How does apathy contribute to being bipolar?

The Bipolar Affective Disorder (also known as "manic-depressive illness") is a mental illness. It manifests itself in the affected people through episodic, voluntarily uncontrollable and extreme deflections of the drive, the activity and the mood, which fluctuate far outside the normal level in the direction of depression or mania.


Bipolar affective disorder is characterized by an episodic course with depressive, manic, hypomanic or mixed episodes:

  • Depression is characterized by an above-average depressed mood and reduced drive. In severe depression, thoughts of suicide occur.
  • A manic episode is characterized by increased drive and restlessness, often with an inappropriately euphoric or irritable mood. The ability to examine reality is severely limited and those affected can get themselves into great difficulties.
  • Hypomania is a mania that is not very pronounced, typically without serious social consequences. However, hypomania is already well above a normal activity and / or mood spike.
  • In a mixed episode, both individual symptoms of mania and depression are present, for example increased drive in a depressed mood.

In between the episodes of illness, there is usually a return to the normal, normal state. Drive and mind are then again within the normal fluctuations between the two extreme poles.

Bipolar people not only oscillate back and forth between manias and depression, but also often fluctuate in the interval, i.e. between acute phases of illness, between extreme constructions of reality and forms of experience.

Most often, bipolar disorder begins in adolescence or early adulthood. It is a serious brain disease that can be dangerous because of the increased risk of suicide and the social consequences. Affected people have a wide range of degrees of severity and the transition to a “charismatic” or exuberant personality is fluid. The symptoms are caused by a disorder of the brain metabolism that manifests itself psychologically. However, the disease itself can have various causes. The disease is usually only recognized many years after the outbreak, both by the person affected and by doctors, so that sick people suffer unnecessarily before they receive treatment. Since the symptoms have a strong impact on decisions and relationships, the life paths of those affected are dramatically affected, especially since the symptoms usually begin at a young age, when the personality is not yet established. Often there are problems in training, in work and family life, or sudden changes in the curriculum vitae. Once the disease is recognized, the right treatment and a balanced, controlled lifestyle can often reduce symptoms and lead a full life.

Bipolar disorder is a fairly common disease - if lighter cases are included, it affects up to 3-4% of the population in industrialized countries at some point in their life. It is often associated with creativity, and it affects many successful people. The increased drive in hypomanic phases can inspire unusual and daring projects and goals are pursued with great commitment. However, it is inappropriate to “romanticize” the disease, its consequences are often catastrophic and if left untreated, it can ruin life.


There are criteria catalogs for both manic and hypomanic and depressive episodes, in which certain symptoms must be fulfilled and must also last for a defined period of time in order to reach a diagnosis.

Such a list of symptoms can be found, for example, in the ICD-10, an international classification of diseases and related health problems published by the World Health Organization (WHO). The various forms of bipolar affective disorder are classified in the ICD 10 under the code F31, a distinction is made between ten different forms.[1]

A national (US) classification system can be found in the “Diagnostic and Statistical Manual of Mental Disorders” (Diagnostic and Statistical Manual of Mental Disorders, abbreviated as DSM-IV).

More under diagnostics.


Until a few years ago, the term "manic-depressive illness“, „manic-depressive psychosis"Or (coined by the psychiatrist Emil Kraepelin at the end of the 19th century)" manic-depressive insanity "is used. Colloquially it is sometimes referred to as "manic depression", which is misleading. The terms “manic-depressive illness” or “manic-depressive illness” are also used as synonyms today and are generally better understood by the public. A term that is often used as a synonym for bipolar disorder among doctors and authorities is bipolar psychosis or affective psychosis.

The term "psychosis" is used differently in the professional world: some subsume only "delusion" under it, others use the term for serious mental disorders, to which bipolar disorders - despite the perhaps "harmless" word "disorder" - certainly belong.


Mania / manic episode

Main Products:mania

During a mania, the person concerned often concentrates his full capacity on mostly pleasant aspects of his life, with other aspects being neglected or completely ignored. It can happen that the person concerned focuses his entire energy on his professional or voluntary commitment, for a new partner or on sexuality, but at the same time completely neglects important or more important things such as his household or his job or his family. The increased willingness to perform can initially also lead to success. In this way, the sick person can achieve very respectable achievements during mania, but even more so with hypomania, if talent is present. The excessive sociability and quick-wittedness can also be well received. However, sleep is extremely reduced and the body is overworked accordingly.

With stronger manifestations, it can lead to a loss of reality and delusion. This is often the case in postmanic mixed states. The overestimation of oneself and the feelings of grandiosity during the mania can turn into a megalomania (megalomania and / or Caesar madness). A religious delusion, even religious megalomania, can occur. Hallucinations can also be caused because of the sometimes extreme lack of sleep caused by the mania.

Many of those affected find it difficult to see a “normal state” or “normality” as something worth striving for. In some cases, the hypomanic state is preferred, which is contrary to phase prophylaxis.


Main Products:Hypomania

Hypomania is the weakened form of mania. Special features are the elevated basic mood and increased drive, which can be associated with simultaneous changes in thinking in the sense of a more erratic, less concentrated thinking (flood of ideas) and a change in psychomotor skills. The elevated mood leads to greater self-confidence, an increased willingness to take risks and breaches of boundaries. The performance is highest in this state. See also:Creative and famous bipolar

Depression / depressive episode

Main Products:depression

Depression reverses all aspects of mania and forces the sufferer to become apathy and listless. In this phase of the disease of the greatest suffering, death very often appears to be a better condition. Often things that have been done in mania are also embarrassing. Depression is perceived as much worse than the "depressed mood" that many healthy people occasionally go through. Depressive episodes are more common as people get older.

