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Bipolar disorder

 

As categorized by the DSM-IV, bipolar disorder is a form of mood disorder

characterised by a notorious emotive oscillation between a phase of maniac

or hypomanic elation, hyperactivity and hyper imagination, and a depressive

phase of inhibition, slowness to conceive ideas and move, and anxiety or

sadness. Together these form what is commonly known as manic depression.

Manic depression with its two principal sub-types, bipolar disorder and

major depression, was first discovered near the end of the 19th century by

psychiatrist Emil Kraepelin who published his account of the disease in his

Textbook of Psychiatry. As described below, there are several forms of

bipolar disorder.

It should be noted that this disease does not consist of mere "ups and

downs". Ups and downs are experienced by virtually everyone and do not

constitute a disease. The mood swings of bipolar disorder are far more

extreme than those experienced by most people.

Note: Bipolar Disorder is also commonly (and wrongly) called "manic

depression" by laymen (and by some psychiatrists in the twentieth century)

although this usage is now unpopular with psychiatrists, who have

standardised on Kraepelin's usage of the term to describe the whole bipolar spectrum.

General description

There is a tendency to romanticize bipolar disorder. Many artists, musicians

and writers have suffered from its mood swings. But in truth, many lives are

ruined by this disease; and without effective treatment, the illness is

associated with a greatly increased risk of suicide.

Bipolar disorder is a serious brain disease that causes extreme shifts in

mood, energy, and functioning. In most populations bipolar disorder affects

around 1 percent of the population. Men and women are equally likely to

develop this disabling illness. The disorder typically emerges in

adolescence or early adulthood, but in some cases appears in childhood.

Cycles, or episodes, of depression, mania, or "mixed" manic and depressive

symptoms typically recur and may become more frequent, often disrupting

work, school, family, and social life.

Depression: Symptoms include a persistent sad mood; loss of interest or

pleasure in activities that were once enjoyed; significant change in

appetite or body weight; difficulty sleeping or oversleeping; physical

slowing or agitation; loss of energy; feelings of worthlessness or

inappropriate guilt; difficulty thinking or concentrating; and

recurrent thoughts of death or suicide.

Mania: Abnormally and persistently elevated (high) mood or irritability

accompanied by at least three of the following symptoms:

overly-inflated self-esteem; decreased need for sleep; increased

talkativeness; racing thoughts; distractibility; increased

goal-directed activity such as shopping; physical agitation;

hypersexuality and excessive involvement in risky behaviors or

activities.

"Mixed" state: Symptoms of mania and depression are present at the same

time. The symptom picture frequently includes agitation, trouble

sleeping, significant change in appetite, psychosis, and suicidal

thinking. Depressed mood accompanies manic activation. Also known as

dysphoric mania (from Greek 'dysphoria', 'dys', difficulty, 'phors',

bearer, and 'mania', mania, insanity).

Especially early in the course of illness, the episodes may be separated by

periods of wellness during which a person suffers few to no symptoms. When 4

or more episodes of illness occur within a 12-month period, the person is

said to have bipolar disorder with rapid cycling. Bipolar disorder is often

complicated by co-occurring alcohol or substance abuse.

Severe depression or mania may be accompanied by symptoms of psychosis.

These symptoms include: hallucinations (hearing, seeing, or otherwise

sensing the presence of stimuli that are not there) and delusions (false

personal beliefs that are not subject to reason or contradictory evidence

and are not explained by a person's cultural concepts). Psychotic symptoms

associated with bipolar disorder typically reflect the extreme mood state at

the time.

Diagnostic criteria

Bipolar disorder takes two principal forms, neither of which requires plural

"cycles". According to the DSM-IV-TR (p. 345), these two principal forms of

Bipolar disorder are:

* Bipolar I disorder, the diagnosis of which requires over the entire

course of the patient's life at least one manic (or mixed state)

episode which is usually (though not always) accompanied by episodes of

Major Depressive disorder.

* Bipolar II disorder, which over the course of the patient's life must

involve at least one Major Depressive episode and must be accompanied

by at least one hypomanic episode; i.e. there need be no full manic

episodes at all.

Therefore Bipolar disorder need not have both severe mania and depression

and in certain cases has only episodes of the one type. There need be no

"cycles" of mania and depression.

This is the reason why certain contemporary psychiatrists shy away from the

original name, Manic Depression, i.e. because the latter name might suggest

that all patients have both mania and depression. It has nothing to do with

the notion of equal distribution of cycles of mania and depression, since

there need not be any cycles at all--in fact, even when there is one (or

more) bout of both mania and depression over the course of a patient's life,

the two episodes may be so unrelated to each other temporally and otherwise

that this need not constitute a cycle. However, a significant portion of

bipolar patients does experience the classical alternating episodes (cycles)

of mania and depression and therefore it is overstating the case to say that

the classical alternation "rarely" occurs.

