The phenomenon of bipolar affective disorder has been a mystery since the 16th century. History has shown that this affliction can appear in almost anyone. Even the great painter Vincent Van Gogh is believed to have had bipolar disorder. It is clear that in our society many people live with bipolar disorder; however, despite the abundance of people suffering from the it, we are still waiting for definate explanations for the causes and cure. The one fact of which we are pianfully aware4 is that bipolar disorder severely undermines its' victoms ability to obtain and maintain social and occupational success. Because bipolar disorder has such debilitating symptoms, it is imperitive that we remain vigilent in the quest for explanations of its causes and treatment.
Affective disorders are characterized by a smorgasbord of symptoms that can be broken into manic and depressive episodes. The depressive episodes are characterized by intense feelings of sadness and despair that can become feelings of hopelessness and helplessness. Some of the symptoms of a depressive episode include anhedonia, disturbances in sleep and appetite, psycomoter retardation, loss of energy, feelings of guilt and worthlessness, guilt, difficulty thinking, indecision, and recurrent thoughts of death and suicide. The manic episodes are characterized by elevated or irritable mood, increased energy, decreased need for sleep, poor judgment and insight, and often reckless or irresponsible behavior (Hollandsworth, Jr. 1990 ).
Bipolar affective disorder affects approximately one percent of the population (approximatly three million people) in the United States. It is presented by both males and females. Bipolar disorder involves episodes of mania and depression. These episodes may alternate with profound depressions characterized by a pervasive sadness, almost inability to move, hopelessness, and disturbances in appetite, sleep, in concentrations and driving.
Bipolar disorder is diagnosed if an episode of mania occurs whether depression has been diagnosed or not (Goodwin, Guze, 1989, p 11). Most commonly, individuals with manic episodes experience a period of depression. 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).
Effects
As the National Depressive and Manic Depressive Association (MDMDA) has demonstrated, bipolar disorder can create substantial developmental delays, marital and family disruptions, occupational setbacks, and financial disasters. This devastating disease causes disruptions of families, loss of jobs and millions of dollars in cost to society. Many times bipolar patients report that the depressions are longer and increase in frequency as the individual ages. Many times bipolar states and psychotic states are misdiagnosed as schizophrenic. Speech patterns help distinguish between the two disorders (Lish, 1994).
Prevalence and Age of Onset
The onset of Bipolar disorder usually occurs between the ages of 20 and 30 years of age, with a second peak in the mid-forties for women. A typical bipolar patient may experience eight to ten episodes in their lifetime. However, those who have rapid cycling may experience more episodes of mania and depression that succeed each other without a period of remission (DSM III-R).
The three stages of mania begin with hypomania, in which patients report that they are energetic, extroverted and assertive. The hypomania state has led observers to feel that bipolar patients are «addicted» to their mania. Hypomania progresses into mania and the transition is marked by loss of judgment. 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).
Anti-convulsants
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.
Neuropletics
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.
Anti-depressants
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.
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The bipolar experience
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