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.

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

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.

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:

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.

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

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

n.

Any of several mood disorders usually characterized by alternating periods of depression with mania or hypomania. Also called manic-depressive illness.