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Bipolar Disorder

Bipolar disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Description

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV ), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not-otherwise-specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A person with bipolar disorder experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep . Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia, a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One third of patients with cyclothymia develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20 percent of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently, at least four times in 12 months, to meet the diagnostic definition. In some cases of "ultra-rapid cycling" the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Demographics

According to the American Academy of Child and Adolescent Psychiatry, up to one third of American children and adolescents diagnosed with depression develop early onset bipolar disorder. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (MDMDA), one half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one third reported waiting ten years or more before they were correctly diagnosed.

Causes and symptoms

The cause of bipolar disorder had not as of 2004 been clearly defined. Because two thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sheath around nerve fibers.) Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder, and these are under investigation as well.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse, which may be an issue in adolescent patients. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30 percent of abusers meet the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions.

When to call the doctor

When symptoms of bipolar disorder are present, a child should be taken to a qualified medical healthcare professional as soon as possible for evaluation. If a child or teen diagnosed with bipolar disorder reveals at any time that they have had recent thoughts of self-injury or suicide , or if they demonstrate behavior that compromises their safety or the safety of others, professional assistance from a mental healthcare provider or care facility should be sought immediately.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist. In addition to an interview with the child and her parents, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Children's Global Assessment Scale (C-GAS), General Behavior Inventory (GBI), Beck Depression Inventory (BDI), Minnesota Multiphasic Personality Inventory Adolescent (MMPI-A), the Youth Inventory (YI-4), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend to demonstrate irritability and aggressiveness instead of the elation of mania in adults. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD). Their aggression can lead to violence, which may be misdiagnosed as a conduct disorder .

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV ) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem , decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization , and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Substance abuse can mask or mimic the presence of bipolar disorder and can make diagnosis more difficult in adolescents. When substance abuse or addiction is present, a patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder can be accurately diagnosed.

Treatment

The manic and depressive symptoms of bipolar disorder are usually controlled by a combination of prescription medications, including lithium, antipsychotics, anticonvulsants, and antidepressants .

Lithium

Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of adult bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea , and hand tremors. Prolonged lithium use also may cause hyperthyroidism .

Antipsychotics

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in adult patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation , and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is another atypical antipsychotic that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea , dry mouth, headache , heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat , fatigue, and weight gain).

Olanzapine (Zyprexa) was approved in 2003 for use in combination with lithium or valproate for treatment of acute manic episodes associated with bipolar disorder. In 2004 it received additional approval for long-term maintenance of bipolar disorder. Possible side effects include drowsiness, dizziness , weight gain, dry mouth, rapid heartbeat, nausea, and muscle weakness.

Quetiapine (Seroquel) was approved by the FDA in 2004 for the treatment of acute mania associated with bipolar disorder. Potential side effects of the drug include dizziness, sleepiness, dry mouth, weight gain, and constipation.

Ziprasidone (Geodon) is a schizophrenia drug that is often prescribed to treat bipolar mania. Common side effects associated with ziprasidone include dizziness, fatigue, constipation, and rash. Unlike the other antipsychotic drugs, however, it does not promote weight gain.

Atypical antipsychotics have been associated with hyperglycemia (high blood sugar) and diabetes in some patients. Their use may be contraindicated (i.e., not recommended) in children and teens with type 1 or type 2 diabetes.

Anticonvulsants

Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. It is also approved for the treatment of mania. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. A 2003 study found that the risk of suicide from death is about two and one half times higher in people with bipolar disorder taking divalproex than those taking lithium.

Gabapentin (Neurontin) has been prescribed by some physicians for the treatment of bipolar disorder, although there is no conclusive clinical evidence as to its effectiveness.

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug often is used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. Clinical trials continue as of 2004 in an attempt to obtain FDA approval of carbamazepine for use in bipolar treatment.

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, is often used in patients with a history of rapid cycling and antidepressant-induced mania. A University of Cincinnati one-year study of the drug in patients with bipolar I disorder found that it provided sustained relief of depressive symptoms. Lamotrigine may be used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting .

Antidepressants

Because antidepressants may stimulate manic episodes in some bipolar children and teens, their use is typically short-term. Some researchers have hypothesized that the use of antidepressants for depression may even trigger bipolar disorder in children who are genetically predisposed.

When antidepressants are prescribed for episodes of bipolar depression, they are usually selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors). Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety , diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.

MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

In 2004, 10 antidepressant drugs (including fluoxetine, sertraline, paroxetine, and bupropion) came under scrutiny when the FDA issued a public health advisory and announced it was requesting the addition of a warning statement in drug labeling that outlined the possibility of worsening depression and increased suicide risk. These developments were the result of several clinical studies that found that some children taking these antidepressants had an increased risk of suicidal thoughts and actions. The FDA announced at the time that the agency would embark on a more extensive analysis of the data from these clinical trials and decide if further regulatory action was necessary.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) has a high success rate for treating both unipolar and bipolar depression and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia, and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct therapies

Other drugs that may be use as adjunct therapies (i.e., in addition to regular treatment) to treat manic episodes include the following:

  • Calcium channel blockers: Nimodipine (Nimotop, Admon) and verapamil (Calan, Covera, Isoptin), typically used to treat angina and hypotension, have been found effective in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium build up in cells that is thought to be a cause of bipolar disorder. They usually are used in conjunction with other drug therapies such as carbamazepine or lithium.
  • Long-acting benzodiazepines: Lorazepam (Ativan), clonazepam (Klonapin), and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
  • Neuroleptics: Chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because the side effects of these drugs can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms , severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

Because bipolar disorder is thought to be biological in nature, therapy and/or counseling is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. A 2003 report revealed that people on medication for bipolar disorder had better results if they also participated in family-focused therapy.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise , and proper diet. Biofeedback may be effective in helping some children and adolescents control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Repeated transcranial magnetic stimulation (rTMS) is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Prognosis

While most children show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90 percent of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15 to 25 percent and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by 10 years.

According to the American Psychiatric Association, bipolar children and adolescents experiencing a manic episode have a one-year recovery rate of 37.1 percent and a relapse rate of 38.3 percent. Discontinuing lithium treatment too early may increase the risk of relapse in adolescents with bipolar disorder. In one 1990 study, 92 percent of adolescents hospitalized for mania who stopped taking the drug experienced a relapse of symptoms within 18 months of discharge, compared to 37 percent of those who stayed on lithium therapy.

Children and teens with bipolar disorder are at a greater risk for substance abuse than their non-bipolar peers, and substance abuse can worsen or complicate bipolar treatment. In a 1999 two-year follow-up study of adolescents hospitalized for manic episodes, patients who had ongoing drug or alcohol abuse problems had more manic episodes and poorer functioning than those patients who were not substance abusers. In addition, some studies have indicated that children who develop bipolar disorder in adolescence are more likely to develop a substance abuse problem than those who have early-onset of bipolar disorder in childhood.

Prevention

The ongoing medical management of bipolar disorder is critical for preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Education in the form of psychotherapy or self-help groups is crucial for training bipolar patients and their caregivers to recognize signs of mania and depression and to take an active part in their treatment program.

Parental concerns

Children with bipolar disorder may require special accommodations in the classroom. Section 504 of the Rehabilitation Act of 1973 enables parents to develop both a Section 504 plan (which describes a child's medical needs) and an individualized education plan (IEP), which describes what special accommodations a child requires to address those needs. The IEP may cover issues such as allowing extra time on tests, modifying assignments, and providing home tutoring or a classroom aide when necessary.

Children who are diagnosed with bipolar disorder should be reassured that the condition is due to factors beyond their control (i.e., genetics, neurochemical imbalance) rather than any fault of their own. For those children and teens who feel stigmatized or self-conscious about their diagnosis, arranging psychotherapy sessions outside school hours may lessen their burden. Any child on prescription medication for bipolar disorder should be carefully monitored for any sign of side effects, and these should be reported to their physician when they do occur. A dosage adjustment or medication change may be warranted if side effects are disruptive or potentially dangerous.

See also Depressive disorders; Minnesota Multiphasic Personality Inventory.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Press Inc., 2000.

Papolos, Demitri, and Janice Papolos. The Bipolar Child, 2nd ed. New York: Broadway Books, 2002.

PERIODICALS

American Psychiatric Association. "Practice Guideline for the Treatment of Patients with Bipolar Disorder (Revision)." American Journal of Psychiatry 149, no.4.(April2002):150.

"Education and Your Bipolar Child." Brown University Child and Adolescent Behavior Letter 20, no. 7 (July 2004): 9.

"Lithium and Risk of Suicide." The Lancet (September 20, 2003): 969.

"Schizophrenia and Bipolar Disorder Could Have Similar Genetic Causes." Genomics & Genetics Weekly (September 26, 2003): 85.

Sherman, Carl. "Bipolar's Clinical, Financial Impact Widely Missed. (Prevalence May Be Greater than Expected)." Clinical Psychiatry News (August 2002): 6.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Web site: <www.psych.org>.

American Psychological Association (APA). 750 First St. NE, Washington, DC 200024242. Web site: <www.apa.org>.

Child and Adolescent Bipolar Foundation (CABF). 1187 Wilmette Ave., PMB #331, Wilmette, IL 60091. Web site: <www.bpkids.org>.

Depression and Bipolar Support Alliance (DBSA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. Web site: <www.dbsalliance.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 222013042. Web site: <www.nami.org>.

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 208929663. Web site: <www.nimh.nih.gov>.

WEB SITES

U.S. Food and Drug Administration. "Antidepressant Use in Children, Adolescents, and Adults." Available online at <www.fda.gov/cder/drug/antidepressants/default.htm> (accessed November 9, 2004).

Paula Ford-Martin Teresa Odle

KEY TERMS

Affective disorder An emotional disorder involving abnormal highs and/or lows in mood. Now termed mood disorder.

Anticonvulsant Drugs used to prevent convulsions or seizures. They often are prescribed in the treatment of epilepsy.

Antipsychotic drug A class of drugs used to control psychotic symptoms in patients with psychotic disorders such as schizophrenia and delusional disorder. Antipsychotics include risperidone (Risperdal), haloperidol (Haldol), and chlorpromazine (Thorazine).

Benzodiazepine One of a class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety. Diazepam (Valium), alprazolam (Xanax), and chlordiazepoxide (Librium) are all benzodiazepines.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

Electroconvulsive therapy (ECT) A psychological treatment in which a series of controlled electrical impulses are delivered to the brain in order to induce a seizure within the brain. This type of therapy is used to treat major depression and severe mental illness that does not respond to medications.

Hyperthyroidism A condition characterized by abnormal over-functioning of the thyroid glands. Patients are hypermetabolic, lose weight, are nervous, have muscular weakness and fatigue, sweat more, and have increased urination and bowel movements. Also called thyrotoxicosis.

Hypomania A milder form of mania that is characteristic of bipolar II disorder.

Mania An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyperactivity, disorganization of behavior, and inappropriate elevation of mood.

Mixed mania A mental state in which symptoms of both depression and mania occur simultaneously. Also called mixed state.

Neurotransmitter A chemical messenger that transmits an impulse from one nerve cell to the next.

Psychomotor retardation Slowed mental and physical processes characteristic of a bipolar depressive episode.

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Bipolar disorder

Bipolar disorder

Definition

Bipolar, or manic-depressive, disorder is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania (an elevated or euphoric mood or irritable state) and depression.

Description

In the United States alone, bipolar disorder afflicts an estimated three million people. According to a report by the National Institutes of Mental Health, the disorder costs over $45 billion annually. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised (DSM-IV-TR ), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from unipolar depression (depression without mania, as found in major depressive disorder ). Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomniaa sleep disorder marked by a need for excessive sleep or sleepiness when awake) than people with unipolar depression.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. A third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequentlyat least four times in 12 monthsto meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. There is significant evidence that correlates bipolar II with genetic causes. Studies have shown that identical twins have an 80% concordance rate (presence of the same disorder). Additionally, studies have demonstrated that the disorder is transmitted to children by autosomal dominant inheritance. This means that either affected parent (father or mother) has a 50% chance of having a child (regardless if the child is male or female) with the disorder.

Further studies concerning the genetic correlations have revealed specific chromosomes (the structures that contain genes) that contain mutated genes. Susceptible genes are located in specific regions of chromosomes 13, 18, and 21. The building blocks of genes, called nucleotides, are normally arranged in a specific order and quantity. If these nucleotides are repeated, a genetic abnormality usually results. Recent evidence suggests that a special type of nucleotide repeat is observed in persons with bipolar II on chromosome 18. However, the presence of this sequence does not worsen the disorder or change the age of onset. It is currently thought that expression of bipolar II involves multiple mutated genes. Further research is ongoing to discover precise mechanisms and to develop genetic markers (gene tags) that would predict which individuals are at higher risk.