The DSM-IV treats these bipolar disorders as variants of mood or affective

disorders. Others types include Major Depressive Disorder and Dysthymic

Disorder. Bipolar and other mood disorders may have no identifiable medical,

traumatic or other external cause (endogenous) or may be due to e.g. a

medical condition (exogenous).

Cycles in bipolar disorder

Kraepelin included in his description of Manic Depression the phenomenon

that episodes of acute illness, whether mania or depression, are usually

punctuated by relatively symptom-free intervals during which the patient is

able to function normally both at work and in social affairs.

The cycles of bipolar disorder may be long or short, and the ups and downs

may be of different magnitudes: for instance, a person suffering from

bipolar disorder may suffer a protracted mild depression followed by a

shorter and intense mania. The manic periods typically include euphoria,

tirelessness, and impulsiveness; the depressed periods may seem much worse

following a manic period.

The name bipolar disorder is used to distinguish the condition from unipolar

depression, and bipolar disorder is in turn divided into two forms, "Bipolar

I" and the "Bipolar II" form, considered by some as a 'milder' version of

the disorder. However, other doctors believe there is no sound basis for the

blanket statement that Bipolar II is "milder" than Bipolar I.

Treatment of bipolar disorder (original article text)

Medications, called "mood stabilizers" can sometimes be used to prevent

manic or depressive episodes. Periods of depression can also be treated with

antidepressants. In extreme cases where the mania or the depression is

severe enough to cause psychosis, antipsychotic drugs may also be used. In

contrast to schizophrenia, insight oriented psychotherapy may be of some use

in treating bipolar disorder.

These drugs do not work in all patients, work sometimes in others, and it is

very difficult to determine in any particular case whether they are

effective at all since bipolar disorder is mostly transient or episodic, and

patients experience remissions and periods of virtually normal functioning

whether or not they receive treatment.

It is not clear how it would even be possible to determine that medications

prevent such episodes. Tens of millions of patients have severe mood

disorders and if any medication could prevent episodes, such diseases as

bipolar disorder would be rare indeed. There is some evidence that they may

be effective for some patients, some of the time but the evidence for their

efficacy is at best statistical and it is virtually impossible to say that

any particular patient was benefitted by any particular treatment. In

discussing these medications one must also take into account the fact that

many patients experience severe side effects. Until recently, one might

reasonably question whether the enormously harmful side effects and the

tendency to abuse psychotropic drugs outweighed any possible benefits (real

or imagined).

Compliance with medications can be a major problem because some people

becoming manic lose insight, or an awareness of having an illness, and

discontinue medications; then they often suffer a manic episode and may

suddenly find themselves initiating multiple projects often being scattered

and ineffective, or may go on a spending spree or take a poorly planned trip

landing them in an unfamiliar location without cash. The manic periods,

euphoric as they may be, are often disastrous because of the impulsiveness

and irrationality that comes with them. Contrary to the patient's wishes,

the depression does not respond instantaneously to resumed medication,

typically taking 2-6 weeks to respond.

Whilst bipolar disorder can be one of the most severe and devastating

medical conditions, many individuals with bipolar disorder can also live

full and mostly happy lives with correct management of their condition.

Compared to patients with schizophrenia, persons with bipolar disorder are

more likely to have periods of normal functioning in the absence of

medication. Although schizophrenic patients may have remissions with

relatively high levels of functioning, schizophrenic patients tend to suffer

some impairment during these intervals, if they are not medicated, in

contrast to persons with bipolar disorder who often appear completely normal

when they are between mood swings.

Electroconvulsive therapy (ECT) was an accepted treatment in the past, and

is still used today when other treatments have failed. There is current

research work on transcranial magnetic stimulation as an alternative to ECT.

Treatments

A variety of medications are used to treat bipolar disorder. But even with

optimal medication treatment, many people with the illness have some

residual symptoms. Certain types of psychotherapy or psychosocial

interventions, in combination with medication, often can provide additional

benefit. These include cognitive-behavioral therapy, interpersonal and

social rhythm therapy, family therapy, and psychoeducation.

Lithium has long been used as a first-line treatment for bipolar disorder.

Approved for the treatment of acute mania in 1970 by the U.S. Food and Drug

Administration (FDA), lithium has been an effective mood-stabilizing

medication for many people with bipolar disorder.

