Bipolar disorder in adults

• This disorder affects approx. 1-2% of the Danish population.
• Bipolar disorder is seen equally frequently in women and men.
• As a general rule, the onset of the disorder is in adolescence or in early adulthood.
• It takes an average of 8-9 years from the onset of the first symptoms and until the diagnosis is made. One reason for this may be that the doctor does not see the patient’s depression as part of a bipolar disorder. Or perhaps signs of hypomania or a mixed state are overlooked.
• There is a high risk of recurrence. But treatment and prevention can greatly help mitigate the course of illness. This also reduces the psychological and social costs that may result from bipolar disorder – both for the individual person and for his or her family.

It is generally not possible to pinpoint one particular cause that triggers an episode of illness. In some cases, however, one or more factors can be ascertained which have contributed to triggering the episode.

The following factors may be of importance to whether you develop symptoms of mania or depression:

• Light: The effect of light sometimes influences the course of the illness. There are most manic episodes in the spring and summer months, while some forms of depression are especially seen during the dark winter months.
  
  
• Hormones: In women, hormonal changes may contribute to provoking mania, depression or mixed state, for example in connection with pregnancy and childbirth.
  
  
• Daily rhythm: Disruption of the daily rhythm (sleep-wake cycle) plays a major part in the development of an episode of illness. Mania may, for example, occur if you do not sleep, or in connection with jet lag when travelling across time zones.
  
  
• Substances: Hashish, alcohol, speed and cocaine may contribute to provoking mania, mixed state and depression. Many people feel that hashish, for example, has an immediate calming effect on them, but it actually increases the risk of episodes. It is therefore very important not to use hashish or other substances.
  
  
• Medication: Antidepressants as well as some other forms of medication may occasionally provoke an episode of illness in people with underlying bipolar disorder.
  
  
• Events: Both positive and negative events or changes may result in mental stress and contribute to activating manic or depressive symptoms. Your susceptibility to stress increases with the number of episodes of illness.
  
  
• Social conditions: Loss, violations, lack of support and family conflicts are some of the factors that can typically contribute to triggering an episode of illness.
• Increased commitment: Goal-oriented behaviour and increased commitment, for example in connection with exams, overtime work or falling in love, can help develop the episode of illness.

If you have a bipolar disorder, you will experience unnaturally large energy and mood swings You will have repeated periods of illness with mania, hypomania, depression or mixed state. A period of illness may last from a few weeks up to several months.

In between the periods of illness, you will typically have stable periods in which you notice no – or only very light – signs of illness.

• During periods of mania, you may feel in extremely good spirits or downright euphoric, optimistic, outgoing, full of ideas and exceptionally quick-thinking.
• At the same time, you may feel that you have much more energy and less need for sleep. You may also have an unpleasant restlessness in your body.
• You may have many plans and ideas. You talk a lot and change the subject often.
• You may also be more irritable and may appear angry or aggressive.
• In connection with mania, you may tend to overestimate yourself. Your judgment may be impaired, and one may lose your self-control. This may result in reckless and uninhibited behaviour, such as unrealistic, excessive spending, substance abuse or increased sexual appetite and activity.
• In severe cases of mania, psychotic symptoms may be experienced in the form of either delusions or hallucinations. 

During a manic period, you will often need hospitalisation.

Hypomania is a mild form of mania.

• You may feel more elated or irritable.
• You may have increased energy, more self-confidence and feel better.
• You are typically more productive than usual.
• Your need for sleep may be reduced by two to three hours.

You may have hypomania if the symptoms have persisted for at least four days.

A hypomania episode will not always affect your ability to function in your daily life, but those closest to you will usually notice that your state of mind is altered.

In some people, a hypomania may be a precursor to mania, while, in others, a hypomania can suddenly turn into a depression.

• During periods of depression, you may lack energy and desire, feel depressed, have poor self-esteem and memory problems.
• You may find it difficult to manage your daily chores, feel a sense of hopelessness and perhaps have suicidal thoughts.
• Some people with depression sleep more than usual, while others have more difficulties sleeping.