Another possible biological cause for bipolar disorder under investigation is the presence of an excessive calcium buildup in the cells. Also, dopamine and other neurochemical transmitters (the chemicals that transmit messages from nerve cell to nerve cell) appear to be implicated in bipolar disorder and these are under intense investigation.

Over half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions (ideas that the person affected is extremely important or has some unrecognized talent or insight).

Demographics

Manic-depression is a common psychological disorder that is difficult to detect. As stated, it is estimated that about three million people in the United States are affected. The disorder is more common among women than men. Women have been observed at increased risk of developing subsequent episodes in the period immediately following childbirth.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the DSM-IV-TR as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization , and do not have psychotic features (no delusions or hallucinations). In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often appear differently in children and adolescents than they appear in adults. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia . Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention-deficit/hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder .

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Bipolar disorder is usually treated with both medical and psychosocial interventions. Psychosocial therapies address both psychological and social issues.

Medical interventions

A combination of mood-stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

MOOD-STABILIZING AGENTS. Mood-stabilizing agents such as lithium, carbamazepine , and valproic acid (valproate) are prescribed to regulate the manic highs and lows of bipolar disorder:

  • Lithium (lithium carbonate , Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics (other psychiatric drugs) and/or benzodiazepines (medications that ease tension by slowing down the central nervous system) to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)
  • Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug (a drug to treat seizures ) usually prescribed in conjunction with other mood-stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.
  • Valproic acid (divalproex sodium , or Depakote; valproate, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate.

ANTIDEPRESSANTS. Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

  • SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
  • MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet.
  • Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

ADJUNCT TREATMENTS. Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

  • Long-acting benzodiazepines (medications that ease tension by slowing the central nervous system) such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood-stabilizing agents can take effect. Sedation is a common effect, and clumsiness, light-headedness, and slurred speech are other possible side effects of benzodiazepines.
  • Neuroleptics (antipsychotic medications) such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
  • ECT, or electroconvulsive therapy , has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Calcium channel blockers (nimodipine, or Nimotop), typically used to treat angina and hypotension (low blood pressure), have been found effective, in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium buildup in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an antipsychotic medication used to control manic episodes in patients who have not responded to typical mood-stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an antipsychotic medication that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

A new potential treatment for bipolar II disorder may be gabapentin , an anticonvulsant that may help treat mania. Recent reports indicate that gabapentin is effective for treating sudden onset bipolar II. Very recent evidence suggests, however, that gabapentin can potentially induce aggressive and disruptive behavior in children treated with this drug for seizures.

rTMS, or repeated transcranial magnetic stimulation is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Psychosocial interventions

Because bipolar disorder is thought to be biological in nature, psychological therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy , such as cognitive-behavioral therapy , can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide . Also, educative counseling is recommended for the patient and family.

In educative counseling, patients (and their families) learn of the high rates of social dysfunction and marital discord associated with this disorder. Patients also learn how their treatment will progress, which factors can affect treatment, and what kind of follow-up after treatment will be implemented. Genetic counseling should be a part of family education programs since this disorder is more prevalent among first-degree relatives of individuals with the disorder.

Social support for individuals with bipolar disorder is also important. Some people with the disorder, as well as their families, may find support groups helpful.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding over-stimulation, getting plenty of rest, regular exercise, and proper diet. Some Chinese herbs may soften mood swings, but care must be taken (and good communication with the physician is essential) when combining herbal therapies with medications. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drugs and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient increases by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse (recurrence) of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revised. Washington, DC: American Psychiatric Press, Inc., 2000.

Maxmen, Jerrold S. and Nicholas G. Ward. "Mood Disorders." In Essential Psychopathology and Its Treatment. 2nd ed. New York: W. W. Norton, 1995.

Tasman, Allan, Jerald Kay MD, and Jeffrey A. Lieberman MD, eds. Psychiatry. 1st edition. Philadelphia: W. B. Saunders, Co., 1997.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Keck, P., S. McElroy, L. Arnold. "Advances in the pathophysiology and treatment of psychiatric disorders: implications for internal medicine." Medical clinics of North America 85, no. 3 (May 2001).

Kilzieh, N., and H. Akiskal. "Rapid-cycling bipolar disorder: an overview of research and clinical experience." Psychiatric Clinics of North America 22, no. 3 (September 1999).

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. <http://www.psych.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. <http://www.nami.org>.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. <http://www.ndmda.org>.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. <http://www.nimh.nih.gov>.

Paula Anne Ford-Martin, M.A. Laith Farid Gulli, M.D. Nicole Mallory, M.S., PA-C

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Bipolar Disorder

Bipolar Disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Description

In the United States alone, more than two million people are diagnosed with bipolar disorder. Research shows that as many as 10 million people might be affected by bipolar disorder, which is the sixth-leading cause of disability worldwide. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (MDMDA), one-half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of ten years or more before they were correctly diagnosed.

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A person with bipolar disorder experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently; at least four times in 12 months; to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sort of layer or sheath around nerve fibers.) Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

KEY TERMS

Affective disorder An emotional disorder involving abnormal highs and/or lows in mood. Now termed mood disorder.

Anticonvulsant medication A drug used to prevent convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication A drug used to treat psychotic symptoms, such as delusions or hallucinations, in which patients are unable to distinguish fantasy from reality.

Benzodiazpines A group of tranquilizers having sedative, hypnotic, antianxiety, amnestic, anticonvulsant, and muscle relaxant effects.

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

ECT Electroconvulsive therapy sometimes is used to treat depression or mania when pharmaceutical treatment fails.

Hypomania A milder form of mania which is characteristic of bipolar II disorder.

Mixed mania/mixed state A mental state in which symptoms of both depression and mania occur simultaneously.

Mania An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder.

Neurotransmitter A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation Slowed mental and physical processes characteristic of a bipolar depressive episode.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnosis.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose illusions.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD ). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Treatment of bipolar disorder is usually achieved with medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder:

  • Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it sometimes is prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium also has been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use also may cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)
  • Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug often is used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.
  • Valproate (divalproex sodium, or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. Note: valproate also is approved for the treatment of mania. A 2003 study found that the risk of death from suicide is about two and one-half times higher in people with bipolar disorder taking divalproex than those taking lithium.

Treating the depression associated with bipolar disorder has proven more challenging. In early 2004, the first drug to treat bipolar administration was approved by the U.S. Food and Drug Administration (FDA). It is called Symbyax, a combination of olanzipine and fluoxetine, the active ingredient in Prozac.

Because antidepressants may stimulate manic episodes in some bipolar patients, their use typically is short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

  • SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
  • MAOIs such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.
  • Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.
  • ECT, or electroconvulsive therapy, has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

  • Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
  • Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) also are used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
  • Psychotherapy and counseling. Because bipolar disorder is thought to be biological in nature, therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family. In fact, a 2003 report revealed that people on medication for bipolar disorder had better results if they also participated in family-focused therapy.

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an atypical antipsychotic medication that has been successful in controlling mania when low doses were administered. In early 2004, the FDA approved its use for treating bipolar mania. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

Olanzapine (Zyprexa) is another atypical antipsychotic approved in 2003 for use in combination with lithium or valproate for treatment of acute manic episodes associated with bipolar disorder. Side effects include hypotension (low blood pressure) associated with dizziness, rapid heartbeat, and syncope, or low blood pressure to the point of fainting.

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, was found to alleviate manic symptoms in a 1997 trial of 75 bipolar patients. The drug was used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise, and proper diet. Chinese herbs may soften mood swings. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

A surprising study in 2004 found that a rarely used combination of magnetic fields used in magnetic resonance imaging (MRI) scanning improved the moods of subjects with bipolar disorder. The discovery was made while scientists were using MRI to investigate effectiveness of certain medications. However, they found that a particular type of echo-planar magnetic field led to reports of mood improvement. Further studies may one day lead to a smaller, more convenient use of magnetic treatment.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Resources

PERIODICALS

"Family-focused Therapy May Reduce Relapse Rate." Health & Medicine Week (September 29, 2003): 70.

"FDA Approves Medication for Bipolar Depression." Drug Week (January 23, 2004): 320.

"FDA Approves Risperidone for Bipolar Mania." Psychopharmacology Update (January 2004): 8.

"Lithium and Risk of Suicide." The Lancet (September 20, 2003): 969.

Rossiter, Brian. "Bipolar Disorder." Med Ad News (March 2004): 82.

"Schizophrenia and Bipolar Disorder Could Have Similar Genetic Causes." Genomics & Genetics Weekly (September 26, 2003): 85.

Sherman, Carl. "Bipolar's Clinical, Financial Impact Widely Missed. (Prevalence May be Greater Than Expected)." Clinical Psychiatry News (August 2002): 6.

"Unique Type of MRI Scan Shows Promise in Treating Bipolar Disorder." AScribe Health News Service (January 1, 2004).

"Zyprexa." Formulary 9 (September 2003): 513.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. http://www.psych.org.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. http://www.ndmda.org.

National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. http://www.nimh.nih.gov.

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Bipolar Disorder

Bipolar disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression .

Description

In the United States alone, bipolar disorder afflicts approximately 2.3 million people, and nearly 20% of this population will attempt suicide without effective treatment intervention. The average age at onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. In a survey of bipolar patients conducted by the National Depressive and Manic Depressive Association (NDMDA), one-half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of 10 years or more before they were correctly diagnosed.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV ), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not-otherwise-specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently, at least four times in 12 months, to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes & symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. Recent studies emphasize a hereditary connection and early research links several chromosomes, one particularly related to bipolar II, to development of the disorder. A 2003 study found that schizophrenia and bipolar disorder could have similar genetic causes that arise from certain problems with genes associated with myelin development in the central nervous system. (Myelin is a white, fat-like substance that forms a sort of layer or sheath around nerve fibers.)

Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

Over one-half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose illusions.

Diagnosis

Bipolar disorder usually is diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV ) as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

In late 2001, a study reported at an international psychiatric conference that impulsivity remains a key distinguishing characteristic for bipolar disorder, at least when patients are in manic phases.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups typically are characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention-deficit hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Alternative treatments for bipolar disorder generally are considered to be complementary treatments to conventional therapies. General recommendations for controlling bipolar symptoms include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise , and proper diet. Psychotherapy and counseling are generally recommended treatments for the disease, whether treated alternatively or allopathically. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder and in reducing the risk of suicide. Also, educational counseling is recommended for the patient and family. In fact, a 2003 report revealed that people on medication for bipolar disorder have better results if they also participate in family-focused therapy.

Chinese herbs also may help to soften mood swings. Traditional Chinese medicine (TCM) remedies are prescribed based on the patient's overall constitution and the presentation of symptoms. These remedies can stabilize moods, not just treat swings in mood. A TCM practitioner might recommend a mixture called the Iron Filings Combination (which includes the Chinese herbs asparagus, ophiopogon, fritillaria , arisaema, orange peel, polygala, acorus, forsythia, hoelen, fu-shen, scrophularia, uncaria stem, salvia, and iron filings) to treat certain types of mania in the bipolar patient. There are other formulas for depression. A trained practitioner should guide all of these remedies. Compliance can be better with natural remedies if they work. These remedies do not flatten moods and people in manic states do not like to be suppressed.

Acupuncture can be used for treatment to help maintain a more even temperament.

Biofeedback is effective in helping some patients control symptoms such as irritability, poor self control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

In 2003, a report stated that rhythm therapy, or simply taking steps to go to bed and wake up at consistent times each day, helps some people with bipolar disorder maintain mood stability, especially when faced with psychosocial stress .

Recommended herbal remedies to ease depressive episodes may include damiana (Turnera diffusa ), ginseng (Panax ginseng ), kola (Cola nitida ), lady's slipper (Cypripedium calceolus ), lavender (Lavandula angustifolia ), lime blossom (Tilia x vulgaris ), oats (Avena sativa ), rosemary (Rosmarinus officinalis ), skullcap (Scutellaria laterifolia ), St. John's wort (Hypericum perforatum ), valerian (Valeriana officinalis ), and vervain (Verbena officinalis ).

Allopathic treatment

Allopathic treatment of bipolar disorder is usually by means of medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder:

  • Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Possible side effects of the drug include weight gain, thirst, nausea and hand tremors . Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms).
  • Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy.
  • Valproate (divalproex sodium , or Depakote; valproic acid, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss , appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate.

Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAOIs) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

Electroconvulsive therapy (ECT), has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT usually is employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. In bipolar patients, ECT often is used in conjunction with drug therapy.

Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) also are used to control mania while a mood stabilizer such as lithium or valproate takes effect. Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug also has been a useful prophylactic, or preventative treatment, in some bipolar patients.

The treatment rTMS, or repeated transcranial magnetic stimulation, is a relatively new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Expected results

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all treatments, alternative or allopathic. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years and work productivity increases by 10 years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse, or recurrence, of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Biederman, Joseph A. "Is There a Childhood Form of Bipolar Disorder?" Harvard Mental Health Letter. 13, no. 9 (March 1997): 8.

Bowden, Charles L. "Choosing the Appropriate Therapy for Bipolar Disorder." Medscape Mental Health. 2, no. 8 (1997). http://www.medscape.com.

Bowden, Charles L. "Update on Bipolar Disorder: Epidemiology, Etiology, Diagnosis, and Prognosis." Medscape Mental Health. 2, no. 6 (1997). http://www.medscape.com.

"Family-focused Therapy May Reduce Relapse Rate." Health & Medicine Week (September 29, 2003): 70.

Francis, A., J.P Docherty, and D.A. Kahn. "The Expert Consensus Guideline Series: Treatment of Bipolar Disorder." Journal of Clinical Psychiatry. 57, supplement 12A (November 1996): 1-89.

Sherman, Carl. "Progress in Bipolar Genetics slow, but promising." Clinical Psychiatry News. 29, no. 12 (December 2001): 4.

Sherman, Carl. "Impulsivity a Key Characteristic of Bipolar Disorder." Clinical Psychiatry News. 29, no. 11 (November 2001): 35.

"Schizophrenia and Bipolar Disorder Could Have Similar Genetic Causes." Genomics & Genetics Weekly (September 26, 2003): 85.

Spete, Heidi. "Rhythm Therapy Can Stabilize Bipolar Disorder Patients." Clinical Psychiatry News. (July 2003): 55.

ORGANIZATIONS

American Psychiatric Association (APA). Office of Public Affairs. 1400 K Street NW, Washington, DC 20005. (202) 682-6119. http://www.psych.org/.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754. (800) 950-6264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. http://www.ndmda.org.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02, Bethesda, MD 20857. (301) 443-4513. http://www.nimh.nih.gov/.

Paula Ford-Martin

Teresa G. Odle

KEY TERMS

Anticonvulsant medication
A drug used to prevent convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.
Antipsychotic medication
A drug used to treat psychotic symptoms, such as delusions or hallucinations, in which patients are unable to distinguish fantasy from reality.

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Bipolar Disorder

Bipolar disorder

A condition (traditionally called manic depression) in which a person alternates between the two emotional extremes of depression and mania (an elated, euphoric mood).

Bipolar disorder is classified among affective disorders in the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders . The National Institute of Mental Health (NIMH) estimates that about one in one hundred people will develop the disorder, which affects some two million Americans. While this condition occurs equally in both males and females and in every ethnic and racial groups, it is more common among well-educated, middle- and upper-income persons. Those suffering from untreated bipolar disorder will generally experience an average of four depression/mania episodes in a ten-year period. However, some people go through four or more mood swings a month, while others may only experience a mood swing every five years. The onset of bipolar disorder usually occurs in the teens or early twenties.

Of all types of depressive illness, bipolar disorder is the one that is most likely to have biological origins, specifically an imbalance in the brain's chemistry. Genetic factors play an important role in the disease. In one study, one-fourth of the children who had one manic-depressive parent became manic-depressive themselves, and three-fourths of those with two manic-depressive parents developed the disorder. The likelihood of bipolar disorder being shared by identical twins is also exceptionally high. Manic depression has also been associated with the "biological clock" that synchronizes body rhythms and external events.

The depressed state of a person suffering from bipolar disorder resembles major depression. It is characterized by feelings of sadness, apathy, and loss of energy. Other possible symptoms include sleep disturbances; significant changes in appetite or weight; languid movements; feelings of worthlessness or inappropriate guilt ; lack of concentration; and preoccupation with death or suicide . When they shift to a manic state, people with bipolar disorder become elated and overly talkative, speaking loudly and rapidly and abruptly switching from one topic to another. Plunging into many work, social, or academic activities at once, they are in constant motion and are hyperactive. They also demonstrate grandiosity an exaggerated sense of their own powers, which leads them to believe they can do things beyond the power of ordinary persons. Other common symptoms include excessive and/or promiscuous sexual behavior and out-of-control shopping sprees in which large amounts of money are spent on unnecessary items. People in a manic phase typically become irritable or angry when others try to tone down their ideas or behavior, or when they have difficulty carrying out all the activities they have begun. Mania may also be accompanied by delusions and hallucinations .

Mania creates enormous turmoil in the lives of its victims, many of whom turn to drugs or alcohol as a way of coping with the anxiety generated by their condition61 percent of persons with bipolar disorder have substance abuse or dependency problems. In addition, 15 percent of those who fail to receive adequate treatment for bipolar disorder commit suicide. The disease may be misdiagnosed as schizophrenia , unipolar depression, a personality disorder, or drug or alcohol dependence. Individuals commonly suffer from it for as long as seven to ten years without being diagnosed or treated.

However, effective treatment is available. Lithium, which stabilizes the brain chemicals involved in mood swings, is used to treat both the mania and depression of bipolar disorder. This drug, which is taken by millions of people throughout the world, halts symptoms of mania in 70 percent of those who take it, usually working within one to three weekssometimes within hours. Antipsychotic drugs or benzodiazepines (tranquilizers) may initially be needed to treat cases of full-blown mania until lithium can take effect. Persons taking lithium must have their blood levels, as well as kidney and thyroid functions, monitored regularly, as there is a relatively narrow gap between toxic and therapeutic levels of the drug. Since lithium also has the ability to prevent future manic episodes, it is recommended as maintenance therapy even after manic-depressive symptoms subside. Some persons resist remaining on medication, however, either because they fear of becoming dependent on the drug or because they are reluctant to give up the "highs" or alleged creativity of the manic state. However, psychiatrists have reported instances in which lithium was not as effective after being discontinued as it had been initially.

Many great artists, writers, musicians, and other people prominent in both creative and other fields have suffered from bipolar disorder, including composers Robert Schumann and Gustav Mahler, painter Vincent van Gogh, writers Virginia Woolf and Sylvia Plath, and actresses Patty Duke and Kristy McNichol. The NIMH reports that 38 percent of all Pulitzer Prize-winning poets have had the symptoms of bipolar disorder.

Further Reading

Duke, Patty. Call Me Anna. New York: Bantam, 1987.

Jamison, Kay. Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. New York: Free Press, 1993.

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Bipolar disorders

Bipolar disorders

Definition

Bipolar disorders is the name given to a group of mental disorders characterized by extreme fluctuations in mood. People diagnosed with bipolar disorders experience moods ranging from deepest depression to mania, often with periods of less extreme moods, or even emotional stability, in between.

Description

Individuals diagnosed with bipolar disorders experience fluctuations in mood over which they have no control. All of the bipolar disorders cause great emotional distress. Even the state of elevated mood, or "mania," might sound as if it would feel good; but it is, in fact, a painful, pressured feeling that is not at all pleasurable. People with mania find their thoughts running at an unstoppable pace; they cannot sleep, often for many nights at a time. Their speech may become rapid, and they may have grandiose ideas. Often people in manic states spend money they do not have, and make important but disastrous life decisions.

Individuals in the depressed mood state experience loss of interest in activities and people. They also experience loss of appetite, difficulty sleeping, lack of sexual desire, and an extreme loss of general energy. The ability to concentrate and think clearly is also compromised. Work, social, and family relationships are always impaired. Feelings of worthlessness and helplessness are common, as is the feeling that nothing will every improve. While depressed individuals may or may not report feeling "down" or "depressed," the feelings they do experience are very painful.

The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as the DSM-IV-TR. It includes four basic types of bipolar disorder : Bipolar I Disorder, Bipolar II Disorder, Cyclothymia, and Bipolar Disorder Not Otherwise Specified.

Bipolar I disorder is characterized by one or more manic episodes, or so-called "mixed" episodes, which involve both manic and depressive feelings alternating rapidly, often within the same day or week. Individuals with Bipolar I disorder may also experience one or more major depressive episodes. Suicide occurs in 10-15% of individuals with this disorder.

Bipolar II disorder is characterized by the occurrence of one or more major depressive episodes, interspersed with periods of mild manic episodes referred to as "hypomania." Hypomanic episodes are similar to manic ones, but are far less intense and less severe in their consequences. In fact, individuals may not see their hypomanic episodes as a problem, feeling, instead, that they have bursts of energy in which they can accomplish a great deal.

Cyclothymic disorder is a chronic, low-level disturbance of mood, punctuated by periods of depressive symptoms and periods of hypomanic symptoms. Cyclothymia often begins early in life, and people with the disorder may not know they have it; they may simply think of themselves as sadder and/or less energetic than other people, with occasional bursts of energy.

Bipolar disorder not otherwise specified is the term used in the DSM-IV-TR for individuals who do not meet the criteria for one of the other three diagnoses, but who nevertheless experience patterns of mood swings alternating between depression and mania.

See also Affect; Bipolar disorder; Cognitive-behavioral therapy; Cyclothymic disorder; Depression and depressive disorders; Dysthymic disorder; Lithium carbonate; Manic episodes

Resources

BOOKS

American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Kaplan, Harold I., MD and Benjamin J. Sadock., MD Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th edition. Baltimore, MD: Lippincott Williams and Wilkins, 1998.

Barbara Sternberg, Ph.D.

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bipolar disorder

bipolar disorder, formerly manic-depressive disorder or manic-depression, severe mental disorder involving manic episodes that are usually accompanied by episodes of depression. The term "manic-depression" was introduced by the German psychiatrist Emil Kraepelin in 1896. The manic phase of the disorder is characterized by an abnormally elevated or irritable mood, grandiosity, sleeplessness, extravagance, and a tendency toward irrational judgment. During the depressed phase, the person tends to appear lethargic and withdrawn, shows a lack of concentration, and expresses feelings of worthlessness, self-blame, and guilt. This dual character of the disorder has given it the name bipolar disorder, in contrast to the unipolar depression symptomatic of the majority of mood disorders. The symptoms range in intensity and pattern and may not be recognized at first. Individuals suffering from bipolar disorder may have long periods in their lives without episodes of mania or depression, but manic-depressives have the highest suicide rate of any group with a psychological disorder.

Incidence

Estimates suggest that about 2 million Americans suffer from bipolar disorders. Symptoms usually appear in adolescence or early adulthood and continue throughout life. The disorder occurs in males and females equally and is found more frequently in close relatives of people already known to have it.. It has had notable incidence among creative individuals, affecting such artists as Hector Berlioz, Gustav Mahler, Ernest Hemingway, and Virginia Woolf.

Treatment

Therapy includes lithium (to control mania and stabilize mood swings), anticonvulsant drugs such as valproate and carbamazepine, and antidepressants. Electroconvulsive therapy has been useful in cases where other treatments have had little success. Psychotherapy can provide support to the patient and the family.

Bibliography

See F. K. Goodwin and K. R. Jamison, Manic-Depressive Illness (1990); D. Healy, Mania: A Short History of Bipolar Disorder (2011); publications of the National Institute of Mental Health.

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Bipolar Disorder

BIPOLAR DISORDER

DEFINITION


Bipolar disorder is a mental condition that usually involves extreme mood swings. A person with the condition may feel happy and excited at one moment and depressed the next. The disorder was once called manic-depression. Mania is a mental disorder characterized by great excitement and sometimes uncontrolled, violent behavior. Depression (see depressive disorders entry) is characterized by persistent and long-term sadness or despair.

DESCRIPTION


Bipolar disorder affects about two million Americans. The average age at which the disorder first appears is between adolescence and the midtwenties. Sometimes a correct diagnosis of the disorder is not made for years. It is complex and difficult to identify. In one study of bipolar disorder patients, half said that they saw three or more doctors before receiving a correct diagnosis. Over one third waited more than ten years before their condition was recognized.

Psychiatrists list four types of bipolar disorder. The four types differ largely on three factors. One factor is whether mania (the highs) or depression (the lows) is more common in the patient. The second factor is how serious each condition is. The third factor is how fast the patient alternates between stages.

Patients with bipolar I disorder, for example, have extreme high periods with relatively moderate periods of depression. By contrast, those with bipolar II disorder are more likely to have severe depression, separated by relatively modest periods of mania.