Gradient forms

Manic or depressive episodes occur frequently, but not exclusively, after a stressful life event. The first appearance of the disease can happen at any age. However, the first symptoms usually appear between the ages of 15 and 30. Those affected usually go through four different phases in the first 10 years. The frequency and duration of the individual phases are very different. In general, however, it can be said that manic phases usually last a little shorter than depressive episodes, that the intervals between the phases become shorter over time and that with increasing age, depressive phases occur more frequently and last longer. After a few phases of the disease, internal rhythms can develop that also work independently of external events. While sometimes - especially if recognized quickly and treated correctly - no further episodes occur after the first or the first episodes, bipolar disorder appears for many as a lifelong, chronic disease.

According to the latest studies, up to 40% no longer achieve their original functional level after periods of mania or depression. Only 40% of those affected have a favorable psychosocial course or can maintain their social environment or their position in society. In the case of persistent symptoms such as poor concentration or fatigue, one speaks of residual symptoms. If the illness lasts longer with several longer hospital stays, there is a risk that the person concerned will often lose social stability, often also the job. The family may break up and the circle of friends may turn away helplessly.

Bipolar I - Bipolar II - Switching - Cyclothymia

The bipolar disorders are divided into Bipolar I. and Bipolar II.


As Bipolar I. will last 7 to 14 days or less often longer manic episode (High phase), followed by at least one depressive episode. Bipolar I disorder occurs in approximately 1 to 2% of the population. Women and men are equally affected.

Bipolar II includes a minimum of 14 days depressive episodefollowed by at least one Hypomania (lighter form of mania). Bipolar II disorder occurs in approximately 4% of the population.

Recurrent Depressive Disorders (Depression that recurs after an intermediate state of the normal) can with a Bipolar II- Disorder being confused when the hypomanic phases are not recognized.

  Switching (Polarity change) is called the seamless change between mania (or hypomania) and depression.

At a CyclothymiaICD-10, those affected are exposed to slight manic and depressive fluctuations for at least two years, although these are still well above normal mood fluctuations. According to ICD-10, cyclothymia is not counted as a bipolar disorder.

Rapid cycling

Rapid Cycling (RC) is used to describe at least four mood changes per year, Ultra Rapid Cycling (URC) describes mood changes within a few days and Ultra Rapid Ultradian Cycling (URUC) describes the changes within a few hours. Patients with rapid cycling are often treated in a clinic. Rapid cyclers require special therapy because the frequent change of episodes can often not be adequately treated with classic medication, and mood stabilizers are therefore usually used. The causes have not yet been clarified. The risk of suicide is high with "Rapid Cycling" and the prognosis is poor.

Mixed states (dysphoric manias)

When depressive and manic symptoms occur in rapid succession during a bipolar episode of illness, or when depressive and manic symptoms mix by simultaneous occurrence, this is called a mixed manic-depressive state or a mixed episode. For example, the affected patients can think or speak very quickly, as is typical of a manic episode. At the same time, however, they can be very anxious, have suicidal thoughts, and suffer from depressed mood; URC and URUC can also be found in these episodes in patients who are otherwise not affected by this type of switching. Mixed states often occur in the postmanic phase and are also due to the fact that those affected in the manic phase are no longer able to sleep properly. They are common and occur at least as often as "classic" manias. The increased drive can cause depressive thoughts to be put into action, so that the risk of suicide in these states is much higher than in pure depression, in which the drive is paralyzed. As with Rapid Cycling, mood-stabilizing psychotropic drugs are often used here. These are severe episodes that are more difficult to treat than the classic phases of bipolar illness.

Concomitant diseases (comorbidity)

  • In adults, alcohol and other drug abuse are the most common comorbidities with 2/3.
  • Drug abuse occurs mainly in postmanic mixed states and the subsequent severe depression. Daily drug allocation and intake monitoring should be a matter of course in these episodes.
  • Panic Disorders and Personality Disorders

Suicide risk

People suffering from bipolar disorder generally have a much higher risk of suicide. On average, 15 to 30% commit suicide. In some areas - as demonstrated for Scotland - the suicide rate of those affected is 23 times higher than the population average, and in some stages of life - for example, within two to five years after the first onset - suicides are particularly high.[2]

Depression is particularly risky if the drive is not yet paralyzed or has already improved somewhat so that suicide can be implemented. Mixed phases (mixed states), in which agonizingly manic and depressive symptoms occur at the same time, harbor a risk of suicide as a result of the dysphoric or desperate mood and the extremely high level of drive. Another reason can persist between the phases, even with clear deliberation: Many experts consider depression to be the illness from which one suffers most. Bipolar people with an unfavorable prognosis and many phases before know that depression will come again and again.


Doctors often ignore the hypomanias, or they do not learn anything about it in the usually short medical history, so that bipolar disorders are not treated appropriately. Often times, depression is not even recognized. The symptoms of manic-depressive illnesses are still very little known, not only in public, but also among doctors, although many - in Germany at least 2 million people - are affected by bipolar disorders.

Although bipolar affective disorder is widespread and a very serious disease, information about it in public has been rather rare until now. Even general practitioners often overlook the signs of the disease. They usually don't have enough time to take a long anamnesis.

Only a small proportion of all bipolar patients are currently correctly diagnosed (Grunze & Severus 2005).

