The phenomenon of bipolar affective disorder has been a mystery since the 16th
century. History has shown that this affliction can appear in almost anyone. Even the
great painter Vincent Van Gogh is believed to have had bipolar disorder. It is clear
that in our society many people live with bipolar disorder; however, despite the
abundance of people suffering from the it, we are still waiting for definite explanations
for the causes and cure. The one fact of which we are painfully aware is that bipolar
disorder severely undermines its' victims ability to obtain and maintain social and
occupational success. Because bipolar disorder has such debilitating symptoms, it is
imperative that we remain vigilant in the quest for explanations of its causes and
treatment.
Affective disorders are characterized by a smorgasbord of symptoms that can be
broken into manic and depressive episodes. The depressive episodes are characterized by
intense feelings of sadness and despair that can become feelings of hopelessness and
helplessness. Some of the symptoms of a depressive episode include anhedonia,
disturbances in sleep and appetite, psycomoter retardation, loss of energy, feelings of
worthlessness, guilt, difficulty thinking, indecision, and recurrent thoughts of death
and suicide (Hollandsworth, Jr. 1990 ). The manic episodes are characterized by elevated
or irritable mood, increased energy, decreased need for sleep, poor judgment and insight,
and often reckless or irresponsible behavior (Hollandsworth, Jr. 1990 ). Bipolar
affective disorder affects approximately one percent of the population (approximately
three million people) in the United States. It is presented by both males and females.
Bipolar disorder involves episodes of mania and depression. These episodes may alternate
with profound depressions characterized by a pervasive sadness, almost inability to move,
hopelessness, and disturbances in appetite, sleep, in concentrations and driving.
Bipolar disorder is diagnosed if an episode of mania occurs whether depression has
been diagnosed or not (Goodwin, Guze, 1989, p 11). Most commonly, individuals with manic
episodes experience a period of depression. Symptoms include elated, expansive, or
irritable mood, hyperactivity, pressure of speech, flight of ideas, inflated self esteem,
decreased need for sleep, distractibility, and excessive involvement in reckless
activities (Hollandsworth, Jr. 1990 ). Rarest symptoms were periods of loss of all
interest and retardation or agitation (Weisman, 1991).
As the National Depressive and Manic Depressive Association (MDMDA) has
demonstrated, bipolar disorder can create substantial developmental delays, marital and
family disruptions, occupational setbacks, and financial disasters. This devastating
disease causes disruptions of families, loss of jobs and millions of dollars in cost to
society. Many times bipolar patients report that the depressions are longer and increase
in frequency as the individual ages. Many times bipolar states and psychotic states are
misdiagnosed as schizophrenia. Speech patterns help distinguish between the two
disorders (Lish, 1994).
The onset of Bipolar disorder usually occurs between the ages of 20 and 30 years of
age, with a second peak in the mid-forties for women. A typical bipolar patient may
experience eight to ten episodes in their lifetime. However, those who have rapid
cycling may experience more episodes of mania and depression that succeed each other
without a period of remission (DSM III-R).
The three stages of mania begin with hypomania, in which patients report that they
are energetic, extroverted and assertive (Hirschfeld, 1995). The hypomania state has led
observers to feel that bipolar patients are "addicted" to their mania. Hypomania
progresses into mania and the transition is marked by loss of judgment (Hirschfeld,
1995). Often, euphoric grandiose characteristics are displayed, and paranoid or
irritable characteristics begin to manifest. The third stage of mania is evident when
the patient experiences delusions with often paranoid themes. Speech is generally rapid
and hyperactive behavior manifests sometimes associated with violence (Hirschfeld, 1995).
When both manic and depressive symptoms occur at the same time it is called a mixed
episode. Those afflicted are a special risk because there is a combination of
hopelessness, agitation, and anxiety that makes them feel like they "could jump out of
their skin"(Hirschfeld, 1995). Up to 50% of all patients with mania have a mixture of
depressed moods. Patients report feeling dysphoric, depressed, and unhappy; yet, they
exhibit the energy associated with mania. Rapid cycling mania is another presentation of
bipolar disorder. Mania may be present with four or more distinct episodes within a 12
month period. There is now evidence to suggest that sometimes rapid cycling may be a
transient manifestation of the bipolar disorder. This form of the disease exhibits more
episodes of mania and depression than bipolar.
Lithium has been the primary treatment of bipolar disorder since its introduction in
the 1960's. It is main function is to stabilize the cycling characteristic of bipolar
disorder. In four controlled studies by F. K. Goodwin and K. R. Jamison, the overall
response rate for bipolar subjects treated with Lithium was 78% (1990). Lithium is also
the primary drug used for long- term maintenance of bipolar disorder. In a majority of
bipolar patients, it lessens the duration, frequency, and severity of the episodes of
both mania and depression.
