Male western lowland silverback gorilla.
Yes this is ink-dot and I made every single dot of ink by hand. It took 4 months and my hand fell off but it was worth it.
Bipolar disorder, formerly manic depression, is a mental disorder with periods of depression and periods of elevated mood. The elevated mood is significant and is known as mania or hypomania depending on its severity, or whether symptoms of psychosis are present. During mania an individual behaves or feels abnormally energetic, happy or irritable. Individuals often make poorly-thought-out decisions with little regard to the consequences. The need for sleep is usually reduced during manic phases. During periods of depression there may be crying, a negative outlook on life, and poor eye contact with others. Other mental health issues such as anxiety disorders and panic disorders are commonly associated.
The causes are not clearly understood, but both environmental and genetic factors play a role. Many genes of small effect, contribute to risk. Environmental factors include a history of childhood abuse and long-term stress. It is divided into bipolar I disorder, if there is at least one manic episode, and bipoloar II disorder, if there are at least one hypomanic episode and one major depressive episode.
Treatment commonly includes psychotherapy, as well as medications such as mood stabilizers and anti-psychotics. Examples of mood stabilizers that are commonly used include lithium and anticonvulsants. Treatment in the hospital against a person's consent may be required at times as people may be a risk to themselves or others yet refuse treatment. Severe behavioral problems may be managed with short term antipsychotics or benzodiazepines. Electroconvulsive therapy (ECT) may be helpful for those who do not respond to other treatments. If treatments are stopped, it is recommended that this be done slowly. Many individuals have financial, social or work-related problems due to the illness. The risk of death from natural causes such as heart disease is twice that of the general population. This is due to poor lifestyle choices and the side effects from medications.
About 3 percent of people in the US are estimated to have bipolar disorder. Lower rates of around 1 percent are found in other countries. The most common age at which symptoms begin is 25. Rates appear to be similar in females as males. People with bipolar disorder often face problems with social stigma.
Mania is a distinct period of at least one week of elevated or irritable mood which can take the form of euphoria, and exhibit three or more of the following behaviors (four if irritable): speak in a rapid, uninterruptible manner, are easily distracted, have racing thoughts, display an increase in goal-oriented activities or feel agitated, or exhibit behaviors characterized as impulsive or high-risk such as hypersexuality or excessive money spending. To meet the definition for a manic episode, these behaviors must impair the individual's ability to socialize or work. If untreated, a manic episode usually lasts three to six months.
People with mania may also experience a decreased need for sleep, speak excessively in addition to speaking rapidly, and may have impaired judgment. Manic individuals often have issues with substance abuse due to a combination of thrill-seeking and poor judgment. At more extreme levels, a person in a manic state can experience pyschosis, or a break with reality, a state in which thinking is affected along with mood. They may feel out of control or unstoppable, or as if they have been "chosen" and are on a special mission, or have other grandiose or delusional ideas. Approximately 50 percent of those with bipolar disorder experience delusions or hallucinations. This may lead to violent behaviors and hospitalization in an inpatient psychiatric hospital.
Hypomania is a milder form of mania defined as at least four days of the same criteria as mania, but does not cause a significant decrease in the individual's ability to socialize or work, lacks psychotic features—such as delusions or hallucinations—and does not require psychiatric hospitalization. Overall functioning may actually increase during episodes of hypomania and is thought to serve as a defense mechanism against depression. Hypomanic episodes rarely progress to true manic episodes. Some hypomanic people show increased creativity while others are irritable or demonstrate poor judgment. Hypomanic people generally have increased energy and increased activity levels.
Hypomania may feel good to the person who experiences it. Thus, even when family and friends recognize mood swings, the individual will often deny that anything is wrong. What might be called a "hypomanic event", if not accompanied by depressive episodes, is often not deemed as problematic, unless the mood changes are uncontrollable, volatile or mercurial. Most commonly, symptoms continue for a few weeks to a few months.
Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, irritability or anger, loss of interest in previously enjoyable activities, excessive or inappropriate guilt, hopelessness, sleeping too much or not enough, changes in appetite and/or weight, fatigue, problems concentrating, self-loathing or feelings of worthlessness, and thoughts of death or suicidal ideation. In severe cases, the individual may develop symptoms of psychosis, a condition also known as severe bipolar disorder with psychotic features. These symptoms include delusions and hallucinations. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated.
The earlier the age of onset, the more likely the first few episodes are to be depressive. Because a bipolar diagnosis requires a manic or hypomanic episode, many patients are initially diagnosed and treated as having major depression.
In the context of bipolar disorder, a mixed state is a condition during which symptoms of both mania and depression occur at the same time. Individuals experiencing a mixed state may have manic symptoms such as grandiose thoughts while at the same time experiencing depressive symptoms such as excessive guilt or feeling suicidal. Mixed states are considered to be high-risk for suicidal behavior since depressive emotions such as hopelessness are often paired with mood swings or difficulties with impulse control. Anxiety disorder occurs more frequently as a comorbidity in mixed bipolar episodes than in non mixed bipolar depression or mania. Substance abuse (including alcohol) also follows this trend.
Associated features are clinical phenomena that often accompany the disorder but are not part of the diagnostic criteria. In adults with the condition, bipolar disorder is often accompanied by changes in cognitive processes and abilities. These include reduced attention and executive capabilities and impaired memory. How the individual processes the universe also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states. Some studies have found a significant association between bipolar disorder and creativity. Those with bipolar disorder may have difficulty in maintaining relationships. There are several common childhood precursors seen in children who later receive a diagnosis of bipolar disorder; these disorders include mood abnormalities, full major depressive episodes, and attention deficit hyperactivity disorder (ADHD).
The DSM and the ICD characterize bipolar disorder as a spectrum of disorders occurring on a continuum. The DSM-5 lists three specific subtypes:
Most people who meet criteria for bipolar disorder experience a number of episodes lasting three to six months. Rapid cycling, however, is a course specifier that may be applied to any of the above subtypes. It is defined as having four or more mood disturbance episodes within a one-year span and is found in a significant proportion of individuals with bipolar disorder. These episodes are separated from each other by a remission (partial or full) for at least two months or a switch in mood polarity (i.e., from a depressive episode to a manic episode or vice versa). The definition of rapid cycling most frequently cited in the literature (including the DSM) is at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period. Ultra-rapid (days) and ultra-ultra rapid or ultradian (within a day) cycling have also been described. The literature examining the pharmacological treatment of rapid cycling is sparse and there is no clear consensus with respect to its optimal pharmacological management.
People with bipolar disorder often experience a decline in cognitive functioning during (or possibly before) their first episode, after which a certain degree of cognitive dysfunction typically becomes permanent, with more severe impairment during acute phases and moderate impairment during periods of remission. As a result, two-thirds of people with BD continue to experience impaired psychosocial functioning in between episodes even when their mood symptoms are in full remission. A similar pattern in seen in both BD-I and BD-II, but people with BD-II experience a lesser degree of impairment. Cognitive deficits typically increase over the course of the illness. Higher degrees of impairment correlate with the number of previous manic episodes and hospitalizations, and with the presence psychotic symptoms. Early intervention can slow the progression of cognitive impairment, while treatment at later stages can help reduce distress and negative consequences related to cognitive dysfunction.
Despite the overly ambitious goals that are frequently part of manic episodes, symptoms of mania undermine the ability to achieve these goals and often interfere an individual's social and occupational functioning. One third of people with BD remain unemployed for one year following a hospitalization for mania. Depressive symptoms during and between episodes, which occur much more frequently for most people than hypomanic or manic symptoms over the course of illness, are associated with lower functional recovery in between episodes, including unemployment or underemployment for both BD-I and BD-II. However, the course of illness (duration, age of onset, number of hospitalizations, and presence or not of rapid cycling) and cognitive performance are the best predictors of employment outcomes in individuals with bipolar disorder, followed by symptoms of depression and years of education.