Bipolar Disorder: Symptoms & Treatment
Bipolar disorder type I and type II, cyclothymia. A neurobiological approach, mood stabilizers, pharmacogenomics and rTMS by psychiatrist Paschalis Gkikas in Athens.
Bipolar Disorder: Symptoms & Treatment
Bipolar disorder is a chronic psychiatric condition characterized by shifts between elevated mood states and depressive episodes. It is often misunderstood as simple “mood swings” — in reality, it is one of the most diagnostically and therapeutically demanding psychiatric conditions.
What is bipolar disorder?
Bipolar disorder (ICD-10: F31) is defined by the presence of at least one manic or hypomanic episode, usually alternating with depressive episodes. It is not “extreme moods” — it consists of neurobiologically distinct phases with specific diagnostic criteria and serious functional consequences.
The main clinical entities are:
- Bipolar I Disorder (F31.1–F31.5): At least one full manic episode, often with psychotic features. Depressive episodes are usually present but are not required for the diagnosis.
- Bipolar II Disorder (F31.8): At least one hypomanic episode and one major depressive episode. Hypomania does not reach the intensity of mania — but depression can be extremely severe. It is often misdiagnosed as unipolar depression.
- Cyclothymic Disorder (F34.0): Chronic fluctuations of hypomanic and mild depressive symptoms for at least 2 years, without meeting criteria for a full episode.
Clinical presentation and symptoms
Manic / hypomanic episode
- Reduced need for sleep without feeling tired
- Inflated self-esteem or grandiosity
- Increased talkativeness, pressured speech
- Flight of ideas, overactive mind
- Increased goal-directed activity or psychomotor agitation
- Impulsive decisions with serious consequences, such as excessive spending, disinhibited sexuality or business risks
- In full mania: hallucinations and grandiose delusions
Depressive episode
- Depressed mood, inner emptiness
- Anhedonia — loss of pleasure in previously enjoyable activities
- Psychomotor slowing or agitation
- Cognitive decline, difficulty concentrating
- Hypersomnia or insomnia, appetite changes
- Suicidal ideation — higher risk compared with unipolar depression
Neurobiological basis
- Mood-circuit dysregulation: Pathological fluctuation in activity between the prefrontal cortex (hypofunction in depression) and subcortical structures — amygdala, hippocampus and basal ganglia.
- Glutamatergic dysfunction: Disruption of neuronal excitability as the substrate of cyclic phases.
- Mitochondrial dysfunction: Findings indicating abnormalities in neuronal energy metabolism.
- Dopamine and norepinephrine: Hyperactivity during mania, hypofunction during depression.
- Chronobiology: Circadian rhythm disturbances are a core feature — explaining the central role of sleep in illness stabilization.
- Genetics: Heritability of approximately 80% in twin studies — among the highest in psychiatry.
Treatment approach
Bipolar disorder requires chronic, structured follow-up. Paschalis Gkikas specializes in bipolar disorder and treats the full spectrum — from acute stabilization to long-term relapse prevention.
First-line treatments
- PGx-guided mood stabilizers: Lithium, valproate, lamotrigine — selection depends on type (I or II), phase and clinical profile. Pharmacogenomic analysis helps prevent toxic levels and optimize effectiveness — critical in a medication regimen that the patient may follow for years.
- Atypical antipsychotics: For acute stabilization or as adjunctive treatment in resistant depressive phases.
- Psychoeducation: Proven to reduce relapses — the patient learns to recognize the early warning signs of each phase.
- Circadian rhythm regulation: Stable sleep schedule, avoidance of alcohol and psychostimulants — part of every treatment plan.
Second-line and resistant cases
- rTMS for bipolar depression: In depressive phases that do not respond to pharmacotherapy, rTMS is an effective treatment with a lower risk of inducing mania compared with antidepressants.
- Combination treatment: In resistant cases, targeted combination pharmacotherapy based on updated PGx assessment.
- ECT: Remains the most effective intervention in acute states of immediate risk — rare, but irreplaceably useful.
Bipolar disorder is not “cured” with one medication — it is stabilized through a long-term relationship of trust between patient and psychiatrist. In Paschalis Gkikas’ practice, follow-up is structured, continuous and adapted to the needs of each phase.
Frequently asked questions (FAQ)
How does bipolar disorder differ from depression?
Classic depression (MDD) does not include manic or hypomanic episodes. Bipolar II is particularly difficult to distinguish because patients usually seek help during the depressive phase — hypomania is often not reported or not recognized as a problem.
Is it dangerous to take antidepressants with bipolar disorder?
Antidepressants without a concurrent mood stabilizer can induce mania or accelerate cycling — which is why accurate diagnosis before prescribing any medication is critical.
Can someone with bipolar disorder live a normal life?
Yes — with proper treatment, most patients achieve stable functioning. Psychoeducation, medication adherence and regular psychiatric follow-up are the three pillars of long-term stability.
Is bipolar disorder hereditary?
The genetic contribution is among the strongest in psychiatry. The risk in a first-degree relative of a patient reaches 10–15%. This does not mean inevitable onset — environmental factors play an important role in illness expression.