A third type of bipolar disorder is called cyclothymia (pronounced siekluh-THIE-mee-uh). Patients with this condition have relatively moderate periods of both mania and depression. They may almost appear to be without either symptom for long periods of time. The fourth type of bipolar disorder is called rapid cycling. In this condition, a patient changes from periods of great energy to periods of depression fairly often, usually at least four times in a single year.

CAUSES


The cause of bipolar disorder has not yet been discovered. Many researchers believe that heredity is an important factor. Two-thirds of bipolar patients have a family history of mental disorders. Some research studies claim to have found a genetic link for bipolar disorder. Genes are the chemical units present in all cells that tell cells what functions to perform. Genes are passed down from parents to children.

Some researchers also believe that abnormal levels of certain chemicals in the body can cause bipolar disorder. For example, some studies have shown that people with bipolar disorder have abnormal levels of dopamine in their brains. Dopamine is a neurotransmitter, a chemical that carries messages in the brain.

Drug abuse may be associated with bipolar disorder also. Up to 30 percent of those who abuse cocaine also have bipolar disorder. Researchers are not sure about this connection, however. It may be that bipolar disorder leads to drug abuse, or that drug abuse leads to bipolar disorder. Or it may be that both conditions are caused by some abnormal condition in a person's body.

Bipolar disorder has also been shown to be associated with the seasons. Some patients experience mania during the summer months and depression during the winter months.

Bipolar Disorder: Words to Know

Anticonvulsant medication:
A drug used to prevent convulsions or seizures that is sometimes also effective in the treatment of bipolar disorder.
Benzodiazepines:
A group of tranquilizing drugs that have a calming influence on a person.
DSM-IV:
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the standard reference book used for diagnosing and treating mental disorders.
ECT:
Electroconvulsive shock therapy, a method for using electric shocks to treat patients with mental disorders, such as bipolar disorder.
Mania:
A mental condition in which a person feels unusually excited, irritated, or happy.
Neurotransmitter:
A chemical found in the brain that carries electrical signals from one nerve cell to another nerve cell.

SYMPTOMS


The symptoms of bipolar disorder vary depending on the part of the cycle a patient is experiencing. During a low period, the patient has low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and slower mental and physical functions.

The manic, or high, part of a cycle is characterized by feelings of happiness and well-being, lack of restraint, talkativeness, racing thoughts, reduced need for sleep, and irritability. In extreme cases, mania can be expressed in the form of hallucinations and other mental fantasies.

DIAGNOSIS


Bipolar disorder is usually diagnosed by a psychiatrist, a doctor who specializes in mental conditions. One set of tools that is often used is a series of tests of a person's mental condition. Some examples of these tests include the Millon Clinical Multiaxial Inventory III (MCMI-III), the Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), and the Self-Report Manic Inventory (SRMI). These tests may be either verbal or written and are conducted in a hospital or a doctor's office.

Psychiatrists rely on a book called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), in diagnosing bipolar disorder. DSM-IV is the standard reference manual for all kinds of mental disorders. It describes the conditions for which a psychiatrist should look in diagnosing a condition. The guidelines set down in DSM-IV are very clear and specific for each condition.

For example, DSM-IV defines mania as a period of abnormally intense excitement that lasts for a period of at least one week. The patient must also demonstrate at least three specific symptoms from the following list:

  • Inflated self-esteem
  • Decreased need for sleep
  • Talkativeness
  • Racing thoughts
  • Becoming distracted easily
  • Increase in desire to get specific jobs done
  • Unusual interest in activities that can lead to painful results

The symptoms of bipolar disorder are often different in children and adolescents. For example, their symptoms may be considerably more severe than in adults. A psychiatrist may diagnose schizophrenia (pronounced skit-suh-FREE-nee-uh, see schizophrenia entry), a severe and disabling mental disorder, rather than bipolar disorder. The symptoms of bipolar disorder in those under the age of twenty lead to many incorrect diagnoses, including attention-deficit/hyperactivity (ADHD; see attention-deficit/hyperactivity disorder entry) or conduct disorder.

Other conditions can also produce symptoms similar to those of bipolar disorder. Drug abuse is one such condition. A drug abuser cannot be examined for possible bipolar disorder until he or she has stopped using drugs. Disorders of the thyroid gland and the use of prescribed and over-the-counter medication can also produce bipolar-like symptoms.

TREATMENT


Bipolar disorder is usually treated with some form of medication. Some drugs help to elevate a person's moods during the low part of a bipolar cycle. Others help to calm the person down during the high part of a cycle. Some examples of commonly used drugs include:

  • Lithium. The common name for a group of chemicals that contain the chemical element lithium. These chemicals are among the oldest and most frequently prescribed of all drugs for the treatment of bipolar disorder. While they do not work equally well for all forms of the disorder, they can be very effective for many patients when taken according to the schedule prescribed by a doctor. Some side effects of lithium drugs include weight gain, thirst, nausea, and hand tremors (shaking). Long-term use sometimes leads to hyperthyroidism. Hyperthyroidism is a condition caused by an overactive thyroid gland. It can result in a variety of symptoms, both mild and serious.
  • Carbamazepine. Carbamazepine (pronounced KAHR-buh-MAZ-uh-peen) is an anticonvulsant drug used to prevent convulsions (spasms). It is often prescribed to patients for whom lithium treatment is ineffective. Blurred vision and other eye problems are possible side effects of carbamazepine use.
  • Valproate. Used primarily for the treatment of patients with rapid cycling bipolar disorder. These patients often do not respond to treatment with lithium. Side effects of valproate use include stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain.
  • Antidepressants. Sometimes used to treat bipolar disorder on a short-term basis. An antidepressant is a drug that tends to overcome a person's depression and lift his or her spirits. Antidepressants are not used on a long-term basis because they may intensify the manic period in a person's bipolar cycle. That is, the person may not be depressed, but he or she may become more manic. Some examples of antidepressants used to treat bipolar disorder are the drugs known as selective serotonin (pronounced sihr-uh-TOE-nun) reuptake inhibitors (SSRIs), monoamine (pronounced mon-oh-AM-een) oxidase inhibitors (MAO inhibitors), and tricyclic antidepressants.

Electroconvulsive Shock Therapy

Bipolar disorder is sometimes treated with electroconvulsive shock therapy, or ECT. ECT is a procedure in which intense electrical shocks are administered through electrodes attached to the patient's head. The patient is first given anaesthesia (pronounced an-is-THEE-zhuh) and a muscle relaxant. The muscle relaxant prevents the patient from going into convulsions that would cause broken bones and strained muscles.

No one knows how electric shocks affects the patient's brain. In some cases, however, the treatment is able to relieve the conditions of bipolar disorder. The side effects of ECT include headaches, muscle soreness, nausea, confusion, and memory loss.

Some doctors are reluctant to use ECT unless all other treatments fail. The procedure has many critics who regard it as inhumane. Most cases of bipolar disorder now respond to some form of drug treatment, making ECT unnecessary.

Other Drugs

A variety of drugs are available for treating other aspects of bipolar disorder. For example, some patients have very severe episodes of mania or depression. They may need to have drugs to get them through the worst parts of these episodes. One group of drugs, known as benzodiazepines (pronounced ben-zo-die-A-zuh-peenz), can be used to calm a patient who is having a severe attack of mania. The drug known as clozapine (pronounced KLO-zuh-peen) can also be used to help prevent manic episodes and to treat patients who do not respond to other drugs designed to stabilize their moods.

Counseling

Counseling can also be of some help with bipolar disorder. While it cannot cure the disorder because mania and depression are caused by biological factors, patients can sometimes better understand the nature of their condition and learn to adjust to it. Perhaps most important, counseling can help patients and their families to understand the need for a person to stay on a strict schedule of drug therapy.

Alternative Treatment

Bipolar patients can often benefit from some simple suggestions, such as maintaining a calm environment, avoiding over-simulation, getting plenty of rest and regular exercise, and eating a proper diet. Some practitioners believe that Chinese herbs can soften mood swings. Biofeedback can sometimes help patients control their symptoms, such as irritability, poor self-control, racing thoughts, and sleep problems. During biofeedback a patient watches the brain waves produced when he or she is behaving a certain way. The patient than learns to adjust that behavior to produce correct brain waves. A diet high in vitamin C is thought by some to help reduce depression.

PROGNOSIS


Most patients benefit to some extent from treatment, however responses vary widely from complete recovery to no improvement at all with any form of treatment. One of the most difficult problems is to find the right drug, the right combination of drugs, and the right dosage for any one patient. Bipolar disorder is a chronic condition. That is, most patients experience the condition throughout their lives and require lifelong treatment and observation.

Suicide is common among people with severe bipolar disorder who do not receive prompt or adequate treatment. The suicide rate is 15 to 25 percent among these individuals. With proper and early diagnosis and treatment, however, it is possible for bipolar patients to live normal lives.

PREVENTION


There is currently no known way to prevent bipolar disorder, but the chances of stabilizing the condition improves considerably with proper treatment. Educating the patient about the disorder is also important. He or she can learn to recognize the signs of mania and depression and be taught how to respond to those signs.

FOR MORE INFORMATION


Books

Mondimore, Francks Mark. Bipolar Disorder: A Guide for Parents and Families. Baltimore: Johns Hopkins Press, 1999.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

Organizations

American Psychiatric Association. Office of Public Affairs. 1400 K Street NW, Washington, DC 20005. (202) 6826119. http://www.psych.org.

National Alliance for the Mentally Ill. 200 North Glebe Road, Suite 1015, Arlington, VA 222033754. (800) 9506264. http://www.nami.org.

National Depressive and Manic-Depressive Association. 730 North Franklin Street, Suite 501, Chicago, IL 60610. (800) 8263632. http://www.ndmda.org.

National Institute of Mental Health. 5600 Fishers Lane, Room 7C02, Bethesda, MD 20857. (301) 4434513. http://www.nimh.nih.gov.

Web sites

"Ask NOAH About: Bipolar Disorders." NOAH: New York Online Access to Health [Online]. http://www.noah.cuny.edu/mentalhealth/mental.html#BipolarDisorder (accessed on October 7, 1999).

Bowden, Charles L. "Choosing the Appropriate Therapy for Bipolar Disorder." Medscape Mental Health. [Online] http://www.medscape.com (accessed on October 7, 1999).

Bowden, Charles L. "Update on Bipolar Disorder: Epidemiology, Etiology, Diagnosis, and Prognosis." [Online] Medscape Mental Health, http://www.medscape.com (accessed on October 7, 1999).

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Bipolar Disorder

Bipolar Disorder

What Is Bipolar Disorder?

Who Has Bipolar Disorder?

What are the Symptoms of Bipolar Disorder?

How is Bipolar Disorder Diagnosed?

How Is Bipolar Disorder Treated?

Living with Bipolar Disorder

Resources

Bipolar (by-POLE-ar) disorder is a condition in which periods of extreme euphoria* (yoo-FOR-ee-uh), called mania (MAY-nee-uh), alternate with periods of severe depression*. Bipolar disorder is sometimes also called manic (MAN-ik) depression.

* euphoria
is an abnormally high mood with the tendency to be overactive and over-talkative, and to have racing thoughts and overinflated self-confidence.
* depression
(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.

Keywords

for searching the Internet and other reference sources

Depression

Mania

Manic-depressive illness

Mood disorders

What Is Bipolar Disorder?

Bipolar disorder is a type of depressive disorder*. People with bipolar disorder experience two (thus the prefix bi) extremes in mood; they have periods of extreme happiness and boundless energy that are followed by periods of depression. Bipolar disorder can range from severe to mild. Different forms of bipolar disorder are distinguished from one another by the severity of mood extremes and how quickly mood swings take place. For example, full-blown bipolar disorder, or bipolar I, involves distinct manic episodes followed by depression. People with this form of bipolar disorder often experience trouble sleeping, changes in appetite, psychosis*, and thoughts of suicide. Another form of bipolar disorder called bipolar II affects some people. In bipolar II the mania is not extreme and the person does not lose touch with reality but does have periods of depression. Some people also experience mixed states where symptoms of mania and depression exist at the same time, and this form may be more common in children. Other people may experience a form of bipolar disorder in which there is a rapid cycling between up and down moods with few, if any, normal moods in between. Cyclorhythmia is a condition in which there are mood swings but with milder highs and lows.

* depressive disorders
are mental disorders that involve long periods of excessive sadness and affect a persons feelings, thoughts, and behavior.
* psychosis
(sy-KO-sis) refers to mental disorders in which the sense of reality is so impaired that a patient can not function normally. People with psychotic disorders may experience delusions (exaggerated beliefs that are contrary to fact), hallucinations (something that a person perceives as real but that is not actually caused by an outside event), incoherent speech, and agitated behavior.

Who Has Bipolar Disorder?

