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.
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
Mania: Abnormally and persistently elevated (high) mood or irritability
“Mixed” state: Symptoms of mania and depression are present at the same
thinking. Depressed mood accompanies manic activation. Also known as
dysphoric mania (from Greek ‘dysphoria’, ‘dys’, difficulty, ‘phors’,
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
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:
episode which is usually (though not always) accompanied by episodes of
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
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
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.
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.
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:
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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