Bipolar theory

The phenomenon of Bipolar Affective Disorder has been a mystery since the 16th

and 17th century.  The Dutch painter Vincent Van Gogh was thought to of suffered from

bipolar disorder.  It appears that there are an abundance of people with the disorder yet,

no true causes or cures for the disorder.  Clearly the Bipolar disorder severely undermines

their ability to obtain and sustain social and occupational success.  However, the journey

for the causes and cures for the Bipolar disorder must continue.

Affective disorders are primarily characterized by depressed mood, elevated

mood or (mania), or alternations of depressed and elevated moods.  The classical term is

manic-depressive illness, a newer term is Bipolar disorder.  The two are interchangeable.

Milder forms of a depressive syndrome are called dysthymic disorder, mild forms of

mania are hypomania and the milder expressions of Bipolar disorder are called

cyclothymic disorders.  The use of the term primary affective disorder refers to the

individuals who had no previous psychiatric disorders or else only episodes of mania or

depression.  Secondary affective disorder refers to patients with preexisting psychiatric

illness other than depression or mania (Goodwin, Guze. 1989, p.7 ).

  Bipolar affective disorder affects approximately one percent or three million

persons in the United States, afflicting both males and females.  Bipolar disorder involves

episodes of mania and depression.  The manic episodes are characterized by elevated or

irritable mood, increased energy, decreased need for sleep, poor judgment and insight,

and often reckless or irresponsible behavior (Hollandsworth, Jr. 1990 ). These episodes

may alternate with profound depressions characterized by a pervasive sadness, almost

inability to move, hopelessness, and disturbances in appetite, sleep, in concentrations and

driving.

Bipolar disorder is diagnosed if an episode of mania occurs whether depression

has been diagnosed or not (Goodwin, Guze, 1989, p 11).  Most commonly, individuals

with manic episodes experience a period of depression.  Mood is either elated, expansive,

or irritable, hyperactivity, pressure of speech, flight of ideas, inflated self esteem,

decreased need for sleep, distractibility, and excessive involvement in activities with high

potential for painful consequences.  Rarest symptoms were periods of loss of all interest

and retardation or agitation (Weisman, 1991).

As the National Depressive and Manic Depressive Association (MDMDA) has

demonstrated, bipolar disorder can create substantial developmental delays, marital and

family disruptions, occupational setbacks, and financial disasters.  This devastating

disease causes disruptions of families, loss of jobs and millions of dollars in cost to

society.  Many times bipolar patients report that the depressions are longer and increase

in frequency as the individual ages.  Many times bipolar in a psychotic state are

misdiagnosed as schizophrenic.  Speech patterns help distinguish between the two

disorders (Lish, 1994).

 

       The onset of Bipolar disorder usually occurs between the ages of 20 and 30 years

of age, with a second peak in the mid-forties for women.  A typical bipolar patient may

experience eight to ten episodes in their lifetime.  However, those who have rapid cycling

may experience more episodes of mania and depression that succeed each other without a

period of remission (DSM III-R). 

The three stages of mania begins with hypomania, which patients report that they

are energetic, extroverted and assertive.  The hypomania state has let observers to feel

that bipolar patients are "addicted" to their mania.  Hypomania progresses into mania as

the transition is marked by loss of judgment.  Often, euphoric grandiose characters are

recognized as well as a paranoid or irritable character begins to manifest.  The third stage

of mania is evident when the patient experiences delusions with often paranoid themes.

Speech is generally rapid and behavior manifests with hyperactivity and sometimes

assaultiveness.

       

        When both manic and depressive symptoms occur at the same time it is called a

mixed episode.  These people are a special risk because of the combination of

hopelessness, agitation and anxiety make them feel like they "could jump out of their

skin"(Hirschfeld, 1995).  Up to 50% of all patients with mania have a mixture of

depressed moods.  Patients report feeling very dysphoric, depressed and unhappy yet

exhibit the energy associated with mania.  Rapid cycling mania is yet another

presentation of bipolar disorder.  Mania may be present with four or more distinct

episodes within a 12 month period.  There is now evidence to suggest that sometimes

rapid cycling may be a transient manifestation of the bipolar disorder.  This form of the

disease experiences more episodes of mania and depression than bipolar.