Unfortunately, as many as 40% of bipolar patients are either unresponsive to
lithium or can not tolerate the side effects. Some of the side effects include thirst,
weight gain, nausea, diarrhea, and edema. Patients who are unresponsive to lithium
treatment are often those who experience dysphoric mania, mixed states, or rapid cycling
bipolar disorder.
One of the problems associated with lithium is the fact the long-term lithium
treatment has been associated with decreased thyroid functioning in patients with bipolar
disorder. Preliminary evidence also suggest that hypothyroidism may actually lead to
rapid-cycling (Bauer et al., 1990). Another problem associated with the use of lithium
is experienced by pregnant women. Its use during pregnancy has been associated with
birth defects, particularly Ebstein's anomaly. Based on current data, the risk of a
child with Ebstein's anomaly being born to a mother who took lithium during her first
trimester of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general
population (Jacobson et al., 1992).
There are other effective treatments for bipolar disorder that are used in cases
where the patients cannot tolerate lithium or have been unresponsive to it in the past.
The American Psychiatric Association's guidelines suggest the next line of treatment to
be Anticonvulsant drugs such as valproate and carbamazepine. These drugs are useful as
antimanic agents, especially in those patients with mixed states. Both of these
medications can be used in combination with lithium or in combination with each other.
Valproate is especially helpful for patients who are lithium noncompliant, experience
rapid-cycling, or have comorbid alcohol or drug abuse.
Neuroleptics such as haloperidol or chlorpromazine have also been used to help
stabilize manic patients who are highly agitated or psychotic. Use of these drugs is
often necessary because the response to them are rapid, but there are risks involved in
their use. Because of the often severe side effects, Benzodiazepines are often used in
their place. Benzodiazepines can achieve the same results as Neuroleptics for most
patients in terms of rapid control of agitation and excitement, without the severe side
effects.
Antidepressants such as the selective serotonin reuptake inhibitors (SSRI's)
fluovamine and amitriptyline have also been used by some doctors as treatment for bipolar
disorder. A double-blind study by M. Gasperini, F. Gatti, L. Bellini, R.Anniverno, and
E. Smeraldi showed that fluvoxamine and amitriptyline are highly effective treatments for
bipolar patients experiencing depressive episodes (1992). This study is controversial
however, because conflicting research shows that SSRI's and other antidepressants can
actually precipitate manic episodes. Most doctors can see the usefulness of
antidepressants when used in conjunction with mood stabilizing medications such as
lithium.
In addition to the mentioned medical treatments of bipolar disorder, there are
several other options available to bipolar patients, most of which are used in
conjunction with medicine. One such treatment is light therapy. One study compared the
response to light therapy of bipolar patients with that of unipolar patients. Patients
were free of psychotropic and hypnotic medications for at least one month before
treatment. Bipolar patients in this study showed an average of 90.3% improvement in
their depressive symptoms, with no incidence of mania or hypomania. They all continued
to use light therapy, and all showed a sustained positive response at a three month
follow-up (Hopkins and Gelenberg, 1994). Another study involved a four week treatment of
bright morning light treatment for patients with seasonal affective disorder and bipolar
patients. This study found a statistically significant decrement in depressive symptoms,
with the maximum antidepressant effect of light not being reached until week four (Baur,
Kurtz, Rubin, and Markus, 1994). Hypomanic symptoms were experienced by 36% of bipolar
patients in this study. Predominant hypomanic symptoms included racing thoughts,
deceased sleep and irritability. Surprisingly, one-third of controls also developed
symptoms such as those mentioned above. Regardless of the explanation of the emergence
of hypomanic symptoms in undiagnosed controls, it is evident from this study that light
treatment may be associated with the observed symptoms. Based on the results, careful
professional monitoring during light treatment is necessary, even for those without a
history of major mood disorders.
Another popular treatment for bipolar disorder is electro-convulsive shock therapy.
ECT is the preferred treatment for severely manic pregnant patients and patients who are
homicidal, psychotic, catatonic, medically compromised, or severely suicidal. In one
study, researchers found marked improvement in 78% of patients treated with ECT, compared
to 62% of patients treated only with lithium and 37% of patients who received neither,
ECT or lithium (Black et al., 1987).
A final type of therapy that I found is outpatient group psychotherapy. According
to Dr. John Graves, spokesperson for The National Depressive and Manic Depressive
Association has called attention to the value of support groups, and challenged mental
health professionals to take a more serious look at group therapy for the bipolar
population.
Research shows that group participation may help increase lithium compliance,
decrease denial regarding the illness, and increase awareness of both external and
internal stress factors leading to manic and depressive episodes. Group therapy for
patients with bipolar disorders responds to the need for support and reinforcement of
medication management, and the need for education and support for the interpersonal
difficulties that arise during the course of the disorder.
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