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- Bipolar Disorder
- Psyc 103
- Fall 95
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- 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 itsÆ 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
- (SSRIÆs) 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 SSRIÆs
- 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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- References
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- Bauer, M.S., Kurtz, J.W., Rubin, L.B., and Marcus, J.G. (1994).
- Mood and
- Behavioral effects of four-week light treatment in winter depressives
- and controls. Journal of Psychiatric Research. 28, 2: 135-145.
- Bauer, M.S., Whybrow, P.C. and Winokur, A. (1990). Rapid
- Cycling Bipolar Affective Disorder: I. Association with grade I
- hypothyroidism. Archives of General Psychiatry. 47: 427-432.
- Black, D.W., Winokur, G., and Nasrallah, A. (1987). Treatment of
- Mania: A naturalistic study of electroconvulsive therapy versus lithium
- in 438 patients. Journal of Clinical Psychiatry. 48: 132-139.
- Gasperini, M., Gatti, F., Bellini, L., Anniverno, R., Smeralsi,
- E., (1992). Perspectives in clinical psychopharmacology of
- amitriptyline and fluvoxamine. Pharmacopsychiatry. 26:186-192.
- Goodwin, F.K., and Jamison, K.R. (1990). Manic Depressive
- Illness. New York: Oxford University Press.
- Goodwin, Donald W. and Guze, Samuel B. (1989). Psychiatric
- Diagnosis. Fourth Ed. Oxford University. p.7.
- Hirschfeld, R.M. (1995). Recent Developments in Clinical
- Aspects of Bipolar Disorder. The Decade of the Brain. National
- Alliance for the Mentally Ill. Winter. Vol. VI. Issue II.
- Hollandsworth, James G. (1990). The Physiology of Psychological
- Disorders. Plenem Press. New York and London. P.111.
- Hopkins, H.S. and Gelenberg, A.J. (1994). Treatment of Bipolar
- Disorder: How Far Have We Come? Psychopharmacology Bulletin. 30
- (1): 27-38.
- Jacobson, S.J., Jones, K., Ceolin, L., Kaur, P., Sahn, D.,
- Donnerfeld, A.E., Rieder, M., Santelli, R., Smythe, J., Patuszuk, A.,
- Einarson, T., and Koren, G., (1992). Prospective multicenter study of
- pregnancy outcome after lithium exposure during the first trimester.
- Laricet. 339: 530-533.
- Lish, J.D., Dime-Meenan, S., Whybrow, P.C., Price, R.A. and
- Hirschfeld, R.M. (1994). The National Depressive and Manic Depressive
- Association (DMDA) Survey of Bipolar Members. Affective Disorders. 31:
- pp.281-294.
- Weisman, M.M., Livingston, B.M., Leaf, P.J., Florio, L.P.,
- Holzer, C. (1991). Psychiatric Disorders in America. Affective
- Disorders. Free Press.
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