Lithium has been the primary treatment of bipolar disorder since its introduction

in the 1960's.  It is main function is to stabilize the cycling characteristic of bipolar

disorder.  In four controlled studies by F. K. Goodwin and K. R. Jamison, the overall

response rate for bipolar subjects treated with Lithium  was 78% (1990).  Lithium is also

the primary drug used for long- term maintenance of bipolar disorder.  In a majority of

bipolar patients, it lessens the duration, frequency, and severity of the episodes of both

mania and depression.Unfortunately, there are up to 40% of bipolar patients who are

either unresponsive to lithium or who cannot tolerate the side effects.  Some of the side

effects include thirst, weight gain, nausea, diarrhea, and edema.  Patients who are

unresponsive to lithium treatment are often those who experience dysphoric mania,

mixed states, or rapid cycling bipolar disorder (those patients who experience at least

four distinct episodes within one month period). 

       

Among the problems associated with lithium includes the fact the long-term

lithium treatment has been associated with decreased thyroid functioning in patients with

bipolar disorder.  Preliminary evidence also suggest that hypothyroidism may actually

lead to rapid-cycling (Bauer et al., 1990).  Another problem associated with the use of

lithium is its use by pregnant women.  Its use during pregnancy has been associated with

birth defects, particularly Ebstein's anomaly.  Based on current data, the risk of a child

with Ebstein's anomaly being born to a mother who took lithium during her first trimester

of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general population

(Jacobson et al., 1992).

There are other effective treatments for bipolar disorder that are used in cases

where the patients cannot tolerate lithium or can become unresponsive to it in the past.

The American Psychiatric Association's guidelines suggest the next line of to be

anticonvulsant such as valproate and carbamazepine.  These drugs are useful as

antimanic agents, especially in those patients with mixed states.  Both of these

medications can be used in combination with lithium or in combination with each other.

Valproate is especially helpful for patients who are lithium noncompliant, experience

rapid-cycling, or have comorbid alcohol or drug abuse.

        Neuroleptics such as haloperidol or chlorpromazine have also been used to help

stabilize manic patients who are highly agitated or psychotic.  Use of these drugs is often

necessary because the response to them are rapid, but there are risks involved in their use.

Because of the often severe side effects, benzodiazepines are often used in their place.

Benzodiazepines can achieve the same results as Neuroleptics for most patients in terms

of rapid control of agitation and excitement, without the severe side effects.

Antidepressants such as the selective serotonin reuptake inhibitors (SSRIs)

fluovamine and amitriptyline have also been used by some doctors as treatment for

bipolar disorder.  A double-blind study by M. Gasperini, F. Gatti, L. Bellini,

R.Anniverno, and E. Smeraldi showed that fluvoxamine and amitriptyline are highly

effective treatments for bipolar patients experiencing depressive episodes.  This study is

controversial, however, because conflicting research shows that SSRIs and other

antidepressants can actually precipitate manic episodes.  Most doctors can see the

usefulness of antidepressants when used in conjunction with mood stabilizing

medications such as lithium.

    

In addition to the mentioned medical treatments of bipolar disorder, there are

several other options available to bipolar patients, most of which are used in conjunction

with medicine.  One such treatment is light therapy.  One study compared the response to

light therapy of bipolar patients with that of unipolar depresses patients.  Patients are free

of psychotropic and hypnotic medications for at least one month before treatment. 

        Bipolar patients in this study showed an average of 90.3% improvement in their

depressive symptoms, with no incidence of mania or hypomania.  They all continued to

use light therapy, and all showed a sustained positive response at a three month follow-up

(Hopkins and Gelenberg, 1994).  Another study involved a four week treatment of

morning bright light treatment of patients with seasonal affective disorder, including

bipolar patients.  This study found a statistically significant decrement in depressive

symptoms, with the maximum antidepressant effect of light not being reached until week

four.  Hypomanic symptoms were experienced by 36% of bipolar patients in this study.

Predominant hypomanic symptoms included racing thoughts, deceased sleep and

irritability.  Surprisingly, one-third of controls also developed symptoms such as those

mentioned above.  Regardless of the explanation of the emergence of hypomanic

symptoms in undiagnosed controls, it is evident from this study that light treatment may

be associated with the observed symptoms.  Based on the results, careful professional

monitoring during light treatment is necessary, even for those without a history of major

mood disorders.

