The phenomenon of bipolar affective disorder has been a mystery sincethe 16th century. History has shown that this affliction can appear inalmost anyone. Even the great painter Vincent Van Gogh is believed tohave had bipolar disorder.
It is clear that in our society many peoplelive with bipolar disorder; however, despite the abundance of peoplesuffering from the it, we are still waiting for definite explanationsfor the causes and cure. The one fact of which we are painfully awareis that bipolar disorder severely undermines its victims ability toobtain and maintain social and occupational success. Because bipolardisorder has such debilitating symptoms, it is imperative that we remainvigilant in the quest for explanations of its causes and treatment. Affective disorders are characterized by a smorgasbord of symptomsthat can be broken into manic and depressive episodes. The depressiveepisodes are characterized by intense feelings of sadness and despairthat can become feelings of hopelessness and helplessness.
Some of thesymptoms of a depressive episode include anhedonia, disturbances insleep and appetite, psycomoter retardation, loss of energy, feelings of worthlessness, guilt, difficulty thinking, indecision, and recurrentthoughts of death and suicide (Hollandsworth, Jr. 1990 ). The manicepisodes are characterized by elevated or irritable mood, increasedenergy, decreased need for sleep, poor judgment and insight, and oftenreckless or irresponsible behavior (Hollandsworth, Jr.
1990 ). Bipolaraffective disorder affects approximately one percent of the population(approximately three million people) in the United States. It ispresented by both males and females. Bipolar disorder involves episodesof mania and depression. These episodes may alternate with profounddepressions characterized by a pervasive sadness, almost inability tomove, hopelessness, and disturbances in appetite, sleep, inconcentrations and driving.
Bipolar disorder is diagnosed if an episode of mania occurs whetherdepression has been diagnosed or not (Goodwin, Guze, 1989, p 11). Mostcommonly, individuals with manic episodes experience a period ofdepression. Symptoms include elated, expansive, or irritable mood,hyperactivity, pressure of speech, flight of ideas, inflated selfesteem, decreased need for sleep, distractibility, and excessiveinvolvement in reckless activities (Hollandsworth, Jr. 1990 ). Rarestsymptoms were periods of loss of all interest and retardation oragitation (Weisman, 1991).As the National Depressive and Manic Depressive Association (MDMDA)has demonstrated, bipolar disorder can create substantial developmentaldelays, marital and family disruptions, occupational setbacks, andfinancial disasters. This devastating disease causes disruptions offamilies, loss of jobs and millions of dollars in cost to society.
Manytimes bipolar patients report that the depressions are longer andincrease in frequency as the individual ages. Many times bipolar statesand psychotic states are misdiagnosed as schizophrenia. Speech patternshelp distinguish between the two disorders (Lish, 1994).The onset of Bipolar disorder usually occurs between the ages of 20and 30 years of age, with a second peak in the mid-forties for women. Atypical bipolar patient may experience eight to ten episodes in theirlifetime. However, those who have rapid cycling may experience moreepisodes of mania and depression that succeed each other without aperiod of remission (DSM III-R). The three stages of mania begin with hypomania, in which patientsreport that they are energetic, extroverted and assertive (Hirschfeld,1995). The hypomania state has led observers to feel that bipolarpatients are “addicted” to their mania.
Hypomania progresses into maniaand the transition is marked by loss of judgment (Hirschfeld, 1995). Often, euphoric grandiose characteristics are displayed, and paranoid orirritable characteristics begin to manifest. The third stage of maniais evident when the patient experiences delusions with often paranoidthemes. Speech is generally rapid and hyperactive behavior manifestssometimes associated with violence (Hirschfeld, 1995).
When both manic and depressive symptoms occur at the same time itis called a mixed episode. Those afflicted are a special risk becausethere is a combination of hopelessness, agitation, and anxiety thatmakes them feel like they “could jump out of their skin”(Hirschfeld,1995). Up to 50% of all patients with mania have a mixture of depressedmoods. Patients report feeling dysphoric, depressed, and unhappy; yet,they exhibit the energy associated with mania.
Rapid cycling mania isanother presentation of bipolar disorder. Mania may be present withfour or more distinct episodes within a 12 month period. There is nowevidence to suggest that sometimes rapid cycling may be a transientmanifestation of the bipolar disorder. This form of the diseaseexhibits more episodes of mania and depression than bipolar.Lithium has been the primary treatment of bipolar disorder sinceits introduction in the 1960’s. It is main function is to stabilize thecycling characteristic of bipolar disorder.
In four controlled studiesby F. K. Goodwin and K. R. Jamison, the overall response rate forbipolar subjects treated with Lithium was 78% (1990). Lithium is alsothe primary drug used for long- term maintenance of bipolar disorder.