The following obstacles make a diagnosis difficult:

  • 30% mixed state: only just under half of all manias are characterized by euphoria ("sky high-cheering"), contrary to the widespread view and representation. Often times, depressive symptoms are also associated, which ultimately (40%) can lead to a mixed state. If these mixed symptoms are not recognized as such, misdiagnosis can quickly occur.
  • Widespread descriptions cite financial ruin, fearlessness in separation and delusion in manias as typical elements, so that manias that do not exhibit these phenomena are not perceived as such.
  • In mania, there is often excessive alcohol or drug consumption, so that a bipolar disorder is rashly classified as an alcohol or drug addiction.
  • When addictive diseases occur as a comorbidity, there is an increased risk that the underlying disease will be masked.
  • Depression: "Recurrent unipolar depression" is the most common misdiagnosis in bipolar disorder. This is because hypomanic phases are usually not recognized, reported or inquired about as such.
  • ADHD: In children and adolescents, it is difficult to distinguish it from “Attentional Deficit Hyperactivity Disorder” (ADHD).
  • Schizophrenia: Psychotic symptoms, which can occur in severe manias at their peak, often lead to the misdiagnosis of schizophrenia or a schizoaffective disorder.

ICD-10 or DSM-IV criteria

For the diagnosis there are some structured interviews and / or the criteria of the ICD-10 or DSM-IV.

Criteria for the manic phase

A. A marked period of abnormal and constant elation, exuberance, or irritability that lasts for over 1 week (or hospitalization).

B. During the mood disorder period, three (or more) of the following symptoms persist to a significant degree (four if mood is just irritable):

  1. Exaggerated self-respect or greatness
  2. Decreasing need for sleep (e.g. feels refreshed after only 3 hours of sleep)
  3. More talkative than usual or pressure to talk
  4. Flight of ideas or subjective experience that thoughts are racing
  5. Absent-mindedness (attention is easily drawn to unimportant or insignificant external stimuli)
  6. Increase in targeted activities (either social, at work or school, or sexual) or psychomotor restlessness
  7. Excessive pleasures that have a high potential for painful consequences (e.g., uninhibited shopping spree, sexual tactlessness, or foolish business investments).

C. Symptoms do not fit the criteria of a mixed episode.

D. The mood disorder is sufficiently severe to cause significant impairment in job areas or unusual social activities or relationships with others, or to require hospitalization to prevent harm to oneself or others, or to other psychotic traits.

E. The symptoms are not caused by the direct physiological effects of a substance (e.g. substance abuse, medication, or other treatments) or a general medical condition (e.g. overactive thyroid).

Criteria for a major depressive phase [3]

A. Five (or more) of the following symptoms are present during the same 2 week period and indicate a change from previous activity.

  1. depressed mood for most of the day, almost every day, indicated either by subjective reporting (e.g., feeling sad or empty) or by observing others (e.g., appearing weepy). Note: Children and adolescents may have an irritable mood.
  2. Significantly decreased interest or enjoyment in all, or almost all activities for most of the day, almost every day (indicated either by one's own report or by observations of others)
  3. Significant weight loss without dieting or weight gain (e.g. a change in body weight of more than 5% in a month) or an increase or decrease in appetite almost every day.
  4. Insomnia or need to sleep almost every day.
  5. psychomotor restlessness or slowing down almost every day (observed by others, not just subjective feelings of restlessness or exhaustion).
  6. Exhaustion or loss of energy almost every day.
  7. Feelings of worthlessness, or excessive or inappropriate guilt (which may be due to self-deception) almost every day (not just reproach or guilt for being sick)
  8. decreased ability to think or concentrate, or indecision almost every day (either through subjective reporting or observation of others)
  9. recurring thoughts of death (inadequate fear of dying), recurring suicidal ideation without a specific plan, or attempted suicide or a precise plan to commit suicide

B. Symptoms do not fit criteria for mixed phase.

C. Symptoms cause clinically significant pain or impairment in social, professional, or other important roles.

D. The symptoms are not based on a direct physiological effect of a substance (e.g. drug abuse, medication) or a general medical condition (e.g. overactive thyroid)

E. Symptoms are caused by bereavement, e.g. B. the loss of a loved one. The symptoms last longer than 2 months or are characterized by a pronounced functional impairment, pathological preoccupation with worthlessness, suicidal thoughts, psychotic symptoms or psychomotor slowdown.

Criteria for the hypomanic phase

A. A distinct period of constantly elated, exuberant, or irritable mood lasting four days through and through, which is clearly different from the usual non-depressive mood.

B. During the mood disorder phase, three (or more) of the following symptoms (four if mood is just irritable) are persistent to some degree:

  1. excessive self-esteem or megalomania
  2. decreased need for sleep (e.g. feels relaxed after 3 hours of sleep)
  3. more talkative than usual or urge to talk
  4. Flight of ideas or subjective experience of racing thoughts
  5. Absent-mindedness (this means paying attention to simply unimportant or insignificant external stimuli)
  6. Increase in targeted activities (either social, professional, or school, or sexual or psychomotor restlessness)
  7. excessive engagement in amusements that have highly painful consequences (e.g., unrestrained shopping spree, sexual indiscretions, or stupid business investments)

C. The episode is accompanied by a definite change in mode of action that is uncharacteristic of the person when without symptoms.

D. The mood disorder and the change in appearance are observed by others.

E. The episode is not severe enough to cause significant social or professional impairment, or to require hospitalization, and has no psychotic characteristics.

Q. The symptoms are not caused by the direct physiological effects of a substance (e.g. substance abuse, medication, or other treatments) or a general medical condition (e.g. overactive thyroid).

Note: Episodes similar to hypomania that are clearly caused by somatic antidepressant treatment (medication, electroshock therapy, light therapy) should not be assigned to a diagnosis: "Bipolar II disorder".


Due to the lack of insight on the part of those affected, especially in manic episodes or when there is an acute risk of suicide, treatment in the acute phase of the disease in mania or severe depression must sometimes be carried out against the will of the patient as compulsory treatment. In most cases, however, those affected show understanding and, also because of their high level of suffering, allow themselves to be treated voluntarily. If, however, manic phases appear for the first time, those affected cannot have any insight, as they have not yet gained any experience of the serious negative consequences. For many, the insight only comes after several phases. It is very helpful for successful treatment if those affected inform themselves about their own illness and read a lot about it, so that they can understand for themselves which treatment is best in which phase, and so that they can take countermeasures in good time to ensure a regular life imperative to learn.