       

Another popular treatment for bipolar disorder is electro-convulsive shock

therapy.  ECT is the preferred treatment for severely manic pregnant patients and patients

who are homicidal, psychotic, catatonic, medically compromised, or severely suicidal.  In

one study, researchers found marked improvement in 78% of patients treated with ECT,

compared to 62% of patients treated only with lithium and 37% of patients who received

neither, ECT or lithium (Black et al., 1987). 

A final type of therapy that I found is outpatient group psychotherapy.  According

to Dr. John Graves, spokesperson for The National Depressive and Manic Depressive

Association have called attention to the value of support groups, challenging mental

health professionals to take a more serious look at group therapy for the bipolar

population. 

Research shows that group participation may help increase lithium compliance,

decrease denial regarding the illness, and increase awareness of both external and

internal stress factors leading to manic and depressive episodes. Group therapy for

patients with bipolar disorders  responds to the need for support and reinforcement of

medication management, the need for education and support for the interpersonal

difficulties that arise during the course of the disorder                                    

References

       

        Bauer, M.S., Kurtz, J.W., Rubin, L.B., and Marcus, J.G. (1994).  Mood and

Behavioral effects of four-week light treatment in winter depressives and controls.

Journal of Psychiatric Research. 28, 2: 135-145.

       

       Bauer, M.S., Whybrow, P.C. and Winokur, A. (1990).  Rapid Cycling Bipolar

Affective Disorder: I. Association with grade I hypothyroidism.  Archives of  General

Psychiatry.  47: 427-432.

       

       Black, D.W., Winokur, G., and Nasrallah, A. (1987). Treatment of Mania: A

naturalistic study of electroconvulsive therapy versus lithium in 438 patients.  Journal of

Clinical Psychiatry. 48: 132-139.

        Deltito, J.A., Moline, M., Pollak, C., Martin, L.Y. and Maremani, I. (1991).  Effects

of Phototherapy on nonseasonal unipolar and bipolar depressive spectrum disorders.

Journal of Affective Disorders. 23: 231-237.

        Fawcett, Jan. (1994).  Bipolar depression highlights of the first international

conference on bipolar disorder.  University of Pittsburgh, Pennsylvania.

   Forster, P.L.  Videoconference program synopsis.  Annenburg Center for Health

Services at Eisenhower Rancho Mirage, C.A.

(http://www.wpic.pitt.edu/research/stanley/othnws/vidtel12.htm).

        Gasperini, M., Gatti, F., Bellini, L., Anniverno, R., Smeralsi, E., (1992).

Perspectives in clinical psychopharmacology of amitriptyline and fluvoxamine.

Pharmacopsychiatry. 26:186-192.

        Goodwin, F.K., and Jamison, K.R. (1990).  Manic Depressive Illness.  New York:

Oxford University Press.

        Goodwin, Donald W. and Guze, Samuel B. (1989).  Psychiatric Diagnosis.  Fourth

Ed. Oxford University. p.7.

        Hirschfeld, R.M. (1995).  Recent Developments in Clinical Aspects of Bipolar

Disorder.  The Decade of the Brain.  National Alliance for the Mentally Ill.  Winter. Vol.

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        Hollandsworth, James G. (1990). The Physiology of Psychological Disorders.

Plenem Press. New York and London. P.111.

Hopkins, H.S. and Gelenberg, A.J. (1994). Treatment of Bipolar Disorder:      

How Far Have We Come? Psychopharmacology Bulletin.  30 (1): 27-38.

        Jacobson, S.J., Jones, K., Ceolin, L., Kaur, P., Sahn, D., Donnerfeld, A.E., Rieder,

M., Santelli, R., Smythe, J., Patuszuk, A., Einarson, T., and Koren, G.,   (1992).

Prospective multicenter study of pregnancy outcome after lithium exposure during the

first trimester. Laricet. 339: 530-533.

        Lish, J.D., Dime-Meenan, S., Whybrow, P.C., Price, R.A. and Hirschfeld, R.M.

(1994). The National Depressive and Manic Depressive Association (DMDA) Survey of

Bipolar Members.  Affective Disorders. 31: pp.281-294.

        Weisman, M.M., Livingston, B.M., Leaf, P.J., Florio, L.P., Holzer, C. (1991).

Psychiatric Disorders in America.  Affective Disorders. Free Press.

        University of Pittsburgh, Pennsylvania.  (1994).  Bipolar  depression highlights of   

the first international conference on bipolar disorder.

(http://www.wpic.pitt.edu/research/bipolar2.htm).