In a majority of bipolar patients, it lessens the duration, frequency,and severity of the episodes of both mania and depression.Unfortunately, as many as 40% of bipolar patients are eitherunresponsive to lithium or can not tolerate the side effects. Some ofthe side effects include thirst, weight gain, nausea, diarrhea, andedema. Patients who are unresponsive to lithium treatment are oftenthose who experience dysphoric mania, mixed states, or rapid cyclingbipolar disorder. One of the problems associated with lithium is the fact thelong-term lithium treatment has been associated with decreased thyroidfunctioning in patients with bipolar disorder. Preliminary evidencealso suggest that hypothyroidism may actually lead to rapid-cycling(Bauer et al.
, 1990). Another problem associated with the use oflithium is experienced by pregnant women. Its use during pregnancy hasbeen associated with birth defects, particularly Ebstein’s anomaly. Based on current data, the risk of a child with Ebstein’s anomaly beingborn to a mother who took lithium during her first trimester ofpregnancy is approximately 1 in 8,000, or 2.5 times that of the generalpopulation (Jacobson et al.
, 1992).There are other effective treatments for bipolar disorder that areused in cases where the patients cannot tolerate lithium or have beenunresponsive to it in the past.The American Psychiatric Association’sguidelines suggest the next line of treatment to be Anticonvulsantdrugs such as valproate and carbamazepine. These drugs are useful asantimanic agents, especially in those patients with mixed states. Bothof these medications can be used in combination with lithium or incombination with each other. Valproate is especially helpful forpatients who are lithium noncompliant, experience rapid-cycling, or havecomorbid alcohol or drug abuse.
Neuroleptics such as haloperidol or chlorpromazine have also beenused to help stabilize manic patients who are highly agitated orpsychotic. Use of these drugs is often necessary because the responseto them are rapid, but there are risks involved in their use. Becauseof the often severe side effects, Benzodiazepines are often used intheir place. Benzodiazepines can achieve the same results asNeuroleptics for most patients in terms of rapid control of agitationand excitement, without the severe side effects.Antidepressants such as the selective serotonin reuptake inhibitors(SSRIs) fluovamine and amitriptyline have also been used by somedoctors as treatment for bipolar disorder.
A double-blind study by M.Gasperini, F. Gatti, L. Bellini, R.Anniverno, and E. Smeraldi showedthat fluvoxamine and amitriptyline are highly effective treatments forbipolar patients experiencing depressive episodes (1992).
This study iscontroversial however, because conflicting research shows that SSRIsand other antidepressants can actually precipitate manic episodes. Mostdoctors can see the usefulness of antidepressants when used inconjunction with mood stabilizing medications such as lithium.In addition to the mentioned medical treatments of bipolardisorder, there are several other options available to bipolar patients,most of which are used in conjunction with medicine. One such treatmentis light therapy. One study compared the response to light therapy ofbipolar patients with that of unipolar patients. Patients were free ofpsychotropic and hypnotic medications for at least one month beforetreatment. Bipolar patients in this study showed an average of 90.
3%improvement in their depressive symptoms, with no incidence of mania orhypomania. They all continued to use light therapy, and all showed asustained positive response at a three month follow-up (Hopkins andGelenberg, 1994). Another study involved a four week treatment ofbright morning light treatment for patients with seasonal affectivedisorder and bipolar patients. This study found a statisticallysignificant decrement in depressive symptoms, with the maximumantidepressant effect of light not being reached until week four (Baur,Kurtz, Rubin, and Markus, 1994). Hypomanic symptoms were experienced by36% of bipolar patients in this study. Predominant hypomanic symptomsincluded racing thoughts, deceased sleep and irritability. Surprisingly, one-third of controls also developed symptoms such asthose mentioned above. Regardless of the explanation of the emergenceof hypomanic symptoms in undiagnosed controls, it is evident from thisstudy that light treatment may be associated with the observedsymptoms.
Based on the results, careful professional monitoring duringlight treatment is necessary, even for those without a history of majormood disorders.Another popular treatment for bipolar disorder iselectro-convulsive shock therapy. ECT is the preferred treatment forseverely manic pregnant patients and patients who are homicidal,psychotic, catatonic, medically compromised, or severely suicidal. Inone study, researchers found marked improvement in 78% of patientstreated with ECT, compared to 62% of patients treated only with lithiumand 37% of patients who received neither, ECT or lithium (Black et al.
,1987). A final type of therapy that I found is outpatient grouppsychotherapy. According to Dr.
John Graves, spokesperson for TheNational Depressive and Manic Depressive Association has calledattention to the value of support groups, and challenged mental healthprofessionals to take a more serious look at group therapy for thebipolar population. Research shows that group participation may help increase lithiumcompliance, decrease denial regarding the illness, and increaseawareness of both external and internal stress factors leading to manicand depressive episodes. Group therapy for patients with bipolardisorders responds to the need for support and reinforcement ofmedication management, and the need for education and support for theinterpersonal difficulties that arise during the course of the disorder. ReferencesBauer, M.S., Kurtz, J.
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