Ernest Hemingway, winner of the Nobel Prize in literature, showed signs of having bipolar disorder. So did presidents Abraham Lincoln and Theodore Roosevelt and the composer Ludwig von Beethoven. All of these men were intelligent, creative, successful individuals, but they all fought the two faces of bipolar disorder. At one moment they would be on top of the world, full of ideas and creative and physical energy. Then a few days, weeks, or months later they would be sunk in the despair and lethargy of depression.

Bipolar disorder affects about 1 out of every 100 people, or at least 2 million Americans. It affects people of all races, cultures, professions, and income levels. Men and women are affected at equal rates. Bipolar disorder tends to run in families and is believed to have an inherited genetic component. Studies on twins show that if one member of a pair of identical twins (twins who have identical genes*) has bipolar disorder, the other twin has about a 70 percent chance of also having the disorder. If one of a pair of fraternal twins (twins who do not have identical

* genes
are chemicals in the body that help determine a persons characteristics, such as hair or eye color. They are inherited from a persons parents and are contained in the chromosomes found in the cells of the body.

Virginia Woolf (18821941), the British novelist and critic, suffered from bipolar disorder. She finally succumbed to her bouts of severe depression in 1941, when she committed suicide in Sussex, England. Hulton-Deutsch Collection/Corbis

What are the Symptoms of Bipolar Disorder?

Bipolar disorder has two distinctive sets of symptoms.

Depression

During the depression phase, a person may experience:

  • persistent feelings of sadness and anxiety
  • feelings of worthlessness or hopelessness
  • loss of interest in activities that were formerly enjoyable
  • fatigue and decreased energy
  • sleeping too much or too little; difficulty getting up or going to sleep
  • eating too little or too much
  • unexplained periods or restlessness, irritability, or crying
  • difficulty concentrating or remembering things
  • difficulty making decisions
  • thoughts of suicide or suicide attempts
  • increased difficulties in relationships with friends, family, teachers, or parents
  • alcohol or substance abuse

Mania

During the manic or euphoric stage, a person may experience:

  • great energy; ability to go with little sleep for days without feeling tired
  • severe mood changes from extreme happiness or silliness to irritability or anger
  • over-inflated self-confidence; unrealistic belief in ones own abilities
  • increased activity, restlessness, distractibility, and the inability to stick to tasks
  • racing, muddled thoughts that cannot be turned off
  • decreased judgment of risk and increased reckless behavior
  • substance abuse, especially cocaine, alcohol, and sleeping pills
  • extremely aggressive behavior

How is Bipolar Disorder Diagnosed?

Bipolar disorder usually begins in early adulthood, although experts now recognize that younger children and teens may also have the disorder. Some children who are diagnosed with attention deficit hyperactivity disorder (ADHD)* may actually have bipolar disorder or both disorders. These children not only have symptoms of ADHD but often also have

* Attention Deficit Hyperactivity Disorder (ADHD)
is a condition that makes it hard for a person to pay attention, sit still, or think before acting.

symptoms such as significant and sustained tantrums, periods of anxiety* (including separation anxiety*), periods of irritability, and mood changes. With many children, mood states change rapidly and without warning. Children with bipolar disorder are beginning to be researched by psychologists* and psychiatrists* who previously did not believe that such disorders occur in early childhood.

* anxiety
(ang-ZY-e-tee) can be experienced as a troubled feeling, a sense of dread, fear of the future, or distress over a possible threat to a persons physical or mental well-being.
* separation anxiety
is the normal fear that babies and young children feel when they are separated from their parents or approached by strangers.
* psychologist
(sy-KOL-uh-jist) is a mental health professional who can do psychological testing and provide mental health counseling.
* psychiatrist
(sy-KY-uh-trist) refers to a medical doctor who has completed specialized training in the diagnosis and treatment of mental illness. Psychiatrists can diagnose mental illnesses, provide mental health counseling, and prescribe medications.

Doctors often ask family members about the persons symptoms, as people with bipolar disorder are often not aware of the changes they are experiencing. People with bipolar disorder have had at least one period of mania. Often after the first episode five or more years will pass before another manic or a depressive period occurs. Despite the stretches of normal moods, bipolar disorder does not go away. Instead, the time between mania and depression gets shorter and shorter, and the symptoms may become more severe. Not infrequently, bipolar disorder can lead to psychosis or to suicide. About 19 percent of people who have required hospitalization for bipolar disorder commit suicide.

How Is Bipolar Disorder Treated?

Most people with severe mood swings can be helped by treatment. The drug lithium has been one of the medications of choice for treating bipolar disorder, and it is often very effective. Other medications have also have been helpful in controlling mood swings. These include various antiseizure medications (for example, valproate and carbamazepine) and antipsychotic medications. People with bipolar disorder need to continue to take their medications even when they feel normal to prevent the reoccurrence of mood swings.

Living with Bipolar Disorder

Living with a loved one who has bipolar disorder can be very hard on family members.

Perhaps the most effective thing that family members can do is to help the person with the disorder get treatment. Many family members find joining a support group or participating in family therapy to be helpful in understanding and managing the impact of this difficult problem.

People who are taking about suicide need emergency help. Many telephone books list suicide and mental health crisis hotlines in their Community Service sections, or help can be obtained by calling emergency services (911 in most communities).

See also

Anxiety and Anxiety Disorders

Attention Deficit Hyperactivity Disorder

Depression

Genetics and Behavior

Psychosis

Suicide

Resources

Book

Steel, Danielle. His Bright Light: The Story of Nick Traina. New York: Dell Publishing, 2000. Romance novelist Danielle Steel tells the true story of her sons struggle with bipolar disorder.

Organizations

The Child and Adolescent Bipolar Foundation (CABF), 1187 Wilmette Avenue, P.M.B. #331, Wilmette, IL 60091. CABF is an organization that provides information and support for families of children who have early-onset bipolar disorder. Telephone 847-256-8525 http://www.bpkids.org

United States National Institute of Mental Health (NIMH), 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. NIMH is a government agency that provides information about bipolar disorder. Telephone 800-421-4211 http://www.nimh.nih.gov

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bipolar disorder

bi·po·lar dis·or·der • n. a mental disorder marked by alternating periods of elation and depression. Also called manic depression. Compare with unipolar.

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Bipolar Disorder

Bipolar Disorder

Definition

Bipolar, or manic-depressive disorder, is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression. The switch between highs and lows often comes without warning. For instance, a "high" mood can quickly deteriorate into a "low," causing the sufferer exceptional stress.

Description

An estimate by the National Institute of Mental Health states that more than two million American adults—about 1% of the population age 18 and over in any given year—have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, while others develop them late in life. Very often, bipolar disorder is not recognized as an illness. Many people suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

An even grimmer survey by the National Depressive and Manic Depressive Association (NDMDA) estimates that over 17.4 million adults in the United States suffer with an affective disorder each year (one in seven people). Women are twice as likely as men to experience major depression, while manic depression occurs on an even percentage between the sexes. Onset of major or manic depression can occur at any age, however it most commonly develops between the ages of 25 and 44.

The problem is compounded by inaccurate or no diagnoses in the early stages. A survey taken by the NDMDA reports that half of respondents reported visiting three or more professionals before receiving a correct diagnosis, and over one-third reported a wait of 10 years or more before they were correctly diagnosed.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not-otherwise-specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. However, these individuals are usually characterized as mild, moderate, or severe without psychotic features. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur frequently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability). Catatonic features occasionally occur. Two of the following must be present for the bipolar I diagnosis to move into bipolar I with catatonic features: motor immobility; excessive, purposeless motor activity that is not caused by external stimuli; extreme negativity or mutism; inappropriate or bizarre postures, movements, mannerisms, or grimaces; and repetitive or echoing speech patterns.

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. At least one hypomanic instance must occur before the bipolar II criteria are met. Bipolar depression may be difficult to distinguish from a unipolar major depressive episode. Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia; a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than unipolar depressives. Catatonic features may also be present in bipolar II disorder.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. For this diagnosis, symptoms must be present for at least two years for adults and one year for children and adolescents. During the one and two year diagnosis-gathering period, patients may not be symptom-free for more than a two-month consecutive period. After the initial diagnostic periods, there may be superimposed mixed or manic episodes. In these instances, bipolar I and cyclothymic disorder may be diagnosed simultaneously. A third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in 12 months—to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses. Examples include:

  • Very rapid transitions (a matter of days) between manic and depressed symptoms;
  • Recurrent hypomanic episodes without depressive symptoms;
  • Manic or mixed episodes that are superimposed on delusional disorder, residual schizophrenia, or psychotic disorder NOS;
  • Hypomanic episodes that alternate with depression, but are not frequent enough to qualify for a diagnosis of cyclothymia;
  • Situations where it has been assumed that a bipolar condition exists, but a determination cannot be made as to whether it is the primary diagnosis, is substance-induced, or comes from another medical condition.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of affective or emotional disorders, researchers have searched for a genetic link to the disorder. Studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. Another possible biological cause under investigation is the presence of an excessive calcium build-up in the cells of bipolar patients. Also, dopamine and other neurochemical transmitters appear to be implicated in bipolar disorder and these are under intense investigation.

Over half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown that up to 30% of abusers meet the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose illusions.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) as a guideline for diagnosing this disorder and other mental illnesses. DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features. In addition, because hypomanic episodes are characterized by high energy and goal directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often present differently in children and adolescents. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention deficit hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatment

Treatment of bipolar disorder is usually involves medication. A combination of mood stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

Mood stabilizing agents such as lithium, carbamazepine, and valproate are prescribed to regulate the manic highs and lows of bipolar disorder. Lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes 4-10 days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics and/or benzodiazepines to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it, or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thryoid that is marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms.)

Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug usually prescribed in conjunction with other mood stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. As of early 1998, carbamazepine did not have an FDA-approved indication for mania.

Valproate (divalproex sodium or Depakote; valproic acid or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. (Note: valproate is also approved for the treatment of mania.)

Because antidepressants may stimulate manic episodes in some bipolar patients, their use is typically short-term. Selective serotonin reuptake inhibitors (SSRIs) or, less often, monoamine oxidase inhibitors (MAO inhibitors) are prescribed for episodes of bipolar depression. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression.

SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), treat depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.

MAOIs, such as tranylcypromine (Parnate) and phenelzine (Nardil), block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid hypotensive side effects.

Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia.

ECT, or electroconvulsive therapy, has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.

Adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan. Long-acting benzodiazepines such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.

Neuroleptics such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.

Because bipolar disorder is thought to be biological in nature, therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family.

Calcium channel blockers (nimodipine or Nimotop), typically used to treat angina and hypotension, have been found effective in a few small studies for treating rapid cyclers. Calcium channel blockers stop the excess calcium build up in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an atypical antipsychotic medication used to control manic episodes in patients who have not responded to typical mood stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is another atypical antipsychotic medication that has been successful in controlling mania in several clinical trials when low doses were administered. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain).

Lamotrigine (Lamictal, or LTG), an anticonvulsant medication, was found to alleviate manic symptoms in a 1997 trial of 75 bipolar patients. The drug was used in conjunction with divalproex (divalproate) and/or lithium. Possible side effects of lamotrigine include skin rash, dizziness, drowsiness, headache, nausea, and vomiting.

rTMS, or repeated transcranial magnetic stimulation is a new and still experimental treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient's head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding overstimulation, getting plenty of rest, regular exercise, and proper diet. Chinese herbs may soften mood swings. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems. A diet low in vanadium (a mineral found in meats and other foods) and high in vitamin C may be helpful in reducing depression.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to a complete lack of response to all drug and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient will increase by nearly seven years, with work productivity increasing by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical in preventing relapse or recurrence of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

Health care team roles

The health care team roles are crucial to the proper treatment of bipolar disorder. Bipolar disorder requires lifelong care, and regular monitoring is essential so that the optimum treatment goals are achieved. A treatment team comprised of family members and caregivers, as well as professional staff, is advised to meet regularly to discuss progress and assess new needs. The treatment plan is based on input from a psychological or psychiatric evaluation, as well as input from the caregivers and the patient. This plan of care should be regularly updated and personalized to fit the patient's individual needs. Periodic assessment will track the patient's progress/regression and will make use of current research.

KEY TERMS

Affective disorder— An emotional disorder involving abnormal highs and/or lows in mood. Now termed mood disorder.

Anticonvulsant medication— A drug used to prevent convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication— A drug used to treat psychotic symptoms, such as delusions or hallucinations, in which patients are unable to distinguish fantasy from reality.

Benzodiazepines— A group of tranquilizers having sedative, hypnotic, antianxiety, amnestic, anticonvulsant, and muscle relaxant effects.

