CD-ROM Today 1996 January/CD-ROM Today 1996 January.iso/dp/0396/03964.txt

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$Unique_ID{BRK03964}
$Pretitle{}
$Title{Manic Depression, Bipolar}
$Subject{Manic Depression, Bipolar BMD Bipolar Disorder, Manic Depression
Bipolar Disorder, Mixed Manic Depression Manic Depressive Disorder Manic
Depressive Illness Manic Depressive Psychosis Bipolar Disorder, Manic Bipolar
Disorder, Depressed Atypical BMD Bipolar II Bipolar Disorder, Atypical
Cyclothymic Disorder Dysthymic Disorder (Depressive Neurosis) Major
Depression, Single Episode Major Depression, Recurrent}
$Volume{}
$Log{}

Copyright (C) 1987, 1989 National Organization for Rare Disorders, Inc.

449:
Manic Depression, Bipolar

** IMPORTANT **
It is possible the main title of the article (Bipolar Manic Depression)
is not the name you expected.  Please check the SYNONYMS listing on the next
page to find alternate names, disorder subdivisions, and related disorders
covered by this article.

Synonyms

     BMD
     Bipolar Disorder, Manic Depression
     Bipolar Disorder, Mixed
     Manic Depression
     Manic Depressive Disorder
     Manic Depressive Illness
     Manic Depressive Psychosis

Includes:

     Bipolar Disorder, Manic
     Bipolar Disorder, Depressed

Information on the following disorders can be found in the Related
Disorders section of this report:

     Atypical BMD
     Bipolar II
     Bipolar Disorder, Atypical
     Cyclothymic Disorder
     Dysthymic Disorder (Depressive Neurosis)
     Major Depression, Single Episode
     Major Depression, Recurrent

General Discussion

** REMINDER **
The information contained in the Rare Disease Database is provided for
educational purposes only.  It should not be used for diagnostic or treatment
purposes.  If you wish to obtain more information about this disorder, please
contact your personal physician and/or the agencies listed in the "Resources"
section of this report.

Bipolar Manic Depression is a mental illness in which intense mood swings
occur, usually with remissions and recurrences.  Depressive symptoms may be
most common and can last at least a full day and perhaps several weeks or
longer.  Manic symptoms may involve hyperactivity and feelings of
invincibility, happiness and restlessness.

Symptoms

Bipolar Manic Depression consists of two distinct episodes which can
alternate every few days or weeks.  A manic episode usually consists of an
elevated mood with hyperactivity, while a major depressive episode is marked
by depression, anxiety, tearfulness and excessive sleepiness, possibly
leading to stupor.  The course of the disorder varies widely from mild to
severe forms.  Some individuals may have episodes separated by many years of
normal functioning; others may have clusters of episodes; and still others
experience an increased frequency of episodes as they get older.  However,
20% to 35% of cases follow a chronic course with considerable residual
symptomatic and social impairment.

MANIC EPISODES:
During a manic episode, the patient's predominant mood is either
elevated, expansive, or irritable.  Associated symptoms of the manic phase
include hyperactivity, excessive talking, flights of ideas, inflated self-
esteem, decreased need for sleep, distractibility, and excessive involvement
in activities which may have an unrecognized potential for painful
consequences (i.e. charging large sums of money to credit cards without a
thought as to the consequences of having to pay off the loans).

The elevated mood may be described as euphoric, cheerful, or "high".
Often this good mood has an infectious quality for the uninvolved observer,
but is usually recognized as excessive by those who know the individual well.
The expansive quality of the mood disturbance is often characterized by
unceasing and unselective enthusiasm for interacting with people.  Although
an elevated mood is considered the most recognizable manic symptom, the
predominant mood may also appear as irritability, which may become apparent
when the individual's efforts or ideas are thwarted.

