipolar disorders were destined to spend their lives on an emotional roller coaster. Psychotherapists reported almost no success, and antidepressant drugs were of limited help. In fact, the drugs sometimes triggered a manic episode (Courtet et al., 2011; Post, 2011, 2005).

Lithium and Other Mood Stabilizers This gloomy picture changed dramatically in 1970 when the FDA approved the use of lithium, a silvery-white element found in various simple mineral salts throughout the natural world, as a treatment for bipolar disorders. Additional mood stabilizing drugs, or antibipolar drugs, have since been developed, including the antiseizure drugs carbamazepine (Tegretol) and valproate (Depoakote), and several of them are now used as widely as lithium, either because they produce fewer undesired effects or because they are even more effective than lithium.

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Nevertheless, it was lithium that first brought hope to those suffering from bipolar disorders. In her widely read memoir, An Unquiet Mind, psychiatric researcher Kay Redfield Jamison describes how lithium, combined with psychotherapy, enabled her to overcome her bipolar disorder:

All manner of research has attested to the effectiveness of lithium and other mood stabilizers in treating manic episodes (Galling et al., 2015; Geddes & Miklowitz, 2013). More than 60 percent of patients with mania improve on these medications. In addition, most such patients have fewer new episodes as long as they continue taking the medications (Malhi et al., 2013). One study found that the risk of relapse is 28 times higher if patients stop taking a mood stabilizer (Suppes et al., 1991). Thus, today’s clinicians usually continue patients on some level of a mood stabilizing drug even after their manic episodes subside (Gao et al., 2010).

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In the limited body of research that has been done on this subject, the mood stabilizers also seem to help those with bipolar disorder overcome their depressive episodes, though to a lesser degree than they help with their manic episodes (Malhi et al., 2013; Post, 2011). Given the drugs’ less powerful impact on depressive episodes, many clinicians use a combination of mood stabilizers and antidepressant drugs to treat bipolar depression (Nivoli et al., 2011).

Researchers do not fully understand how mood stabilizing drugs operate (Malhi et al., 2013; Aiken, 2010). They suspect that the drugs change synaptic activity in neurons, but in a way different from that of antidepressant drugs. The firing of a neuron actually consists of several phases that ensue at lightning speed. When the neurotransmitter binds to a receptor on the receiving neuron, a series of changes occur within the receiving neuron to set the stage for firing. The substances in the neuron that carry out those changes are often called second messengers because they relay the original message from the receptor site to the firing mechanism of the neuron. (The neurotransmitter itself is considered the first messenger.) Whereas antidepressant drugs affect a neuron’s initial reception of neurotransmitters, mood stabilizers appear to affect a neuron’s second messengers.

In a similar vein, it has been found that lithium and other mood stabilizing drugs also increase the production of neuroprotective proteins—key proteins within certain neurons whose job is to prevent cell death. The drugs may increase the health and functioning of those cells and thus reduce bipolar symptoms (Malhi et al., 2013; Gray et al., 2003).

Adjunctive Psychotherapy As Jamison stated in her memoir, psychotherapy alone is rarely helpful for persons with bipolar disorders. At the same time, clinicians have learned that mood stabilizing drugs alone are not always sufficient either. Thirty percent or more of patients with these disorders may not respond to lithium or a related drug, may not receive the proper dose, or may relapse while taking it. In addition, a number of patients stop taking mood stabilizers on their own (Advokat et al., 2014).

In view of these problems, many clinicians now use individual, group, or family therapy as an adjunct to mood stabilizing drugs (Reinares et al., 2014; Geddes & Miklowitz, 2013). Most often, therapists use these formats to emphasize the importance of continuing to take medications; to improve social skills and relationships that may be affected by bipolar episodes; to educate patients and families about bipolar disorders; to help patients solve the family, school, and occupational problems caused by their disorder; and to help prevent patients from attempting suicide (Hollon & Ponniah, 2010). Few controlled studies have tested the effectiveness of such adjunctive therapy, but those that have been done, along with numerous clinical reports, suggest that it helps reduce hospitalization, improves social functioning, and increases patients’ ability to obtain and hold a job (Culver & Pratchett, 2010).