Anticonvulsant medications, particularly valproate and carbamazepine, have

been used as alternatives to lithium in many cases. Valproate was FDA

approved for the treatment of acute mania in 1995. Newer anticonvulsant

medications, including lamotrigine, gabapentin, and topiramate, are being

studied to determine their efficacy as mood stabilizers in bipolar disorder.

Some research suggests that different combinations of lithium and

anticonvulsants may be helpful.

According to studies conducted in Finland in patients with epilepsy,

valproate may increase testosterone levels in teenage girls and produce

polycystic ovary syndrome in women who began taking the medication before

age 20. Increased testosterone can lead to polycystic ovary syndrome with

irregular or absent menses, obesity, and abnormal growth of hair. Therefore,

young female patients taking valproate should be monitored carefully by a physician.

During a depressive episode, people with bipolar disorder commonly require

additional treatment with antidepressant medication. Typically, lithium or

anticonvulsant mood stabilizers are prescribed along with an antidepressant

to protect against a switch into mania or rapid cycling. The comparative

efficacy of various antidepressants in bipolar disorder is currently being studied.

In some cases, the newer, atypical antipsychotic drugs such as clozapine or

olanzapine may help relieve severe or refractory symptoms of bipolar

disorder and prevent recurrences of mania. More research is needed to

establish the safety and efficacy of atypical antipsychotics as long-term

treatments for this disorder.

Research findings

Bipolar disorder appears to run in families, that is, a vulnerablility for

bipolar disorder may be inherited. The rate of suicide is higher in people

who have bipolar disorder than in the general population. The rate of

prevalence of bipolar disorder is roughly equal (around 1%) in men and women.

More than two-thirds of people with bipolar disorder have at least one close

relative with the disorder or with unipolar major depression, indicating

that the disease has a heritable component. Studies seeking to identify the

genetic basis of bipolar disorder indicate that susceptibility stems from

multiple genes. Scientists are continuing their search for these genes using

advanced genetic analytic methods and large samples of families affected by

the illness. The researchers are hopeful that identification of

susceptibility genes for bipolar disorder, and the brain proteins they code

for, will make it possible to develop better treatments and preventive

interventions targeted at the underlying illness process.

Researchers are using advanced medical imaging techniques to examine brain

function and structure in people with bipolar disorder. An important area of

imaging research focuses on identifying and characterizing networks of

interconnected nerve cells in the brain, interactions among which form the

basis for normal and abnormal behaviors. Researchers hypothesize that

abnormalities in the structure and/or function of certain brain circuits

could underlie bipolar and other mood disorders. Better understanding of the

neural circuits involved in regulating mood states may influence the

development of new and better treatments, and may ultimately aid in diagnosis.

Bipolar disorder, talent and famous people

Many famous people are believed to have been affected by bipolar disorder,

based on evidence in their own writings and contemporaneous accounts by

those who knew them. Some of these people include:

* Adam Ant

* Spike Milligan

* Peter Gabriel

* Kurt Cobain

* Florence Nightingale

* Lord Byron

* Winston Churchill

* Sarah Kane

* Ernest Hemingway

* Jean Claude Van Damme

* Carrie Fisher

* Linda Hamilton

There is no definitive scientific basis for classifying dead people as

having had bipolar disorder, though they may very well have suffered from

severe and even recurrent bouts of disordered mood. Until very recently

there were no diagnostic systems with any degree of reliability. Even with

the development of tools such as DSM-IV, there is a great deal of diagnostic

uncertainty with living patients who have been intensively studied for

decades, and there is no reason to think that it is any easier to diagnose

individuals in their graves. For these reasons, some doctors regard

psycho-history of this sort as a dubious endeavour.

There appears to be an association between bipolar disorder and talent in

many cases - this is documented in Jamison's book "Touched With Fire:

Manic-Depressive Illness and the Artistic Temperament".

New clinical trials

NIMH has initiated a large-scale study at 20 sites across the U.S. to

determine the most effective treatment strategies for people with bipolar

disorder. This study, the Systematic Treatment Enhancement Program for

Bipolar Disorder (STEP-BD), will follow patients and document their

treatment outcome for 5 to 8 years. For more information, visit the Clinical

Trials page of the NIMH Web site.

There are reports that Omega-3 fatty acids may be beneficial in the

treatment of bipolar disorder: the Stanley Foundation is sponsoring research

into these claims.

Recent genetic research

In 2003, a group of American and Canadian researchers published a paper that

used gene linkage techniques to identify a mutation in the GRK3 gene as a

possible cause of up to 10% of cases of bipolar disorder. This gene is

associated with a kinase enzyme called G protein receptor kinase 3, which

appears to be involved in dopamine metabolism, and may provide a possible

target for new drugs for bipolar disorder.

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