In order to be able to make the diagnosis of depression, the symptoms must have persisted for at least 14 days.

Degree of severity:

Depressions are classified by degree of severity:

• Mild depression
• Moderate depression
• Severe depression
• Severe depression with psychotic symptoms (You can read more on the page on depression in adults)

In moderate and severe depression, the person often has suicidal thoughts or, in the worst cases, actually plans to commit suicide.

In severe depression, psychotic symptoms are sometimes observed in the form of delusions or hallucinations. For example, persons suffering from severe depression may hear voices urging them to commit suicide.

When you have a mixed state, you may experience manic and depressive symptoms all at once, or you may fluctuate rapidly between manic and depressive states (from hour to hour or day to day).

A mixed state may be an independent episode of illness, or it may occur in connection with a transition from mania to depression or from depression to mania.

In some cases, there are the same amount of symptoms of mania and depression. In other cases, there is a predominantly manic mixed state or a predominantly depressive mixed state.

The risk of suicide is greater in a mixed state because, at the same time as being depressed, you also have a violent, destructive energy. You may have suicidal thoughts as well as increased energy and drive at the same time.

A mixed state is one of the most unpleasant disorders that you can experience – especially if manic and depressive symptoms occur concurrently.

In order to be able to make the diagnosis of mixed state, the symptoms must have persisted for at least 14 days.

You will be examined for bipolar disorder through one or more consultations with a doctor or a psychologist specialising in psychiatry. You will also need to attend a psychiatric interview, which is a consultation based on a structured guide.

The doctor or psychologist specialising in psychiatry will inquire about your current condition. You will also talk about whether you have previously had periods of unnatural changes in your mood, your thoughts and your energy level.

The doctor or psychologist specialising in psychiatry will assess what symptoms you have had, how long they have lasted, how severe they have been and how they have affected your ability to function in your daily life.

Your relatives can contribute important information about how they experience your condition.

You will also be examined for other diseases. The doctor will examine whether you have physical illnesses or other mental illnesses, such as abuse, anxiety, personality disorder or ADHD. 

You may be diagnosed with bipolar disorder if you have had at least two episodes of illness, one of which is mania, hypomania or a mixed state. If, instead, you have only had an isolated mania, hypomania or mixed state, this is called a single episode.

Cyclothymia is a milder variant of bipolar disorder. If you have cyclothymia, you have persistent fluctuations in a manic or depressive direction (over at least two years) where the criteria for mania or depression are not met at any time.

The course of the disorder differs from person to person. There is a difference in how many episodes of illness you have, how severe they are, how long they last and what type they are.

Some have the classic type of bipolar disorder with manias and depressions, while others solely have hypomanias and depressions. And some have a course of illness with mixed states and depressions.

Studies indicate that depressions occur three times more frequently than manias in people with bipolar disorder.

Persons with bipolar disease will often have stable periods between the episodes of illness. The stable periods may have different lengths – from weeks to years or decades.

However, some people with bipolar disorder will experience mild depressive or manic symptoms outside the serious episodes of illness.

You may have residual symptoms for several weeks or months after an episode of illness. You may feel more tired, have less energy or cognitive difficulties. In other words, problems with attention, memory, planning and overview.

Some people with bipolar disorder may have persistent cognitive impairment outside episodes of the illness. If you constantly have problems with attention, memory, planning and overview, this may affect your ability to function at work or studies – also even if you are in a stable period.

The prognosis for the individual episode of illness is relatively good. The more long-term (years) prognosis will vary from person to person.

Relevant treatment, good personal resources, a stable way of life and support from others will have a positive effect on your course of illness. In turn, the prognosis will typically be poorer if abuse or other mental illnesses are present concurrently. 

Many people with bipolar disorder also have other mental disorders. Especially abuse and various forms of anxiety disorders, ADHD etc.

It is most often painful to experience a depression or mixed state, and they both result in an increased risk of suicide.

Mania and hypomania may sometimes cause a feeling of euphoria. Nevertheless, most people want to prevent and treat hypomania and mania. There are two reasons for this: Firstly, a mania is generally followed by a depression which lasts much longer than the mania itself. Secondly, you often do things in a manic state that you deeply regret afterwards.