DSM-IV— Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States.

ECT— Electroconvulsive therapy is sometimes used to treat depression or mania when pharmaceutical treatment fails.

Hypomania— A milder form of mania which is characteristic of bipolar II disorder.

Mixed mania/mixed state— A mental state in which symptoms of both depression and mania occur simultaneously.

Mania— An elevated or euphoric mood, or irritable state that is characteristic of bipolar I disorder.

Neurotransmitter— A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation— Slowed mental and physical processes characteristic of a bipolar depressive episode.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association Press, Inc., 2000.

Maxmen, Jerrold S., and Nicholas G. Ward. "Mood Disorders." In Essential Psychopathology and Its Treatment, 2nd ed. New York: W.W. Norton, 1995, pp. 206-43.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Biederman, Joseph A. "Is There a Childhood Form of Bipolar Disorder?" Harvard Mental Health Letter vol. 13, no. 9 (March 1997): 8.

Bowden, Charles L. "Choosing the Appropriate Therapy for Bipolar Disorder." Medscape Mental Health, vol. 2, no. 8 (1997). 〈http://www.medscape.com〉.

Bowden, Charles L. "Update on Bipolar Disorder: Epidemiology, Etiology, Diagnosis, and Prognosis." Medscape Mental Health, vol. 2, no. 6 (1997). 〈http://www.medscape.com〉.

ORGANIZATIONS

American Psychiatric Association (APA). Office of Public Affairs. 1400 K Street NW, Washington, DC 20005. (202) 682-6119. 〈http://www.psych.org/〉.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, Suite 1015, Arlington, VA 22203-3754. (800) 950-6264. 〈http://www.nami.org〉.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. 〈http://www.ndmda.org〉.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02, Bethesda, MD 20857. (301) 443-4513. 〈http://www.nimh.nih.gov/〉.

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Bipolar Disorder

Bipolar Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Bipolar, or manic-depressive, disorder is a mood disorder that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania (an elevated or euphoric mood or irritable state) and depression.

Description

In the United States alone, bipolar disorder afflicts an estimated 5% of the general population, or almost 15 million people. According to a 2006 study, bipolar disorder costs the U.S. workplace as much as $14 billion a year, lost to the average 65.5 workdays each worker with bipolar disorder missed annually. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more. There also has been a new recognition of newonset bipolar disorder in later life, which occurs among the elderly at rates of about 1% and appears to be more prevalent among elderly men than elderly women.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised (DSM-IV-TR), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified (NOS).

Bipolar I disorder is characterized by manic episodes, the “high” of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, in which both manic or hypomanic symptoms and depressive symptoms occur at the same time, also frequently occur with bipolar I patients (for example, depression with the racing thoughts of mania). In addition, dysphoric mania (mania characterized by anger and irritability) is common.

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from unipolar depression (depression without mania, as found in major depressive disorder ). Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia—a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than people with unipolar depression.

Cyclothymia refers to the cycling of hypomanic episodes with depression that does not reach major depressive proportions. One-third of patients with cyclothymia will develop bipolar I or II disorder later in life.

A phenomenon known as rapid cycling occurs in up to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in twelve months—to meet the diagnostic definition. In some cases of “ultra-rapid cycling,” the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

Causes

The root causes of bipolar disorder have not been clearly defined, but studies suggest a strong heritable component. The most recent research has identified areas on four different chromosomes (6, 13, 18, and 22) that may carry genes whose protein products confer susceptibility to bipolar disorder. A study from 2006 suggests that inclusion of symptoms of common comorbidities of bipolar disorder and a measurement of social functioning might help researchers pinpoint more closely the genes involved in the development of these disorders.

Studies of the underlying genetics of bipolar disorders also have closely focused on genes related to the regulation of dopamine, a neurotransmitter (nerve-signaling molecule) that is involved generally in mood disorders. Recent studies examining the genes expressed in dopamine neurons (nerve cells) in different parts of the brain have shown that the parts of the brain known to be involved in mood disorders such as bipolar disorder exhibit different patterns of gene expression from other neurons. The area of the brain most closely associated with dopamine’s involvement in bipolar disorders is the ventral tegmental area, which plays a role in the brain’s dopamine-based reward system and in regulation of addictive or emotional behaviors.

Symptoms

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions (ideas that the person affected is extremely important or has some unrecognized talent or insight).

Comorbidities

A large percentage of people diagnosed with bipolar disorder also experience comorbidities, with one study finding that 67% of patients with bipolar disorder had a comorbidity and 76% who had bipolar II disorder also had a comorbidity. Overall, 65% of all bipolar patients will have a comorbidity, including anxiety disorders, attention deficit/hyperactivity disorder, and substance and alcohol abuse. Suicidal ideation (thinking seriously about attempting suicide ) and suicide are relatively common. The type of comorbidity can vary based on sex; women are more likely to have an eating disorder comorbidity or post-traumatic stress disorder (PTSD) as a comorbidity.

Demographics

The disorder is more common among women than men. Women have been observed at increased risk of developing subsequent episodes in the period immediately following childbirth, the postpartum period. The average age at onset in a recent large study was the same for men and women: 17.2 years. Men with bipolar disorder are more likely than women to have a history of violence and to have experienced legal problems, and women are more likely than men to have made a suicide attempt. In the survey of U.S. workers from 2006, twice as many women as men met the criteria for bipolar disorder, but there were no distinctions based on ethnicity.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient’s mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multi-axial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the DSM-IV-TR as a guideline for diagnosis of bipolar disorder and other mental illnesses. The DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that, unlike manic episodes, hypomanic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features (no delusions or hallucinations). In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often manifest differently in children and adolescents than they appear in adults. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a misdiagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of ADHD. Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

Treatments

Bipolar disorder is usually treated with both medical and psychosocial interventions. Psychosocial therapies address both psychological and social issues.

Medical interventions

A combination of mood-stabilizing agents with antidepressants, antipsychotics, and anticonvulsants is used to regulate manic and depressive episodes.

MOOD-STABILIZING AGENTS

Mood-stabilizing agents such as lithium, carbamazepine, and valproic acid (valproate) are prescribed to regulate the manic highs and lows of bipolar disorder:

  • Lithium (lithium carbonate, Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs) is one of the oldest and most frequently prescribed drugs available for the treatment of bipolar mania and depression. Because the drug takes four to ten days to reach a therapeutic level in the bloodstream, it is sometimes prescribed in conjunction with neuroleptics (other psychiatric drugs) and/or benzodiazepines (medications that ease tension by slowing down the central nervous system) to provide more immediate relief of a manic episode. Lithium has also been shown to be effective in regulating bipolar depression, but it is not recommended for mixed mania. Lithium may not be an effective long-term treatment option for rapid cyclers, who typically develop a tolerance for it or may not respond to it. Possible side effects of the drug include weight gain, thirst, nausea, and hand tremors. Prolonged lithium use may also cause hyperthyroidism (a disease of the thyroid marked by heart palpitations, nervousness, the presence of goiter, sweating, and a wide array of other symptoms).
  • Carbamazepine (Tegretol, Atretol) is an anticonvulsant drug (a drug to treat seizures) usually prescribed in conjunction with other mood-stabilizing agents. The drug is often used to treat bipolar patients who have not responded well to lithium therapy. Blurred vision and abnormal eye movement are two possible side effects of carbamazepine therapy. It may also result in a reduction in red blood cells (anemia), which if left untreated can be life threatening (as in aplastic anemia). Signs to watch for and report immediately to a doctor include easy bruising, tiny purple dots or spots on the skin, or mouth sores.
  • Valproic acid (divalproex sodium, or Depakote; valproate, or Depakene) is one of the few drugs available that has been proven effective in treating rapid cycling bipolar and mixed-states patients. Valproate is prescribed alone or in combination with carbamazepine and/or lithium. Stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain are some of the common side effects of valproate. This drug can cause severe damage to the liver and pancreas, with the greatest risk of liver damage in children under age two years and in people taking two or more medications to prevent seizures or people with certain metabolic disorders. Warning signs that warrant an immediate call to the doctor include severe fatigue, nausea, vomiting, facial swelling, or loss of appetite.

ANTIDEPRESSANTS

Although mania receives more attention, the reality is that people with bipolar disorder spend more time in depressive episodes, making antidepressant treatment seem like a logical choice. However, research indicates that antidepressants, including selective serotonin reuptake inhibitors (SSRIs ) and tricyclic antidepressants, may stimulate manic episodes in some bipolar patients. Tricyclic antidepressants used to treat unipolar depression may trigger rapid cycling in bipolar patients and are, therefore, not a preferred treatment option for bipolar depression. Antidepressants that may be used to treat bipolar depression include:

  • SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), regulate depression by regulating levels of serotonin, a neurotransmitter. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, sexual problems, and insomnia are all possible side effects of SSRIs.
  • Monoamine oxidase inhibitors (also called MAOIs), such as tranylcypromine (Parnate) and phenelzine (Nardil), block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking certain kinds of MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diets, although use of a newer, more selective form of MAOI, selegiline, delivered via a low-dose transdermal patch, does not generally require dietary adjustment.
  • Bupropion (Wellbutrin) is a heterocyclic antidepressant. The exact neurochemical mechanism of the drug is not known, but it has been effective in regulating bipolar depression in some patients. Side effects of bupropion include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, and insomnia. It now comes with a warning about its use in teenagers and children because some research indicates an increased risk of suicidal ideation and suicide attempts in young people taking this type of antidepressant. Its use in people under age 18 is not recommended.
  • Lamotrigine is an antiepileptic that has shown some promise in treating bipolar I depression. Its dosage will vary based on whether or not the person is also taking other drugs, such as valproic acid. This drug is associated with a rare incidence of the development of a serious rash, and the risk of the rash increases if the person is also taking valproic acid. Children are more susceptible to this adverse, possibly life-threatening rash. Women who are pregnant should discuss carefully with their doctor whether or not to use lamotrigine. Studies have shown that fetal exposure in the first trimester of pregnancy increases the chances of cleft lip or cleft palate.

ADJUNCT TREATMENTS

These adjunct treatments are used in conjunction with a long-term pharmaceutical treatment plan:

  • Long-acting benzodiazepines (medications that ease tension by slowing the central nervous system) such as clonazepam (Klonapin) and alprazolam (Xanax) are used for rapid treatment of manic symptoms to calm and sedate patients until mania or hypomania have waned and mood-stabilizing agents can take effect. Sedation is a common effect, and clumsiness, lightheadedness, and slurred speech are other possible side effects of benzodiazepines.
  • Neuroleptics (antipsychotic medications) such as chlorpromazine (Thorazine) and haloperidol (Haldol) are also used to control mania while a mood stabilizer such as lithium or valproate takes effect. Because neuroleptic side effects can be severe (difficulty in speaking or swallowing, paralysis of the eyes, loss of balance control, muscle spasms, severe restlessness, stiffness of arms and legs, tremors in fingers and hands, twisting movements of body, and weakness of arms and legs), benzodiazepines are generally preferred over neuroleptics.
  • Electroconvulsive therapy (ECT) has a high success rate for treating both unipolar and bipolar depression, and mania. However, because of the convenience of drug treatment and the stigma sometimes attached to ECT therapy, ECT is usually employed after all pharmaceutical treatment options have been explored. ECT is given under anesthesia and patients are given a muscle relaxant medication to prevent convulsions. The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient’s head. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that this electrical current alters the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Temporary memory loss has also been reported in ECT patients. In bipolar patients, ECT is often used in conjunction with drug therapy.
  • Calcium channel blockers (nimodipine, or Nimotop), typically used to treat angina and hypotension (low blood pressure), have been found effective, in a few small studies, for treating rapid cyclers. Calcium channel blockers stop the excess calcium buildup in cells that is thought to be a cause of bipolar disorder. They are usually used in conjunction with other drug therapies such as carbamazepine or lithium.

Clozapine (Clozaril) is an antipsychotic medication used to control manic episodes in patients who have not responded to typical mood-stabilizing agents. The drug has also been a useful prophylactic, or preventative treatment, in some bipolar patients. Common side effects of clozapine include tachycardia (rapid heart rate), hypotension, constipation, and weight gain. Agranulocytosis, a potentially serious but reversible condition in which the white blood cells that typically fight infection in the body are destroyed, is a possible side effect of clozapine. Patients treated with the drug should undergo weekly blood tests to monitor white blood cell counts.

Risperidone (Risperdal) is an antipsychotic medication that has been successful in controlling mania. The side effects of risperidone are mild compared to many other antipsychotics (constipation, coughing, diarrhea, dry mouth, headache, heartburn, increased length of sleep and dream activity, nausea, runny nose, sore throat, fatigue, and weight gain). However, because of a risk of death in older people with dementia who take antipsychotics, risperidone is not approved by the FDA for treatment of behavioral disorders in older adults with dementia.

