October 23, 2012

Myths and Realities About Bipolar Disorder

Five questions for bipolar disorder expert Eric Youngstrom, PhD

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Media coverage of people who have been diagnosed with bipolar disorder usually does not fully explain this serious mental illness, how best to treat it and how it can affect those who have it, as well as their families, friends and coworkers. To explain what bipolar disorder is and psychology’s role in identifying and treating it, APA asked Eric A. Youngstrom, PhD, to share his knowledge about this mental illness.

Eric A. Youngstrom, PhDDr. Youngstrom is professor of psychology and psychiatry at the University of North Carolina at Chapel Hill and acting director of the Center of Excellence for Research and Treatment of Bipolar Disorder. He earned his doctorate in clinical psychology at the University of Delaware and specializes in the relationship of emotions and psychopathology and the clinical assessment of children and families. Dr. Youngstrom has published more than 150 peer-reviewed articles on clinical assessment and emotion, he has served as an ad hoc reviewer on more than 60 psychology and psychiatry journals and he is on the editorial boards of the Journal of the American Academy of Child and Adolescent Psychiatry, the Journal of Clinical Child and Adolescent Psychology, the Journal of Child and Adolescent Psychopharmacology, and Psychological Assessment.

APA: What is bipolar disorder and how is it different from the general mood swings that many people experience?

Dr. Youngstrom: Bipolar disorder is a condition that leads to extreme changes in mood, energy and sleep. With all of these things, people will experience ups and downs in everyday life. What sets bipolar disorder apart is that the swings happen with more frequency and intensity than developmentally appropriate and they last much longer. The extremes also start to cause problems at school, home, with friends or other important areas in the person’s life. There is no sharp dividing line that separates bipolar disorder from ordinary changes in energy and mood. It is the combination of extremity and impairment that signals when it has become a problem. Interestingly, although we have long thought of bipolar disorder as a “mood disorder,” we’re learning that focusing on shifts in energy may be a more accurate way of detecting episodes of the illness. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) defines four different types of bipolar disorder: bipolar I, where the person has had a manic episode at least once in their lives; bipolar II, where the person becomes seriously depressed, but also has a history of hypomania (a milder mania); cyclothymic disorder, where the person has years of depressive and hypomanic symptoms without developing a full mania or depression; and bipolar “not otherwise specified,” for situations that do not fit into any of the other three definitions.

APA: Is bipolar disorder on the rise or does it just seem that way because of frequent media coverage?

Dr. Youngstrom: Both may be true, but changes in the actual rate are likely to be in the small to medium range, whereas changes in clinical diagnosis and media attention are huge. Several studies have found that the rate of clinical diagnoses of bipolar disorder has increased markedly over the last 20 years, especially in children and teenagers. The media often present these as percentage increases, which exaggerates the appearance of change because the current generation of practitioners was not trained to look systematically for bipolar disorder in youths. When something is rarely or never diagnosed and then starts to be recognized, the change in the rates can be misleading — 40 times more than something very small is still a small rate. A recent meta-analysis found no sign that the rates were increasing over the last 20 years. However, some of the risk factors associated with bipolar disorder, such as obesity, changes in diet, disruption of sleep and earlier onset of puberty, definitely have been increasing over the last few decades, so we cannot rule out the possibility that there is an increase in bipolar disorder. The increase is just much smaller than the changes in attention by the media and clinicians.

APA: How prevalent is bipolar disorder? Is it more common among certain demographic or geographic groups?

Dr. Youngstrom: The meta-analysis mentioned above found that bipolar disorders in children and teens are about half as common in adults, affecting 2 percent of the general population around the world (compared to 4 percent for bipolar in adults, or 6 to 8 percent for depression in teens). This makes bipolar about a third as common as depression and less than half as common as attention-deficit hyperactivity disorder in youths, but about twice as common as autistic spectrum disorders. Many longitudinal studies suggest that roughly a third of all depressions have a bipolar course when followed over time. There is no good evidence that it is more common in some demographic groups than others, although ethnic minorities with bipolar disorder are likely to be misdiagnosed with schizophrenia, conduct disorder or antisocial behavior instead. Women are more likely to be diagnosed with bipolar II, but there is no evidence of a gender linkage. It is more likely that women seek help more often for depression, so clinicians see more women with bipolar II. Internationally, bipolar disorder appears equally common among youths in the USA as in the rest of the world. In adults, rates of bipolar disorder may be lower in Asia than in the USA, but it is hard to tell whether this is due to protective factors — such as lower rates of obesity or higher fish consumption — versus greater social stigma preventing people from acknowledging problems and seeking help.

APA: What causes bipolar disorder? Are there differences in how the disorder affects children, adolescents and adults?

Dr. Youngstrom: Bipolar disorder is caused by a combination of biological and environmental factors. Genes play a major role, but genes are not enough by themselves to cause bipolar disorder. Identical twins share 100 percent of the same genes, but if one twin has bipolar disorder, the other twin does not develop bipolar 20 percent or more of the time. At this point, research has identified lots of genes that each contribute a little bit of risk for bipolar disorder. Diet may play an important role as well. Stress and trauma increase risk, as do intense emotional conflicts in families. Most of the risk factors for bipolar disorder also increase the odds of developing other conditions, such as anxiety or attention problems, which probably is why we see such high rates of co-occurrence among these disorders. Interestingly, the risk factors appear to be the same for children, adolescents and adults, which gives us more confidence that we are dealing with the same condition. The biggest way that the illness seems to change with age is that older individuals are more likely to experience depression and less likely to have mania, whereas in childhood it is more mania or a mixture of high energy with negative mood. Researchers and clinicians have described that pattern for more than a century.

APA: What are the most effective treatments for the disorder?

Dr. Youngstrom: The best treatments for bipolar disorder focus on smoothing out the highs and lows in mood and energy. There are several different psychotherapies that have promising results. These include cognitive behavioral therapy to pay attention to automatic positive thoughts as potential triggers for hypomania or mania; dialectical behavior therapy for improving emotion regulation; psychoeducational therapy to understand triggers and ways of managing the illness; family-focused therapy to improve communication and reduce intense emotional conflict; and interpersonal social rhythm therapy that emphasizes regular sleep and activity patterns. When the mood and energy become extreme, reaching the severity of a full-blown mania or depression, then medication is important in reducing the symptoms to a level where therapy and everyday functioning become possible. Therapy has a lot of promise as a way of preventing progression of bipolar disorder, delaying relapse and improving functioning in between episodes. Many incredibly talented and productive people have successfully dealt with bipolar disorder, so a goal of treatment should not just be symptom reduction, but helping the person to make the most of their gifts and abilities.

For more information, contact Dr. Youngstrom by email.

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