This may, for example, be that you quarrel with your family, or that you do spontaneous, ill-considered things, such as incurring large debt.

The purpose of treating your bipolar disorder is to prevent periods of illness, thereby increasing your quality of life. Treatment will be adapted to you and the different stages of your course of illness. Involving your relatives may also be an element in your treatment.

Hospitalisation is often necessary if you have a mania, a severe depression or a severe mixed state. For some, compulsory admission may be necessary.

Milder episodes of illness can be treated without hospitalisation by a practising psychiatrist, in a psychiatric clinic or by your general practitioner. 

If you are pregnant or are trying get pregnant, you will be referred to the hospital psychiatric services, as there is an increased risk of recurrence in connection with pregnancy. At the same time, there is a need for advice regarding the proper preventive medicine during pregnancy.

Medication for bipolar disorder – mood stabilisers – can treat and prevent depression, mania and mixed state in most people.

There are three overall types of mood stabilisers:

• Lithium
• Medication for epilepsy (antiepileptic drugs)
• Medication for psychoses (antipsychotics)

Most people with bipolar disorder are recommended long-term preventive pharmacological treatment.

Some will receive recommended preventive treatment already after their first episode of illness.

The treatment which the doctor will recommend to you depends on a number of factors, including the effects and side effects you have previously had with medicines and on your course of illness so far.

Read more at the page about Stemningsstabiliserende medicin (Mood stabilisers).

Most people with bipolar disorder may periodically find it difficult to accept that it is necessary for them to take medication. This may be due to their own view of their disorder, unpleasant side effects or a longing for hypomanic periods.

Some feel that their ‘manic I’ is their ‘real’ self. It may therefore be difficult and feel wrong to take medication during a stable period. If you feel that way, it is important that you consult your therapist and look at the pros and cons of the pharmacological treatment.

Psychoeducation is learning about your own disorder. You can participate in psychoeducation as part of your personal treatment or as part of a group therapy course.

In connection with psychoeducation, you receive information about for example:

• Your diagnosis
• Future prospects
• Causes
• Opportunities for treatment and prevention.

In connection with psychoeducation, there is special focus on conditions that are significant for your management of the disorder and for the prevention of recurrence.

When you are in a fairly stable phase, it is a good idea to draw up a personal prevention plan. This may be in cooperation with your relatives.

In a prevention plan, you write down:

• Your early warning signs of hypomania/mania, mixed state and depression
• Any triggering factors
• A plan for what you can do if there are signs that an episode of illness is developing.

Medication can be combined, as needed, with supportive consultations or psychotherapy. Counselling may be individual or in a group.

The content of your course of treatment depends on your needs and is continuously adjusted to the individual phases of the course of your illness.

• If you are in a depressive phase, you will typically need help breaking depressive behavioural patterns. This may, for example, be inactivity, isolation and passivity. Tasks that appear insurmountable can be broken down into smaller, easier-to-deal-with activities.
  
  
• Once the worst depressive symptoms have receded, you can work with your depressive thinking. The aim is to find alternative and more nuanced ways of thinking.
  
  
• If you develop mild symptoms of mania, your therapist can help you limit activities and stimuli. Your therapist can also support you in considering the pros and cons of acting on impulses or ‘good ideas’.
  
  
• An important goal of preventive treatment is to learn to handle stress, or to avoid stress, in an appropriate way. It may, for example, be stress management in relation to job, education, leisure activities or close relationships. You can also receive help in stabilising your daily routines, social activities and sleep patterns.
  
  
• At the emotional level, you may often need to work through loss, violations and defeats that typically follow in the wake of the disease. This may, for example, be grief over the loss of close relationships or sadness about having to interrupt your studies or leave a job.
  
  
• Another subject is the guilt and shame linked to actions carried out during manic or depressive periods. Some people need help to deal with a perception of stigmatisation, i.e. a sense of being different and being singled out because of the illness.
  
  
• Others may need to work on personality difficulties that may be a consequence of the illness itself and/or may relate to temperament, upbringing and other life history.