The hyperactive mood may also involve excessive planning of, and
participation in multiple activities (e.g., sexual, occupational, political,
religious).  Increased sociability, including efforts to renew old
acquaintances or calling friends at all hours of the night can also occur.
The intrusive, domineering, and demanding nature of these behaviors is not
recognized by the person with Manic Depressive illness.  Expansiveness,
unwarranted optimism, grandiosity, and lack of realistic judgment can
frequently lead to irresponsible activities such as buying sprees, reckless
driving, foolish business investments, and sexual behavior unusual for the
individual.  Sometimes these activities have a disorganized, flamboyant, or
bizarre quality such as dressing in exceptionally colorful or strange
garments, wearing excessive or poorly applied make-up, or distributing candy,
money, or advice to passing strangers.

Manic speech is typically loud, rapid, and difficult to interrupt.  Often
it is full of jokes, puns (plays on words), and amusing irrelevancies.  In
severe cases, it may become theatrical, with dramatic mannerisms or singing.
If the manic mood is more irritable than expansive, there may be complaints,
hostile comments, and angry tirades.

Frequently Bipolar Manic Depression patients experience a nearly
continuous flow of accelerated speech with abrupt changes from topic to
topic, usually based on understandable associations, distracting stimuli, or
plays on words.  When this "flight of ideas" is severe, the patient's speech
may become disorganized and incoherent.

Distractibility is usually intense.  The patient may overreact to various
irrelevant external stimuli, such as background noise or pictures hanging on
the wall.

Characteristically, there is inflated self-esteem ranging from intense
self-confidence to marked grandiosity, which is often a delusion.  For
instance, the patient may offer advice on matters about which he/she has no
special knowledge, such as how to run a hospital or the United Nations.
Despite a lack of any particular talent, a novel may be started, music
composed, or publicity sought for some impractical invention.  In severe
cases, grandiose delusions involving a special relationship to God or some
well-known figure from the political, religious, or entertainment world are
also common.

Almost invariably the patient experiences a decreased need for sleep
during manic periods.  The individual may awaken several hours before the
usual time, full of energy.  When the sleep disturbance is severe, the
individual may go for days without any sleep at all and yet not feel tired.

DEPRESSIVE EPISODES:
Mood swings marked by rapid shifts from manic episodes to anger or
depression often occur.  Depression, expressed by tearfulness, suicidal
thoughts, excessive sleep or other depressive symptoms, may last hours, days
or weeks.  At times, the depressive and manic symptoms may intermingle,
occurring together, but more commonly, they alternate.  In Mixed Bipolar
Disorder, the depressive symptoms tend to be more prominent and last at least
a full day.

Rarely, hallucinations may appear.  Their content is usually clearly
consistent with the predominant mood (e.g., the patient may hear God's voice
explaining that the individual has a special mission).  Persecutory delusions
may be based on the idea that the individual is being persecuted because of
some special relationship or attribute.  Less commonly, the content of the
hallucinations or delusions has no apparent relationship to the predominant
mood (mood-incongruent).

MAJOR DEPRESSIVE EPISODES:
Major depressive episodes are primarily characterized by either a bad
mood, a loss of interest in all (or almost all) usual activities and
pastimes, and often a need to sleep excessively.  This disturbance is
prominent, relatively persistent, and associated with other symptoms
including appetite disturbance, change in weight, sleep disturbance,
decreased energy, feelings of worthlessness or guilt, difficulty
concentrating or thinking, and thoughts of death or suicide.

An individual experiencing a depressive episode will usually describe his
or her mood as depressed, sad, hopeless, discouraged, down in the dumps, etc.
Sometimes, however, the mood disturbance may be expressed as "not caring
anymore", or as a painful inability to experience pleasure.

Loss of interest in pleasure is always present in a major depressive
episode to some degree, but the individual may not complain of this or even
be aware of it, although family members may notice.  Withdrawal from friends
and family, and neglect of avocations that were previously a source of
pleasure, are common.

Appetite can be either markedly decreased or increased, with attendant
loss or gain in weight.  Sleep patterns are commonly disturbed, including
either an inability to fall asleep (insomnia), or more often an increased
need to sleep (hypersomnia) for many hours each day.  Insomnia may be
characterized as difficulty falling asleep (initial insomnia), waking up
during sleep and then returning to sleep with difficulty (middle insomnia),
or early morning awakening (terminal insomnia).