Different medication is necessary in the different episodes. A distinction is also made between acute therapy, maintenance therapy and prophylaxis.


Neuroleptics are often administered in acute manias or when severe manias predominate. Modern neuroleptics such as risperidone, quetiapine, olanzapine and others are suitable for the treatment of a manic phase, clozapine and the like, which cannot cause extrapyramidal motor disorders as a side effect, are less suitable because of dangerous side effects such as agranulocytosis. Neuroleptics can also be used when a manic episode is looming; this can prevent a full onset.

Benzodiazepines are used by inexperienced doctors to combat mania. These sedating and anti-anxiety agents have been shown to be unsuccessful in severe mania, even in high doses, and are therefore unsuitable. Despite taking the benzodiazepines, patients are very restless and active. Higher doses can create a kind of high that is very similar to an alcohol intoxication. Psychotic manias are supported by these drugs and sleep is extremely reduced, so that physical damage to the nervous system is the result, which can be irreversible. In any case, the recovery then takes several years or it does not happen at all. See also: Mania Treatment

Mixed states

Mixed conditions are complicated to deal with. Usually several drugs have to be combined. On the one hand, they can be treated with newer atypical neuroleptics such as ziprasidone. On the other hand, the depressive symptoms must also be treated. It may be the case that taking it over a longer period of time is necessary if psychotic symptoms recur on discontinuation.


Antidepressants, especially serotonin norepinephrine reuptake inhibitors, which do not increase the concentration of dopamine, are recommended for acute depression or for rapidly recurring (recurring) occurrences of many types of depression. Many antidepressants can cause those affected to turn into mania or hypomania (“switch”, “switch risk”); therefore, not all antidepressants are equally suitable for bipolar people. Combination therapy with atypical neuroleptics is often recommended in Germany, although it has been proven that the risk of serotonin syndrome is very high when combined with SSRIs.[4] The most obvious is the combination of SNRI or SSRI with mood stabilizers, see phase prophylaxis.

Phase prophylaxis

Preventive treatment for bipolar disorder is done with mood stabilizers like lithium or anti-epileptic drugs like carbamazepine, valproic acid, or lamotrigine. The exact modes of action, especially that of lithium, taken in the form of lithium carbonate, have not yet been clarified.

Carbamazepine, valproic acid and lithium, however, prove to be ineffective, especially for bipolar II patients with severe depression and only mild manic states (hypomania), because these drugs primarily prevent manic states. An exception is lamotrigine, which promises better prophylaxis against depressive states. Since it hardly has an anti-manic effect, hypomanias, which some find pleasant and stimulating, are hardly affected. [5]


Neuroleptics (including atypical neuroleptics) are generally unsuitable for phase prophylaxis because they can trigger extrapyramidal motor disorders and, in contrast to mood stabilizers, do not have a phase prophylactic effect. They should therefore be used more in manic phases or mixed states. If mixed conditions persist for a long time and therefore a longer administration of dopamine-lowering agents is necessary, this should not be regarded as phase prophylaxis, but as treatment of a long-lasting phase.

If there is no longer any possibility of a recovery phase in the mania, artificial damping is required. Long-term treatment with neuroleptics is usually not necessary and also causes a disproportionate number of side effects and significantly reduces the quality of life of those affected.

Caffeine, alcohol, drugs

In addition to stress and lack of sleep, caffeine, alcohol, tobacco smoke and other drugs also have adverse effects on bipolar people. In addition, interactions with the prescribed medication can often be expected, which is why it is advantageous to completely avoid coffee, alcohol and other drugs.

  • Caffeine has an unfavorable effect on the length of sleep and promotes nervousness and restlessness; Bipolar people can be particularly susceptible to this and could trigger a mania as a result.
  • In addition to the risk of addiction, alcohol has a negative effect on the depth of sleep and the duration of sleep, contrary to popular belief, and has a disinhibiting effect, which is contrary to anti-manic prophylaxis. On the other hand, alcohol increases depression.
  • Nicotine makes drug treatment more difficult because the correct setting is impaired by its consumption.
  • Some bipolar people like to use marijuana as self-medication. Despite the possibly positive effects, it should not be forgotten that withdrawnness and indolence (depressive characteristics) as well as paranoia and paranoia (manic characteristics) can be increased many times over by marijuana, which in turn counteracts recovery.


A cognitive behavioral therapy and / or conversation psychotherapy and / or sociotherapy and / or psychoeducation tailored to the disease is useful. Self-help groups such as those that have come together in the “Bipolar Network” are also recommended.

It makes sense for those affected to develop their own warning systems in order not to get into extreme phases again, with self-control concepts, stress management training, self-observation, self-regulation and self-management. The recognition of personal early warning signs of depressive, manic or mixed phases and timely countermeasures through appropriate behavior (e.g. antidepressant activities if there is a risk of depression; antimanic behavior such as enough sleep, restriction, stimulus shielding if there is a risk of mania and the right medication at the right time) can prevent a new episode from breaking out. A regulated, stress-free, fulfilling life with sufficient sleep and plenty of exercise (sport) can delay new episodes or, more rarely, prevent them entirely. The prerequisite for this is that those affected have recovered from the consequences of the last episode.


The probability of developing a bipolar affective disorder in one's life (lifetime risk) is 1% to 1.6% in a wide variety of countries, which is at least one in every hundred. There is no difference in disease risk between men and women.

The risk of developing a high phase frequency (rapid change between elevated and depressed mood) increases with the duration of the illness. About 10% of those affected develop forms of the disease with four or more episodes per year. This goes hand in hand with a more serious prognosis. According to initial research, 80% of the so-called appear Rapid Cycler To be women. About a third of the patients do not achieve a complete remission during their illness (symptom-free interval).