There are a number of things you can try to do yourself to cope with the illness and help prevent new episodes. Whether you will be able to follow the advice depends on factors such as your current state, and whether you receive the necessary support from the people around you.

It is a good idea to learn about bipolar disorder, symptoms and phases.

Often, it takes time to recognise and accept the illness. If you had the illness for a long time before your diagnosis was made, looking back and trying to make sense of the periods when you have been ill can in itself be a major challenge.

It takes time to learn to distinguish between normal emotional fluctuations and symptoms of mania/hypomania or depression. It may be challenging to learn to strike a balance between being aware of any signs and symptoms of your disorder, and not allowing fear of new episodes of illness to consume all your time.

When you are in a stable phase, you can prepare a personal prevention plan jointly with your therapist and possibly your relatives.

For most people with bipolar disorder, it takes time to strike a balance between denial and over-identification with the illness. An important goal could be learning to define yourself in ways other than merely through your illness.

It is important to focus on what activities create content in life and make sense in your daily life. Do what is good for you! Whether it is drawing, knitting, going for walks in nature, having pets, fitness training or something else entirely. It is important that you take time for the activities that are good for you.

If you are depressed, it might help to undertake simple, manageable activities that could help improve your mood. This could be calling a friend for a chat, getting a good cup of coffee or going for a walk. Remember to take into account your current energy level and your ability to concentrate.

If you are more severely depressed, you will often need the people around you to help you produce a daily plan and to perform activities. Exercise and movement may help alleviate signs of depression.

Hypomania will often feel like a positive state in which you may have a strong urge to act. You often have lots of ideas, and it is not far from thought to action.

It may help to consider the pros and cons of new ideas and to discuss them with one or two people you trust. You can also practise postponing risky decisions, for example for three days.

After a period of illness, you are typically more vulnerable. Perhaps you will launch into activities and tasks too quickly, overlooking the fact that you do not have as much drive and energy as usual. There may be some days when your mood is suddenly low or elevated. In some cases, you will need to pay particular attention to whether your state swings to the opposite pole.

An important objective could be to adjust any unrealistically high expectations of yourself and to learn to say no in various contexts. Adjusting your expectations is often a long and challenging process. It can be hard to accept that you can no longer perform as much or take on as much responsibility as you previously could.

After a period of illness, you may experience problems with attention, overview, memory and initiative. It is important that you take this into consideration and that you do not overburden yourself. If you feel up to it, there are a number of things you can do to reduce any cognitive challenges.

A calendar can be useful if you have problems with overview and planning. If you write your appointments and tasks in your calendar, it will be easier to manage what you need to do during the week, and how much you can realistically manage to do in a day or a week.  Regular routines, specific systems and using the calendar can help you remember things and appointments.

It is common for people periodically to find it hard to accept having to take medication. Discuss doubts and considerations regarding your medication with your therapist. It is important that you do not stop taking your medication until you have consulted your therapist.

Disturbances in the daily rhythm are of great importance in bipolar disorder. An important personal goal may therefore be to establish daily routines, regular social activities and a stable sleep pattern.

It is advisable to have a regular daily rhythm in which you get up and go to bed at roughly the same time each day. A healthy, regular diet as well as regular exercise are important too. 

Some people with bipolar disorder increase their consumption of stimulants during some periods. Sometimes people drink more or start smoking hashish in connection with episodes of illness. As previously mentioned, stimulants can trigger, aggravate and maintain symptoms of mania or depression, and long-term substance abuse may have an adverse impact on memory and learning in the long term. If you find it hard to control your intake, it is important to seek help.

How open you should be about your illness is a recurring question for most people with bipolar disorder. When should you tell other people that you have a bipolar disorder? And when should you not disclose it?

There is no clear answer to this question, but, as a general rule, it is a good idea that you consider the pros and cons in the short and long term. Talk to your therapist about it. 

Being close to someone who has a bipolar disorder is often a challenge. Sadness, uncertainty, anxiety, irritation and helplessness are very common reactions among persons close to a bipolar disorder sufferer.