Psychomotor agitation may also occur.  This symptom is characterized by
an inability to sit still, pacing, fidgeting, handwringing, possible pulling
or rubbing of hair, skin, clothing, or other objects, outbursts of
complaining or shouting, or excessive speech.  Psychomotor retardation can
also be present and may take the form of slowed speech, increased pauses
before answering, low or monotonous speech, slowed body movements, a markedly
decreased amount of speech, or an absence of speech (muteness).  A decrease
in energy level is almost invariably present during an episode of depression.
Fatigue persists even in the absence of physical exertion.  The smallest task
may seem difficult or impossible to accomplish during severe depressions.

A sense of worthlessness varies from feelings of inadequacy to completely
unrealistic negative evaluations of one's worth.  The individual may reproach
himself or herself for minor failings that are exaggerated, and may search
for some confirmation of the negative self-evaluation from others.  The sense
of worthlessness and guilt may be delusional.

Difficulty in concentrating, slowed thinking, and indecisiveness are also
frequent symptoms.  The individual may complain about loss of memory and may
appear easily distracted.  Thoughts of death or suicide are common.  There
may be fear of dying, the belief that the individual or others would be
better off dead, wishes to die, or planned or attempted suicide.

The symptoms of Bipolar Manic Depressive illness can be so mild that they
may not be recognized, or so severe that a patient may be completely
disabled.

ASSOCIATED SYMPTOMS OF MAJOR DEPRESSION INCLUDE:
A depressed appearance, tearfulness, feelings of anxiety, irritability,
fear, brooding, excessive concern with physical health, panic attacks and
phobias.

Causes

Bipolar Manic Depression can be a genetic disorder inherited through dominant
genes, either autosomal or sex-linked.  A chromosome marker has been
identified in some people with this disorder which may lead to the discovery
of the defective gene that causes this illness.

Human traits including the classic genetic diseases, are the product of
the interaction of two genes for that condition, one received from the father
and one from the mother.

In dominant disorders, a single copy of the disease gene (received from
either the mother or father) will be expressed "dominating" the normal gene
and resulting in appearance of the disease.  The risk of transmitting the
disorder from affected parent to offspring is 50% for each pregnancy
regardless of the sex of the resulting child.

In X-linked dominant disorders the female with only one X chromosome
affected will develop the disease.  However the affected male always has a
more severe condition.

The exact causative mechanism of this illness is not well understood, but
metabolic abnormalities of chemicals in the brain may interfere with the
normal transmission of electrical impulses between the nerve cells of the
brain.  These chemicals (neurotransmitters) include norepinephrine, dopamine,
or serotonin.

Drugs such as steroidal contraceptives, sedatives, and amphetamines can
cause depressive episodes, while corticosteroids, amphetamines, and tricyclic
antidepressants may cause manic episodes.

Certain infectious diseases such as influenza, mononucleosis, and
syphilis can also cause depression and/or manic episodes.  The autoimmune
disease Lupus, and neurologic disorders such as Parkinson's Disease or
Multiple Sclerosis, may also cause depressive mood swings.  Stress can
trigger these episodes in people who are susceptible to these mood swings.
(For more information on these disorders, choose the following words as your
search terms in the Rare Disease Database:  lupus, ms and Parkinson.
Information on syphilis and mononucleosis can be found in the Prevalent
Health Conditions/Concerns area of NORD Services.)

Affected Population

0.4% to 1.2% of the adult population may have Bipolar Manic Depression
although only a small portion may have symptoms severe enough to interfere
with functioning.  Average age of onset of Bipolar Manic Depression is 35
years old.  The disorder appears to affect more females than males.

Related Disorders

Major Depression is a common mental disorder affecting perhaps 2 million
adults in the United States.

Recurrent Major Depression involves all the symptoms of a Major
Depressive episode, but episodes are recurrent.

Cyclothymic Disorder is characterized by a chronic mood disturbance of at
least two years' duration, involving numerous periods of depression and a
mild form of over-elation and hyperactivity (hypomania).  Symptoms may be
less severe than those of major depressive and manic episodes.

Dysthymic Disorder (Depressive Neurosis) is characterized by a mild
chronic depression or loss of interest or pleasure in usual activities and
pastimes.  Severity and duration of episodes are often less than in a major
depressive episode.