75% of the patients suffer their first episode of the disease by the age of 25. 10% to 15% of those affected have more than 10 episodes in their life. 39% of patients have another psychiatric diagnosis.

The socio-economic impact of mood disorders on the economy is $ 45 billion in the United States alone (1991 study). According to the WHO, bipolar disorder is one of the 10 diseases that most lead to permanent disability worldwide.

Around 25% to 50% of all bipolar patients make at least one suicide attempt. About 15% to 30% of patients suicide.

Children and adolescents

Up to now, the frequency of the occurrence of a manic-depressive episode in childhood and adolescence is estimated to be relatively low with a value of less than 0.1%. However, there is some evidence that this value underestimates the actual frequency of occurrence, since some psychiatrists assume that child psychiatric and psychological practice misinterpret the symptoms of hypomania and mania in the direction of ADHD and behavioral disorders. Common comorbidities are anxiety disorders and aggressive behavior disorders.

Young male patients in particular show mood-incongruent psychotic features in 30% of cases. When it comes to ADHD, many symptoms overlap. Indications of bipolar disorder arise mainly: from an episodic course, a significantly higher impairment, and - in the case of mania - from ideas of size and overestimation of oneself as well as reckless behavior. A precise anamnesis is therefore essential. Incorrect treatment with stimulants such as methylphenidate or modafinil can exacerbate the symptoms of hypomania and mania, which can lead to severe conditions and even physical damage. Compared to purely unipolar depressives, bipolar adolescents have a higher risk of suicide.


The development of a bipolar disorder is most likely multifactorial (vulnerability). Both genetic factors and psychosocial triggers are likely to play a role; H.the genetic makeup sets a framework for the likelihood of the disease (predisposition) and the environmental factors influence the development, course and end of the disease.


Bipolar disorder is hereditary to a certain extent. The likelihood that first-degree relatives of people with bipolar I disorder will also get it is seven times greater than that of the normal population. Their risk of developing any form of emotional disorder - an affective disorder - is even 15 to 20 times higher.[6] In identical twins, the second twin is also affected by bipolar disorder in 60 percent of cases if the first is diseased. However, it also becomes clear from this that, despite the fact that the genome is 100 percent identical, there is no 100 percent correlation in the disease.[6]

Bipolar diseases are not a classic, pure hereditary disease that, according to Mendel's rules, would be inherited as dominant or recessive. Nevertheless, according to the current state of knowledge, various genes contribute to the disease risk. In manic-depressed people, changes were found primarily on chromosomes 18, 4 and 21.[7] For example, a gene that influences the effects of stress on the nervous system. Genetic coding for episodic thinking can also be affected. A gene is also active that is responsible for substances for the formation of nerve sheaths and also for changes during puberty. Genes for monoamine oxidase (MAO), for serotonin transport, for building up the norepinephrine metabolism are also affected.

Every single gene or every single genetic defect has only a relatively minor effect. Such asset carriers are quite common. If, however, many genes that act in this way come together in a person, they have a great disposition to develop bipolar disorder in the course of life if the triggering factors occur.[8]

Biological factors

The neurotransmitters (the chemical messenger substances) that inhibit or reinforce the transmission of information in synapses between the nerve cells of the brain show quantitative deviations in bipolar people from the state in those who are not affected. The transmitter substances serotonin, dopamine and noradrenaline should be mentioned here in particular, and they also play a role in other mental disorders.

  • Depression is favored by a deficiency in the neurotransmitters norepinephrine and serotonin. In the meantime, a disruption of the overall balance of various transmitters is considered to be the cause of depressive phases. In addition, in depressed people, the sensitivity and density of the receptors on which the neurotransmitters act is changed.
  • Mania is favored by an increased concentration of the neurotransmitters dopamine and norepinephrine.

The stress hormone content in the blood of sick people also seems to be increased (cortisol, adrenaline, noradrenaline).

Psychosocial factors

In addition to genetic factors, various environmental factors play a major role that have an impact on the life story, such as traumatic events (breakups, bullying and bossing, job loss, displacement and persecution, torture, sexual abuse / rape and physical abuse in childhood and adolescence , as well as the loss of a loved one) are important here. Just as devastating is other stress as well as all fear-inducing changes (here bipolar people are much more vulnerable than those who are not affected, e.g. a change of residence can trigger phases), especially psychosocial stress, conflicts in the partnership, in family and work (also here are Affected much more at risk).

Lifestyle factor

A weakening of self-esteem is also discussed, in which one of the main pillars of a healthy state is lost (Stavros Mentzos). An irregular day / night rhythm e.g. B. through shift work or lifestyle, lack of sleep, overwork, alcohol - and other drug abuse. Ultimately, any changes can have a phase-triggering effect. Up to 75% of those affected report in reflective retrospect that they had intense stress immediately before the first noticeable episode of the illness - stress, however, which would not have triggered a manic or depressive episode in non-vulnerable people (those who are so vulnerable, affected by vulnerability), since it would be stress process better physically.

Later phases of the illness can less and less be explained by stressful events, or even minimal stress can trigger them.

Research history


Bipolar disorder has been known for a long time. The first written documents from antiquity already prove the knowledge of the two conditions, initially as separate diseases by the famous doctor Hippocrates of Kós. A few centuries later, Aretaeus of Cappadocia recognized the connection between depression and mania.

Hippocrates of Kós described melancholy in the 5th century BC (corresponds to today's depression). He assumed that it arises from an excess of "black bile", which is excreted into the blood by the organically diseased spleen, flooding the entire body, penetrating the brain and causing melancholy. The Greek term “Melancholia” is closely linked to this idea (Greek: μελαγχολια from μελας, melas, “black”, + χολη, cholé, “bile”). Hippocrates also used the term “mania” to describe a state of ecstasy and frenzy. This Greek term (Greek μανία manía = frenzy) has been used in science since then. Instead of the Greek word "melancholy", the technical term "depression" is used today for the other extreme pole of this disease, which comes from the Latin language (lat. depressio "Press down").