As a relative of a person with bipolar disorder, you need knowledge about the illness, about the key symptoms and the various phases of the course of illness.

Knowledge about the disorder can help you understand why the person reacts as he or she does, the best way of dealing with it, and what you might have to try to accept for a while.

If you want to support the bipolar disorder sufferer, you can find out what he or she needs in the various phases of the course of illness. Family counselling with a therapist might be helpful in this connection.

It is important that you, as a relative, support the treatment – both in the acute phase and in the prevention phase.

With depression, mania and mixed state, it is important to recognise the first signs of fluctuations and to help the affected person get treatment.

In acute situations, for example in case of manias, severe depressions or mixed states, where the person has insistent suicidal thoughts, you can help contact his or her general practitioner, the emergency services doctor or psychiatric emergency department.

If the bipolar disorder sufferer is already undergoing treatment, you can initially contact the place of treatment with the affected person’s consent.

In special situations, for example in case of serious threats or violence, you may need to contact the police.

If you are in doubt as to how best to support a person in a depressive phase, it is a good idea to ask the person himself/herself. You can offer contact, but there is a great deal of variation in what a person who has a depression needs or is able to cope with. While some people with depression want to talk about how they feel, others prefer to be distracted, for example by talking about entirely unrelated things.

You can support the person who has a depression in maintaining hope of recovery and help him or her carry on at his or her own pace. It is important that you acknowledge his or her efforts. In fact, very ordinary tasks, such as taking a bath or getting out of bed, require a great deal of effort on the part of someone with a severe depression.

In some cases, you, as a relative, may need to relieve the affected person completely. In other cases, it is better that you do something together rather than you taking over all tasks and functions.

Suicidal thoughts are often part of a depression or a mixed state. If you are worried that the depressed person is contemplating suicide, you must try to talk to him or her about it. Perhaps you can help him or her see other solutions, but, above all, it is important not to be condemnatory towards the depressed person.

If the suicidal thoughts are insistent, the depressed person should not be left alone, and it is important to get in touch with the place of treatment, the person’s general practitioner, the emergency services doctor or a psychiatric emergency unit.

Emergency help – How to get in touch with psychiatric services.

During a mania, difficulties may arise between the manic person and the people around him or her.  A manic person will often not acknowledge his or her illness, and this may be a great challenge for the relatives. It is generally no use arguing too much with him or her. In the worst case, this can contribute to aggravating the condition further. 

In a hypomania, you could perhaps help the person get a good night’s sleep and to restrict appointments and activities that could worsen the condition. However, you must take into account the possibility that the person will regard the hypomanic phase as a positive part of his or her normal condition.

During stable phases, it can be important to discuss how you, as a relative, can best offer support if there are signs of hypomania or mania.

After an episode of illness, the person is typically more tired and vulnerable. The ability to pay attention, to remember things and to keep track of things is often impaired.

There are various ways you can help the person.

• You can help organise the person’s everyday routine and maintain a stable rhythm.
• You can pay attention to how you yourself give messages and make appointments. You might need to repeat important information and messages, or write them down.
• Perhaps you can help with planning, initiating and performing specific tasks, for example housework, shopping, gardening and leisure activities.

If it is not possible for the person to return to his or her former level of functioning at first, you must try to adjust your expectations, even though this may be associated with grief, disappointment and frustration.

If you are to be able to provide long-term support and help, you will also need to take care of your own needs and try to lead as normal a life as possible.

You must try to accept that you will not always have the energy or be in a condition to provide help. You may need to take a short or longer break at times. This is why it helps if you can share the responsibility with other relatives so that you do not have to bear the whole responsibility yourself.

As well as making contact with therapists, you might benefit from contact with other relatives and patient and carer associationssuch as SIND (the Danish Association for Mental Health), Bedre Psykiatri or Depressionsforeningen (the Danish Depression Association), all of which also have hotlines for advice.

If you personally feel that you are becoming emotionally overburdened over an extended period of time and/or that you are developing distinct symptoms of anxiety or depression yourself, you can consult your own doctor to get help and support. In some cases, you can get a referral to a practising psychologist with health insurance reimbursement.