Repeated transcranial magnetic stimulation (rTMS) is a newer treatment for the depressive phase of bipolar disorder. In rTMS, a large magnet is placed on the patient’s head and magnetic fields of different frequency are generated to stimulate the left front cortex of the brain. Unlike ECT, rTMS requires no anesthesia and does not induce seizures.

Psychosocial interventions

Because bipolar disorder is thought to be biological in nature, psychological therapy is recommended as a companion to, but not a substitute for, pharmaceutical treatment of the disease. Psychotherapy, such as cognitive-behavioral therapy, can be a useful tool in helping patients and their families adjust to the disorder, in encouraging compliance to a medication regimen, and in reducing the risk of suicide. Also, educative counseling is recommended for the patient and family.

In educative counseling, patients (and their families) learn of the high rates of social dysfunction and marital discord associated with this disorder. Patients also learn how their treatment will progress, which factors can affect treatment, and what kind of follow-up after treatment will be implemented. Genetic counseling should be a part of family education programs because this disorder is more prevalent among first-degree relatives of individuals with the disorder.

Social support for individuals with bipolar disorder is also important. Some people with the disorder, as well as their families, may find support groups helpful.

Alternative treatment

General recommendations include maintaining a calm environment, avoiding over-stimulation, getting plenty of rest, exercising regularly, and maintaining a proper diet. Some Chinese herbs may soften mood swings, but care must be taken (and good communication with the physician is essential) when combining herbal therapies with medications. Biofeedback is effective in helping some patients control symptoms such as irritability, poor self-control, racing thoughts, and sleep problems.

Prognosis

While most patients will show some positive response to treatment, response varies widely, from full recovery to complete unresponsiveness to all drugs and/or ECT therapy. Drug therapies frequently need adjustment to achieve the maximum benefit for the patient. Bipolar disorder is a chronic recurrent illness in over 90% of those afflicted, and one that requires lifelong observation and treatment after diagnosis. Patients with untreated or inadequately treated bipolar disorder have a suicide rate of 15-25% and a nine-year decrease in life expectancy. With proper treatment, the life expectancy of the bipolar patient increases by nearly seven years and work productivity increases by ten years.

Prevention

The ongoing medical management of bipolar disorder is critical to preventing relapse (recurrence) of manic episodes. Even in carefully controlled treatment programs, bipolar patients may experience recurring episodes of the disorder. Patient education in the form of psychotherapy or self-help groups is crucial for training bipolar patients to recognize signs of mania and depression and to take an active part in their treatment program.

KEY TERMS

Anticonvulsant medication —A medication that prevents convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication —A medication used to treat psychotic symptoms of schizophrenia such as hallucinations, delusions, and delirium. May be used to treat symptoms in other disorders as well.

Benzodiazepines —A group of central nervous system depressants used to relieve anxiety or to induce sleep.

ECT —Electroconvulsive therapy is sometimes used to treat depression or mania when pharmaceutical treatment fails.

Hypomania —A milder form of mania that is characteristic of bipolar II disorder.

Mania —An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyperactivity, disorganization of behavior, and inappropriate elevation of mood.

Mixed mania/mixed state —A mental state in which symptoms of both depression and mania occur simultaneously.

Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation —Slowed mental and physical processes characteristic of a bipolar depressive episode.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Maxmen, Jerrold S., and Nicholas G. Ward. “Mood Disorders.” In Essential Psychopathology and Its Treatment. 2nd ed. New York: W. W. Norton, 1995.

Tasman, Allan, Jerald Kay, MD, and Jeffrey A. Lieberman, MD, eds. Psychiatry, 1st ed. Philadelphia: W. B. Saunders, 1997.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

PERIODICALS

Greene, James G. “Gene Expression Profiles of Brain Dopamine Neurons and Relevance to Neuropsychatric Disease.” Journal of Physiology 575 (2006): 411–16.

Hoblyn, Jennifer. “Bipolar Disorder in Later Life.” Geriatrics 59 (2004): 41–44.

Keck, P., S. McElroy, and L. Arnold. “Advances in the Pathophysiology and Treatment of Psychiatric Disorders: Implications for Internal Medicine.” Medical clinics of North America 85.3 (2001).

Kilzieh, N., and H. Akiskal. “Rapid-cycling Bipolar Disorder: An Overview of Research and Clinical Experience.” Psychiatric Clinics of North America 22.3 (1999).

Nierenberg, Andrew A., and others “Systematic Treatment Enhancement Program for Bipolar Disorder (STEPBD): A Clinical View.” Journal of Clinical Psychiatry 67.11 (2006).

Schulze, Thomas G., and others. “What Is Familial about Familial Bipolar Disorder?” Archives of General Psychiatry 63 (2006): 1368–76.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. <http://www.psych.org>.

Child and Adolescent Bipolar Foundation. 1000 Skokie Boulevard, Suite 570, Wilmette, IL 60091. E-mail: [email protected] <http://www.bpkids.org/site/PageServer>.

Depression and Bipolar Support Alliance. 730 N. Franklin Street, Suite 501, Chicago, IL 60610-7224. Telephone: (800) 826-3632. Fax: (312) 642-7243. <http://www.dbsalliance.org/site/PageServer?pagename=home>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201-3042. Telephone: (800) 950-6264. <http://www.nami.org>.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. Telephone: (800) 826-3632. <http://www.ndmda.org>.

National Institute of Mental Health, Mental Health Public Inquiries. 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. Telephone: (888) 826-9438. <http://www.nimh.nih.gov>.

OTHER

“Bipolar Disorder.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/bipolardisorder.html>.

“Bupropion.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a695033.html>.

“Drug Information: Carbamazepine.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/print/druginfo/medmaster/a682237.html>.

“Lamotrigine.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a695007.html>.

“Patient Information Sheet: Lamotrigine (marketed as Lamictal).” U.S. Food and Drug Administration. <http://www.fda.gov/cder/drug/InfoSheets/patient/lamotriginePIS.htm>.

“Patient Information Sheet: Risperidone Tablets (marketed as Risperdal).” U.S. Food and Drug Administration. <http://www.fda.gov/cder/drug/InfoSheets/patient/risperidonePIS.htm>.

“Risperidone.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a694015.html>.

“Valproic Acid.” National Library of Medicine, National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682412.html>.

Paula Anne Ford-Martin, MA
Laith Farid Gulli, MD
Nicole Mallory, MS, PA-C
Emily Jane Willingham, PhD

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Bipolar disorder

Bipolar disorder

Diagnosis and Treatment

Resources

Bipolar disorder, formerly known as manic depression, is one of the mental illnesses designated as mood disorders. Several million Americans have been diagnosed with bipolar disorder. But, this likely represents a small portion of the actual number of sufferers, since many people go undiagnosed. Indeed, experts have suggested that about one in five families has a family member who has or will experience a manic episode or depression.

Consistent with the designation bipolar, this illness is typically apparent as two extreme moods; depression and mania, where aspects of behavior such as irritability or outright rage become extreme.

Bipolar disorder is characterized by drastic emotional changes and extreme mood swings. The mood may be one of an emotional high where a person has excessive energy, which produces exuberance and bursts of creativity. The person may feel that he or she needs little sleep and may even get only three or four hours of sleep during the manic episode. People in this mode of the illness may have racing thoughts, may have auditory hallucinations, and may suffer from delusions of grandeur. The person often exhibits a great deal of irritability and can become quite argumentative.

The other side of bipolar disorder is a state of depression during which the person feels that everything is hopeless. The mood in the depressed state is flat. The person may have a poor appetite, may sleep too much or too little, feel tired, lose interest in otherwise pleasurable activities, experience difficulty in concentrating, may feel worthless or extremely guilty, and may have thoughts of suicide.

Diagnosis and Treatment

Bipolar disorder exhibits a spectrum of symptoms, from which psychiatrists make their diagnosis. One of the factors they examine is whether the person is in a depressed, manic, or hypomanic state. The latter is one in which a person experiences a more controlled mania. The person may become excessively active and feel elated, but does not become disorganized or delusional. People with these symptoms may be cyclothymic, that is they exhibit periods of depression and mania, but for shorter and less intense durations.

While there is no known single cause of bipolar disorder, there appears to be some genetic predisposition, although no specific genetic defect has yet been detected. It usually appears in late adolescence or early adulthood and continues throughout life. Potential causes, such as increased stress or a traumatic emotional event, are many and varied; experts believe a combination of factors may act as a trigger.

In bipolar disorder, the person who experiences periods of depression that alternate with periods of mania is said to have bipolar disorder I, while the person who suffers mild hypomanic periods alternating with periods of depression is classified as having bipolar disorder II. In both illnesses, episodes are limited in time, lasting from several weeks to several months, although depression can last for more than a year without going into remission. If bipolar disorder is not treated, however, recurrences tend to become more severe over time.

Complicating diagnosis of bipolar disorder is the fact that other medical conditions can cause similar symptoms. Among them are illnesses such as thyroid diseases, infectious diseases (the flu), cancers of the central nervous system, neurological disorders (multiple sclerosis), blood diseases, and even some reactions to metal toxicity.

Lithium has been the treatment of choice for bipolar disorder for several decades. Lithium is a trace element found in plants and in mineral rocks. While there has been a great deal of success in treating bipolar patients with lithium and returning them to a relatively normal life, researchers are not sure how it works. It is a nonaddictive and nonsedating medication, but it must be carefully monitored for possibly dangerous side effects.

More recently, carbamazepine and valproate have been particularly useful with patients who do not respond to lithium. These two anticonvulsants also have to be monitored for proper dosages. Antidepressants may be necessary during severe depressive episodes but may push a patient into the manic

KEY TERMS

Bipolar I disorder An illness characterized by one or more manic episodes, along with a depressive episode.

Bipolar II disorder An illness characterized by a depressive episode and a hypomanic episode.

Cyclothymic disorder An illness in which there are many hypomanic episodes and many periods of depression during a period of time lasting at least two years.

Depression A mood disorder where the predominant symptoms are apathy, hopelessness, sleeping too little or too much, loss of pleasure, self-blame, and possibly suicidal thoughts.

Hypomania A condition in which a person is in an elevated mood and exhibits manic behavior that is not as severe as full-blown mania.

Mania A condition in which the persons mood is elevated, is hyperactive, and has racing thoughts.

Mood disorder An illness that is characterized by a disturbance of mood, which may be depressed or elevated and must be of a significant duration.

state. In severe cases, hospitalization and even electro-convulsive therapy (where electricity is used to alter the transmission of signals in the brain) may be necessary.

Therapy for bipolar disorder combines drug treatment with an educational program for the patient and family, and psychological counseling to help the patient adjust to the medication and learn how to deal with the illness. Because this disorder can be debilitating and is associated with a greater risk of suicide, recognition and accurate diagnosis is essential.

Resources

BOOKS

Copeland, Mary E. and Matthew McKay. The Depression Workbook: A Guide for Living with Depression and Manic Depression. 2nd ed. Oakland: New Harbinger Publications, 2002.

Russell, Sarah. A Lifelong Journey: Staying Well With Manic Depression/Bipolar Disorder. Toronto: Warwick Publishing, 2005.

Torrey, E. Fuller and Michael B. Knable. Surviving Manic Depression: A Manual on Bipolar Disorder for Patients, Families, and Providers. New York: Basic Books, 2005.

Vita Richman

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Bipolar Disorder

Bipolar disorder

Definition

Bipolar disorder (BPD), also known as manic depression or bipolar affective disorder, is characterized by mood swings ranging from high energy, restlessness, and irritability to sadness or deep despair.

Description

The high/low cycling of BPD affects energy, moods, thoughts, emotions, and behavior and interferes with daily life. During manic episodes people may go days without sleep and during depressive episodes they may be unable to get out of bed or go to work. The episodes can last hours, days, weeks, or months and may occur seasonally. Many people with BPD report depression in the winter and mania in the spring. The manic and depressive phases may or may not immediately follow each other. The frequency of episodes can vary from only one or two in a lifetime to four or more per year. Mixed episodes are when symptoms of both mania and depression occur almost daily for at least a week.

BPD I is the most severe form of the illness. It is characterized by extreme mania or mixed episodes and major depressive episodes. BPD II is defined as one or more major depressive episodes and at least one episode of less severe hypomania, possibly with periods of stable moods in between. Cyclothemia is a milder form of BPD in which several hypomanic episodes and less severe depressions alternate for at least two years. Cyclothemia may become more severe over time. People with BPD NOS (not otherwise specified) do not follow a pattern—their swings between some manic and depressive symptoms may be very rapid or they may have hypomania without depression. Rapid cycling involves four or more manic, hypomanic, or depressive episodes over a 12-month period. It may be temporary and can occur with any form of BPD.