The Greek doctor Aretaeus of Cappadocia suspected similar physical causes, but recognized as early as the 1st century AD that the two extreme states were related, which are so far apart as opposing poles, and was the first to describe the bipolar disorder: In my opinion, melancholy is without a doubt the beginning or even part of the disease called mania ... The development of a mania is rather one increase illness as a change to another Illness.[9]

middle Ages

During the Middle Ages, this rational concept was forgotten, as was the search for the cause of physically conditioned factors. Demons and witches were now considered to be the cause of the disease, and not a few of those who were accused of witchcraft fell victim to this "madness" of the "normal" population and authorities. Those affected were also demonized, persecuted and killed as “possessed”.

In the Catholic Church, which was decisive for the West at that time, “Superbia” (pride, vanity, pride, arrogance), “Ira” (anger, anger) and “Luxuria” (lust, unchastity) were among the seven main vices or "root sins" that could lead to deadly sins. The symptoms of mania are here to a great extent congruent. In the "Acedia" (laziness, indolence, indolence of the heart) the "Melancolia" was included. Symptoms of depression have been classified here as a root sin.

Modern times

The much more modern and enlightened concept of Aretaeus of Cappadocia, which, like Hippocrates, assumed physical causes, was only taken up again by French researchers. In 1851 Jean-Pierre Falret described “la folie circulaire” (= circular insanity) as an alternation of depression, mania and a healthy interval, Jules Baillarger three years later his concept of “folie à double forme” as different manifestations of the same disease , whereby there does not necessarily have to be a free interval between these two extreme states.

In 1899, the German psychiatrist Emil Kraepelin called this disease of "circular insanity" also "manic-depressive insanity", whereby he also recognized mixed states in which manic and depressive symptoms occur at the same time. For Kraepelin, too, mania and depression were expressions of the same illness.[10]

During the time of National Socialism, psychiatrists made themselves accomplices of the Nazi racial madness. Prominent German psychiatrists contributed enthusiastically to the “destruction of unworthy life”. Quite a few even initiated this development and advanced it. Manic-depressive people (“circularly lunatic”) were classified as “hereditary diseases” and were forcibly sterilized or even - then with the diagnosis “schizophrenia” - murdered. Tens of thousands of mentally handicapped and mentally ill people were murdered in the gassing facilities of "Aktion T4". It was said that they had been given “euthanasia”, a “beautiful death” that would have been “redemption” for them and that the “people's body” had been cleaned of sick, debilitating, unworthy elements and genetic material.

In 1949 Karl Kleist made a hereditary distinction between unipolar and bipolar forms of illness and in 1966 Jules Angst and Carlo Perris differentiated between bipolar illnesses and unipolar depression. "Bi-" is a Latin prefix with the meaning "two", "Pol" means one of two (outermost) ends. One end is considered to be the extreme opposite of the other end.

Living with Bipolar Affective Disorder

As with other diseases, there are mild or severe courses. The earlier the disease is detected, the better. By recognizing the early warning signs and taking countermeasures and medication, one can lead a full life. For a large number of patients, professional and social mobility are not significantly impaired.

Effects of unfavorable courses

Bipolar people are exposed to severe impairments and suffering in their everyday life due to their illness. But relatives also suffer greatly:

  • under "cheating" or financial ruin and / or
  • distant, restless or conspicuous behavior in the context of a mania and / or
  • under the occupational disability and / or
  • under the failure of cooperative supportive behavior in depression and the grueling recurrence of such phases and / or
  • aggravated by comorbidities such as alcohol abuse and / or
  • through the stigma.

If mentally ill people pose an acute threat or danger to themselves and / or others, they can also be admitted to a psychiatric clinic against their will (e.g. by the social psychological service). In the case of mania, however, only trained specialists are able to assess whether a forced admission is necessary. Cases have already become known in which patients who can be shown to have been in extremely critical phases have been discharged from clinics by judges, and as a result were exposed to irresponsible harm to themselves and others. Since the mania means a high phase of emotions for them personally, they often refuse to voluntarily take medication that would combat this high phase. Relatives have to “sit out” the phase of illness, which can take several weeks and cause permanent social damage.

For example, children and adolescents suffer from mothers or fathers who are completely or partially absent from their upbringing and household tasks during their illness. It has proven to be very important that relatives, who often have to be so supportive, do not forget again and again per se to think.


Those affected not only struggle with the problems that they often lose the support of friends and family members, but that they are marginalized from society. Numerous celebrities who are sick themselves and publicly acknowledge their illness are fighting against discrimination, or projects that are supposed to help these often very creative people to gain self-confidence and thus to gain recognition in society. One such project in Germany is, for example, the Bipol-Art website by Magdalena Maya Ben, which came about under the patronage of Kay Redfield Jamison in 2005.

Creative and famous bipolar

Mental chaos can quickly develop during a mania. By being over-excited during this phase, those affected cause damage and are no longer able to do anything sensible. Depression and mixed episodes, which are particularly agonizing in bipolar people, really throw those affected off course and paralyze them.

The creativity spurts mainly take place in the hypomanic phase. With modern treatment methods (medication, therapies such as cognitive behavioral therapy, creative therapy, creative atelier, sometimes just simple care to compensate for any shock experiences suffered in childhood and adolescence), creativity can usually be preserved, so that it is a positive aspect of this bad and destructive disease can work.