Atypical Bipolar Disorder is a category for individuals with manic
symptoms who cannot be classified as having Bipolar Disorder or Cyclothymic
Disorder.  For example, an individual who previously had a major depressive
episode and now has an episode with mild manic symptoms that are not of
sufficient severity and duration to meet the criteria for a manic episode can
be classified as Atypical Bipolar Disorder; this illness is also referred to
as "Bipolar II".

Therapies:  Standard

Standard treatment of Bipolar Manic Depression is usually with the drug
lithium.  Several tests should be performed to insure tolerance for this
drug.  Side effects of lithium therapy which occur often are a need for
excessive fluid consumption and frequent urination.  Tricyclic
antidepressants may also be prescribed to treat depressive episodes.  If the
patient does not respond to the tricyclics, monoamine oxidase inhibitors
(MAOIs) may be prescribed.  Psychotherapeutic interventions with patient and
family may also be helpful.  In general lithium is an effective therapy for
Bipolar Disease if a patient complies with the treatment regimen.  Since some
patients miss the euphoria of manic episodes, they may stop taking the
medication against physicians advice.

For the depressive symptoms in Bipolar Manic Depression electroconvulsive
therapy (ECT) has been used in the most serious cases.

Therapies:  Investigational

Since the chromosome defect that causes Bipolar Disease has recently been
identified it is hoped that a genetic test may be developed in the near
future.  Furthermore, discovery of the gene may lead to a better
understanding of Bipolar illness so that it may someday be prevented or more
adequately controlled by improved drugs.

This disease entry is based upon medical information available through
September 1989.  Since NORD's resources are limited, it is not possible to
keep every entry in the Rare Disease Database completely current and
accurate.  Please check with the agencies listed in the Resources section for
the most current information about this disorder.

Resources

For more information on Bipolar Manic Depression, please contact:

     National Organization for Rare Disorders (NORD)
     P.O. Box 8923
     New Fairfield, CT  06812-1783
     [phone]

     The Manic & Depressive Support Group, Inc.
     15 Charles Street, 11 H
     New York, NY  10014
     [phone]

     Manic Depressive/Depressive Association
     P.O. Box 753
     Northbrook, IL  60062
     [phone]

     NIH/National Institute of Mental Health (NIMH)
     9000 Rockville Pike
     Bethesda, MD 20205
     [phone] or [phone]
     [phone] (24 hrs.)

     National Mental Health Association
     1021 Prince Street
     Alexandria, VA  22314
     [phone]

     National Alliance for the Mentally Ill
     1901 North Fort Meyer Drive, Suite 500
     Arlington, VA  22209
     [phone]

     National Mental Health Consumer Self-Help Clearinghouse
     311 South Juniper Street, Room 902
     Philadelphia, PA  19107
     [phone]

     Helping Hands
     109 Chestnut Street
     Andover, MA 01810
     [phone]
     [phone]

For genetic information and genetic counseling referrals, please contact:

     March of Dimes Birth Defects Foundation
     1275 Mamaroneck Avenue
     White Plains, NY  10605
     [phone]

     Alliance of Genetic Support Groups
     35 Wisconsin Circle, Suite 440
     Chevy Chase, MD  20815
     (800) 336-GENE
     [phone]

References

LITHIUM AUGMENTATION IN PSYCHOTIC DEPRESSION REFRACTORY TO COMBINED DRUG
TREATMENT:  J.C. Nelson, et al.; American Journal Psychiatry (March 1986:
issue 143(3)).  Pp. 363-366.

ATTEMPTED SUICIDE IN MANIC-DEPRESSIVE DISORDER:  N. Goldring, et al.;
American Journal Psychother (July 1984:  issue 38(3)).  Pp. 373-383.

ECT IN PRIMARY AND SECONDARY DEPRESSION:  C.F. Zorumski, et al.; Journal
Clin Psychiatry (June 1986:  issue 47(6)).  Pp. 298-300.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 3d ed.:  R.L.
Spitzer, et al., Eds; American Psychiatric Association, 1984.)  Pp. 206-218.