Older adults with BPD often have more frequent and longer-lasting episodes. They tend to have longer periods of depression and less frequent, less intense manic episodes. Approximately one-half of older adults who experience mania for the first time have had previous depressive episodes. Manic episodes in older adults may be associated with other medical conditions, medications, or substance abuse. Lateonset mania is often associated with a neurological disease and lesions in the cortical and subcortical regions of the right hemisphere of the brain. Geriatric patients experiencing a first manic episode are at higher risk of death than those who have had multiple manic episodes.

Demographics

BPD affects more than two million adult Americans. It is equally common in males and females. The one-year prevalence of BPD I in Americans aged 55 and over is estimated to be 0.2% and that of BPD II is 0.1%. The prevalence of BPD in patients over age 65 is 0.1-0.4%; however, BPD accounts for 5-12% of geriatric psychiatric hospital admissions.

BPD most often begins as depression in adolescence. Most seniors with BPD have had it throughout their adult lives. Although about 10% of first occurrences happen after age 50, the majority of these people have had earlier depressive episodes. Sometimes seniors have had symptoms of BPD throughout adulthood without being diagnosed.

Causes and symptoms

The exact cause of BPD is not known, but imbalances in brain chemicals play a role. Most cases of BPD are thought to be inherited, yet heredity is less likely to play a role in BPD diagnosed for the first time late in life. Stress , other illnesses, or some medications can trigger episodes.

Symptoms of the manic phase of BPD may include:

  • increased mental and physical energy and activity l heightened mood, exaggerated optimism or self-confidence
  • extreme talkativeness
  • rapid speech and racing thoughts
  • decreased need for sleep
  • distractibility
  • irritability or aggressive behavior
  • grandiose delusions
  • impulsive or reckless behavior, poor judgment
  • hallucinations

Older people with BPD are more likely to be irritable than elated.

Symptoms of the depressive phase of BPD are similar to symptoms of clinical depression in older adults and may include:

  • prolonged sadness or unexplained crying spells
  • irritability, anger
  • agitation, anxiety
  • changes in appetite or sleep patterns
  • apathy, lethargy
  • pessimism
  • feelings of worthlessness or guilt
  • indecisiveness, inability to concentrate
  • social withdrawal, lack of interest in pleasurable pursuits
  • unexplained aches and pains
  • recurring thoughts of suicide or death

Diagnosis

The Depression and Bipolar Support Alliance reports that nearly seven out of 10 people with BPD are misdiagnosed at least once and the average time between the first appearance of symptoms and diagnosis and treatment is 10 years. Misdiagnosis often occurs because patients do not report all of their symptoms, particularly past symptoms, or do not give complete family histories. Mania or hypomania may not be reported because feeling good may not be recognized as a symptom of illness. Other illnesses or medications in seniors can mimic BPD.

BPD II is sometimes misdiagnosed as major depression because the episodes of hypomania go unrecognized. Periods between recurring episodes of depression should be scrutinized for the following symptoms of hypomania:

  • feeling abnormal
  • periods of four or more days of unusual energy or irritability
  • unusual self-confidence or sociability
  • less need for sleep
  • hyperactivity
  • anger
  • abnormally fast thinking
  • poor concentration
  • unusual productivity
  • increased shopping or sexual activity

Treatment

Medications

Medications are prescribed to help stabilize the moods of BPD. Most medications must be taken for two to six weeks before their full effects are realized and it is often necessary to try different medications or combinations to alleviate the symptoms. Older adults may tolerate or metabolize medications for BPD differently than younger adults. Other medications or medical conditions in older adults can alter the metabolism or excretion of psychotropic drugs. Since aging is associated with reduced volume and clearance of urine, dosages are generally lower than in younger patients. Medications for BPD may have to be taken indefinitely. Normal aging and menopause can affect brain chemistry and may require a change in dosage or type of medication.

Lithium is the most commonly prescribed medication for BPD. It is prescribed as an ongoing maintenance treatment as well as for individual episodes because it evens out mood swings in both directions. Lithium increases the neurotransmitter serotonin and brain and nerve-cell activity. Lithium can reduce severe mania in 5–12 days, but it may take weeks or months for BPD to be fully controlled. The response to lithium varies and it is ineffective in some people. Many older patients respond to—and can tolerate—only lower levels of lithium in their bloodstream. Lithium can cause multiple side effects, including cognitive impairment, in older adults.

People who cannot take lithium or do not respond to it may be treated with anticonvulsants, which are usually prescribed to prevent seizures. Many anticonvulsants increase gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits nerve activity. The most common anticonvulsant for treating BPD is valproic acid (divalproex sodium ). It is as effective as lithium for non-rapid-cycling BPD and may be superior to lithium for rapid cycling. Valproic acid is often better tolerated than lithium. Other anticonvulsants that are prescribed for BPD include:

  • gabapentine
  • topiramate
  • zonisamide
  • oxcarbazepine or carbemazepine, which also increase serotonin and other chemicals
  • lamotrigine, which increases N-methyl-D-aspartate (NMDA)

Most people with BPD take other medications in addition to lithium and/or an anticonvulsant to treat agitation, anxiety , insomnia , or depression. Antidepressants can be used along with lithium during depressive episodes. However, in the absence of lithium or another mood stabilizer, antidepressants can switch depressions to mania, hypomania, or rapid cycling.

Antipsychotics are sometimes prescribed for BPD, especially for severe manic symptoms (racing thoughts, delusions, or hallucinations) or until the lithium takes effect. These medications decrease the brain neurotransmitter dopamine and some also increase serotonin:

  • aripiprazole
  • haloperidol
  • olanzapine
  • olanzapine plus the antidepressant fluoxetine (Prozac)
  • quetiapine fumarate
  • risperidone
  • thioridazine
  • trifluoperazine
  • ziprasidone

Side effects

Elderly patients are often more sensitive to side effects of BPD medications than younger people. These side effects include:

  • dry mouth
  • constipation
  • sleepiness or insominia
  • blurred vision
  • weight gain or loss
  • dizziness
  • sexual disinterest or dysfunction

Some side effects may disappear after a few weeks on the drug. Other side effects may require adjusting the dosage or changing the medication. Sometimes a second medication can block the side effects. Alcohol and other drugs can interact with some medications causing serious or dangerous side effects. Some antipsychotics and antidepressants increase the risk of falls in the elderly.

QUESTIONS TO ASK YOUR DOCTOR

  • How will the prescribed medications help me?
  • When should I take the medications? Should I take them with food?
  • What if I miss a dose?
  • What are the possible side effects of these medications and what can be done about them?
  • How long before the medications take effect and what types of improvement should I expect?
  • Are there specific risks to these medications?
  • Can I choose to discontinue the medications?
  • Are there foods, other medications, supplements, or activities that I should avoid?
  • How will my other medical conditions affect the treatment?
  • Are there dietary, physical activity, or lifestyle changes that might help with my bipolar episodes?
  • Are there alternative treatments for bipolar disorder?
  • What type of psychotherapy might useful?
  • Are there support groups available for bipolar disorder?

Nutrition/Dietetic concerns

Healthy eating is important for managing depression. Depressed seniors should:

  • eat plenty of fruits, vegetables, and whole grains;
  • moderate intake of fat, cholesterol, sugars, and salt;
  • drink at least eight glasses of water per day;
  • limit or avoid caffeine and alcohol;
  • not skip meals;
  • avoid radical diets;
  • and be aware of changes in appetite that could be signs of depression.

In some clinical trials many people with BPD improved with high doses of omega-3 fatty acids. These oils are found in:

  • shellfish,
  • sardines,
  • albacore tuna,
  • salmon,
  • canola oil,
  • soybeans,
  • flaxseed,
  • walnuts,
  • and wheat germ.

Omega-3 fatty acids are also available in pill form.

Therapy

Older adults with BPD often profit from talk therapy, group therapy, or peer-support groups in addition to medications. Psychotherapy can help create awareness of the symptoms of developing mania or depression, with the possibility of avoiding or mitigating episodes. It can also help develop coping skills and behaviors.

Prognosis

BPD can usually be controlled with medication, although treatment may be more complicated in older adults. A 2007 study found that older patients with late-onset BPD were at higher risk for stroke than those with early-onset BPD. The two groups did not differ in their physical health or cognitive function.

Prevention

Recognizing triggers and early warning signs may help avoid manic or depressive episodes. Maintaining a regular sleep pattern, eating a healthy diet , and avoiding drugs, alcohol, and risky behaviors are also preventative measures for episodes.

Lifestyle changes that facilitate management of BPD include:

  • establishing regular habits, especially sleep patterns
  • avoiding caffeine
  • reducing stress
  • recognizing and managing the causes of stress
  • relaxation methods including walking, music, yoga, and meditation
  • communicating feelings through talking, writing or other creative outlets
  • exercise

KEY TERMS

Cyclothemia —A milder form of bipolar disorder characterized by alternating hypomania and less severe depressive episodes.

Dopamine —A neurotransmitter in the brain.

Gamma-aminobutyric acid —GABA; a neurotransmitter that inhibits postsynaptic neurons.

Hypomania —Unusual behavior that is less severe than mania, without delusions or hallucinations.

Major depressive episode —A period of prolonged sadness that interferes with daily life.

Mania —High, energetic, or irritable moods that interfere with daily life.

Mixed episode —A period in which symptoms of both mania and depression are present.

Neurotransmitter —A substance that helps transmit impulses between nerve cells.

N-methyl-D-aspartate —NMDA; a brain chemical that binds to some glutamate receptors on neurons.

Omega-3 fatty acids —Substances found in fish and some plant/nut oils that are believed to have multiple health benefits.

Rapid cycling —Four or more manic, hypomanic, mixed, or depressive episodes within a 12-month period.

Serotonin —A neurotransmitter in the brain.

Caregiver concerns

Care givers should be aware of the triggers and warning signs for the onset of depressive or manic episodes and should keep track of patients' mood swings. They should ensure that patients take their medications at the appropriate times and chart any side effects. A 2007 study found that older patients with BPD adhered to their medications better than younger patients. Nevertheless, 39% of older patients had difficulty following their medication regimes, especially if they were homeless or substance abusers.

Resources

BOOKS

Burgess, Wes. The Bipolar Handbook: Real-Life Questions with Up-to-Date Answers. New York: Avery, 2006.

Mondimore, Francis Mark. Bipolar Disorder: A Guide for Patients and Families. 2nd ed. Baltimore: Johns Hopkins University Press, 2006.

Quinn, Brian. Bipolar Disorder. Hoboken, NJ: John Wiley & Sons, 2007.

PERIODICALS

Al Jurdi, Rayan, et al. “Late-Life Mania: Assessment and Treatment of Late-Life Manic Symptoms.” Geriatrics 60 (October 2005): 18–22.

Wallace, Jeremy. “Clinical Review: Common Psychiatric Disorders in Old Age.” General Practitioner (October 14, 2005): 67-8.

OTHER

“Bipolar Disorder.” Depression and Bipolar Support Alliance. October 24, 2007 [cited February 1, 2008]. http://www.dbsalliance.org/site/PageServer?pagename= about_bipolar_overview.

Hirschfeld, Robert, et al. “Practice Guideline for the Treatment of Patients with Bipolar Disorder,” 2nd ed. PsychiatryOnline. April 2002 [cited April 3, 2008]. American Psychiatric Association. http://www.psychiatryonline.com/content.aspx?aID=50053.

“Mental Health, Mental Illness, Healthy Aging: A NH Guide for Older Adults and Caregivers.” National Alliance on Mental Illness New Hampshire. December 2001 [cited February 1, 2008]. http://www.nami.org/Content/ContentGroups/Home4/Home_Page_Spot-lights/Spotlight_1/Guidebook.pdf.

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA, 22209, (703) 907-7300, (888) 35-PSYCH, [email protected], http://www.healthyminds.org.

Depression and Bipolar Support Alliance, 730 N. Franklin Street, Suite 501, Chicago, IL, 60610-7224, (800) 826-3632, (312) 642-7243, [email protected], http://www.ndmda.org.

National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201-3042, (703) 524-7600, (888) 950-NAMI, (703) 524-9094, http://www.nami.org/.

National Mental Health Information Center, PO Box 42557, Washington, DC, 20015, (800) 789-2647, (240) 221-4295, http://mentalhealth.samhsa.gov.

Margaret Alic Ph.D.

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