Manic-depressive people in their seemingly manic work, with appropriate therapy and care, are then capable of works that people without manic experience often consider impossible. In this sense, realizing visions generally requires a manic drive. The creative implementation of the manic-looking energy is therefore always a stroke of luck and in this sense is also to be aimed for, whereby the physical constitution in turn sets limits, e.g. tendonitis on arms and hands or back problems.

According to a 1994 study by Kay Redfield Jamison, the incidence of bipolar illness in creative personalities is 10 times the incidence in the general population. More than a third of all English and Irish poets born between 1705 and 1805 suffered from bipolar illness, according to Jamison, and more than half from mood disorders.[11]


Ernest Hemingway was diagnosed as bipolar, as was Edvard Munch,[12] Hermann Hesse and Thomas Alva Edison.[11]

Goethe knew depressive episodes from his own experience (cf. the self-portrayal of the allegory “Sorge” at the end of Faust II). The marriage proposal of the 74-year-old Goethe to the 19-year-old Ulrike von Levetzow was probably made during a hypomanic phase.

Some creatives are not aware of their illness or they do not confess to it. A contrary example is the musician Gordon Matthew Sumner, known as Sting, who described himself as manic-depressive in an interview and released a song called "Lithium Sunset". The German theater director Andrea Breth openly acknowledges her illness.[13]

The Canadian musician and producer Devin Townsend has also been openly committed to bipolar disorder for years and claims to be taking medication against it. Townsend is known for processing his mood swings in very different music, the spectrum of which ranges from gently melodic to extremely aggressive. For the recordings for the album "Alien" by his band Strapping Young Lad, he said he stopped taking the medication for a time. [14]

The list of famous artists, scientists, explorers, and politicians who are known or suspected of having bipolar disorder is long. Some believed to have committed suicide as a result of the disease. The best-known examples are David Strickland, Kurt Cobain, Virginia Woolf, Sylvia Plath, Sarah Kane, Robert Schumann, Marie Zimmermann and Vincent van Gogh,[15] to name examples from the fields of prose and poetry, music, theater and the visual arts.

Vincent van Gogh


In his diaries and letters, for example, Vincent van Gogh reported on his torn personality, his depression and his "insanity" ("d'exaltation ou de délire", "tristesse", "accès", "crises" and "maladie mental"). Van Gogh writes about his manias in his "Letter 607" from 1890: I am amazed myself ... that such confused and ghastly religious ideas come to me .... In the months of May to June 1889 - shortly before his stay in psychiatry - van Gogh painted an astonishingly large number of masterpieces (Arnold), including his well-known and intensely colored "Starry Night" with cypresses, which appears as a bipolar image "With opposite colors" (Vincent van Gogh from the mental institution of Saint-Rémy-de-Provence in a letter of May 21, 1889 to his brother Theo).


Vincent van Gogh's painting “Starry Night” can, like many of his other paintings, be seen in its colors, contrasts and symbols as a code for bipolar disorder. In a handwritten poem from his “Antwerp Sketchbook” Vincent van Gogh writes: My heart is like the sea / Has storms and ebb and flow .... With this, too, he expresses strong opposites and extreme fluctuations in feelings.

Such phases, which can be explained as mania with overflowing activity and subsequent depression and which are viewed as such by many experts, brought him to the “madhouse” where his father wanted to bring him earlier. His family was also burdened. His brother “Cor” (Cornelius Vincent) committed suicide, his sister “Wil” (Wilhelmina Jacoba) was demonstrably mentally ill, his brother Theo also became mentally ill. The most important source evidence of his illness are the numerous letters between his brother Theo, Vincent van Gogh himself and Doctor Théophile Peyron, the psychiatrist at the institution in Saint-Rémy-de-Provence.

The artist colleague Paul Gauguin, with whom van Gogh lived for a short time, was possibly also bipolar, which presumably escalated in the never resolved dispute between van Gogh and Gauguin, in the course of which van Gogh cut off his ear. Gauguin himself attempted suicide in later years and was increasingly prone to episodes of depression.[11]

Literature and films


  • Assion, Hans-Jörg; Reinbold, Hartmut: "Bipolaricum. Compact knowledge about mania and depression." PsychoGen Verlag Dortmund 2007, ISBN 3-938001-06-2
  • Bräunig, Peter; Gerd Dietrich: Living with Bipolar Disorder. Trias-Verlag 2004, ISBN 3830430698
  • Eberhard J. Wormer: Bipolar Depression and Mania. Life with extreme emotions. Knaur, Munich 2003, ISBN 3-426-66748-7
  • Bock, Thomas: Rollercoaster of feelings. Learning to live with mania and depression. Bonn: Psychiatrie-Verlag, 2nd edition 2005, 176 pages, ISBN 978-3-88414-373-5
  • Bräunig, Peter; Kruger, Stephanie; Rosbander, Yvette: Children of parents with bipolar disease. German Society for Bipolar Disorders e.V. 2005. ISBN 978-3833425844

Psychiatric books

  • Hans-Jörg Assion, Wolfgang Vollmoeller: Handbook of Bipolar Disorders. Kohlhammer, Stuttgart 2006, ISBN 978-3-17-018450-3
  • Jörg Walden, Heinz Grunze: Bipolar Affective Disorders. Causes and Treatment, Stuttgart-New York 2003, ISBN 3131049936
  • Andreas Erfurth (editor): White Paper on Bipolar Disorders in Germany, State of Knowledge - Deficits - What needs to be done?, Short version: ISBN 3-8311-4520-2, Long version: ISBN 3-8311-4521-0
  • Frederick K. Goodwin and Kay Refield Jamison: Manic depressive illness. Oxford University Press 1990, ISBN 0195039343
  • Kay Redfield Jamison: Touched with fire. Manic-depressive illness and the artistic temperament, New York 1993, ISBN 0-684-83183-X
  • Faust, Volker: Mania. A general introduction to the diagnosis, therapy and prophylaxis of pathological high spirits, Enke-Verlag 1997, ISBN 3432278616
  • Klaus Dörner, Ursula Plog, Christine Teller, Frank Wendt: To err is human, Textbook of psychiatry and psychotherapy, Psychiatrie-Verlag (ISBN 3884144006).
  • Christian Scharfetter: General Psychopathology. An introduction. Stuttgart-New York (Thieme) 2002

Psychotherapy books

  • Meyer, Thomas D., Martin Hautzinger: Manic Depressive Disorders. Beltz Psychologie Verlags Union 2004, ISBN 3621275517 Cognitive behavioral therapy tailored to bipolar affective disorder.
  • Stavros Mentzos: Depression and mania. Psychodynamics and Therapy of Affective Disorders, Göttingen 2001, ISBN 3-525-45775-8. An alternative approach, with which the author tries to explain affective mental disorders psychodynamically, in particular postulates a high value of the type of self-esteem.
  • Bock, Thomas; Koesler, Andreas: Bipolar disorder. Understand and treat mania and depression. Bonn: Psychiatrie-Verlag 2005, ISBN 978-3-88414-392-6


  • Gartner, John D .: The Hypomanic Edge: The Bipolar Disorder That Made America the Most Successful Nation in the World. New York: Simon & Schuster 2005, ISBN 0-7432-4344-7

Technical article

  • Heinz Grunze, Emanuel Severus: Recognize bipolar disorder. The art of correct diagnosis, in: The Neurologist & Psychiatrist Special Issue 1/2005.
  • David J. Miklowitz, Michael W. Otto, et al .: Psychosocial Treatments for Bipolar Depression. A 1-Year Randomized Trial From the Systematic Treatment Enhancement Program, Arhives of General Psychiatry, Vol. 64, No. 4, April 2007, pp.419-426


  • Danielle Steele: Its shining light. The story of Nick Traina. Weltbild Verlag 2006, ISBN 3-89897-204-6
  • Kay Redfield Jamison: My restless soul The story of a manic depression. Goldmann-Verlag 1999, ISBN 3442150302
  • Petra Otto: Infarction of the soul, Büro + Service GmbH Rostock, ISBN 3899540395
  • Dr. Renate Kingma (editor): Flying with Broken Wings ... People report bipolar disorder, Books On Demand 2003, ISBN 3-8330-0662-5
  • Scheidgen, Ilka: My friend Johanna. A life of mania and depression. Bonn 2003


  • Martina Ouillon: "THE HAPPINESS, THE WAHN AND ME". Düsseldorf (Droste Verlag) 2007, ISBN 978-3-7700-1278-7. The moving story of the successful Krefeld entrepreneur and manager Peter Kluth. The book is directed against the stigmatization of manic-depressive people. The publication is a mixture of biography, factual report and advice for those affected and their relatives. It describes in detail the changes in the life of a business executive due to illness. Professional and family consequences, but also opportunities and ways of realignment as well as personal coping with and living with the disease are discussed in detail.
  • Matthias Arnold: Vincent van Gogh: biography, Munich (Kindler-Verlag) 1993, ISBN 3-463-40205-X. This extensive and well-founded biography is characterized by the fact that many original letters and other documents are printed in it, including those previously kept under lock and key, which had promoted the creation of “legends”, so that the reader can make his own using the original sources Can make picture. If Vincent van Gogh is quoted in the article, the quotations come from this book.


  • The Secret Life of the Manic Depressive [1] [2]. BBC (2006). Two-part television series with the aim of educating and sensitizing the public.
  • Plinz, N. / Hermann, O .: The poles of Saturn. Bipolar - living between mania and depression. Edited by the German Society for Bipolar Disorders e.V., documentary collage on DVD, 57 min., Psychiatrie-Verlag 2006, ISBN 978-3-88414-453-4. Three sufferers and one family member report on their experience with the disorder.

Feature films

  • A woman under the influence (A Woman Under the Influence), USA 1974. Director: John Cassavetes. Cast: Peter Falk, Gena Rowlands, Fred Draper, Lady Rowlands, Katherine Cassavetes, Matthew Laborteaux and many others. 'A woman under influence' is a masterpiece of the improvising and acting style that made the American director John Cassavetes (1929–1989) famous . The film depicts a mother's bipolar illness. At the time it was assumed that there were 'normal nervous disorders', today the discussion of bipolarity is clear.
  • Mr. Jones, USA 1993. Director: Mike Figgis. Actors: Richard Gere, Lena Olin, Anne Bancroft. The film depicts bipolar illness in two people and for many is still one of the most fascinating film contributions on the subject.
  • Mad Love, USA 1995. Director: Antonia Bird. Book: Paula Milne. Actors: Drew Barrymore, Chris O'Donnell. Two teenagers fall in love, she is bipolar, he learns to love her with her illness.
  • Phenomenon, USA 1996. Director: Jon Turteltaub. Actors: John Travolta, Kyra Sedgwick, Robert Duval, Forest Whitaker, Ashley Buccille. Superhuman (mostly supposed) abilities in the sense of hypomanic and manic behavior.
  • Back from Madness: The Struggle for Sanity, USA 1996. Director: Kenneth Paul Rosenburg. In addition to other psychiatric patients, a homeless bipolar is shown.
  • Lampedusa, Italy 2002, directed by Emanuele Crialese. Actors: Valeria Golino, Vincenzo Amato, Francesco Casisa, Veronica D'Agostino. One woman, Grazia, lives with her husband and children on a fishing island. She is overwhelmed again and again by her moods, and thus falls out of the - there very narrow and not always correct - framework defined by the majority. Your mother-in-law has a syringe ready for such cases.
  • Tattoo Mum - A magical mother