Bipolar disorder: Difference between revisions

Bipolar disorder
Bipolar disorder
Specialty	Psychiatry, clinical psychology

Browse history interactively

← Previous edit Next edit →

Content deleted Content added

VisualWikitext

Inline

Revision as of 16:43, 29 August 2005

You must add a |reason= parameter to this Cleanup template – replace it with {{Cleanup|August 2005|reason=<Fill reason here>}}, or remove the Cleanup template.

Note on usage: "Manic-depression" was the original term used for the disorder. While it is still commonly used to refer to bipolar disorder, the term manic depression is also now used (by a relatively small number of mental health professionals) to refer to the entire clinical spectrum of mood disorders that includes both bipolar disorder and unipolar depression. Others are trying to phase out the term entirely.

General description

Bipolar disorder is a condition that causes extreme shifts in mood, energy, and functioning. In most populations it affects around 1 percent of the population. Men and women are equally likely to develop this often-disabling illness. The disorder typically emerges in adolescence or early adulthood and affects sufferers throughout their lifespan. Although traditionally thought of as an adult disorder, there is now recognition that children also suffer from bipolar disorder. There are no definite known causes. Scientists believe that Bipolar Disorder may be caused by a combination of biological and psychological factors. Most commonly the onset of this disorder can be linked to stressful life events. Cycles, or episodes, of depression, mania, or "mixed" manic and depressive symptoms typically recur and may become more frequent, often disrupting work, school, family, and social life. The "kindling" theory suggests that persons who are genetically prone (toward bipolar) experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Then at some point these mood changes occur spontaneously.^[1] The person then "becomes bipolar". This might explain why the cause of bipolar is difficult to pinpoint but is somehow related to genetics and environment.

There is a tendency to romanticize bipolar disorder, especially in artistic circles. Many artists, musicians, and writers have experienced its mood swings, and some credit the condition with their creativity. However, many lives are ruined by this disease, and it is associated with a greatly increased risk of suicide.

Bipolar disorder manifests itself in numerous ways, most notably:

Depression: Symptoms include a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant change in appetite or body weight; difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; recurrent thoughts of death or suicide.
Mania: Abnormally and persistently elevated (high) mood and/or irritability accompanied by at least three of the following symptoms (four if the mood is merely irritable): overly-inflated self-esteem; decreased need for sleep; increased talkativeness; racing thoughts; distractibility; increased goal-directed activity such as shopping; physical agitation; hypersexuality; excessive involvement in risky behaviors or activities. Mania is often divided diagnostically into two categories: full blown manic episodes, and a less severe form of mania known as hypomania. Hypomania is often not especially problematic for the patient as he or she typically feels very energetic and in a very good mood. As such, hypomania is often unreported and undiagnosed (this is perhaps the biggest cause of incorrect diagnoses between unipolar and bipolar depression.) Some patients only experience hypomania, but in others as hypomania progresses into a full manic state, patients have more and more trouble retaining control and the symptoms become more problematic.
Mixed state: Symptoms of mania and depression are present at the same time. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic activation. Also known as dysphoric mania (from Greek 'dysphoria', 'dys', difficulty, 'phorós', bearer, and 'mania', mania, insanity). This is the form most often seen in children.

Especially early in the course of illness, the episodes may be separated by "normal" periods during which a person suffers few to no symptoms. When four or more episodes of illness occur within a 12-month period, the person is said to have bipolar disorder with rapid cycling. The rapid-cycling form is often considered more difficult to treat and may be more disabling for bipolar persons since the mood transitions are faster.

Bipolar disorder is often complicated by co-occurring alcohol or substance abuse. Traditionally this has been viewed as an attempt by patients to self-medicate the condition. More recently, some have doubted if this is an entirely accurate description. In some cases, the substance abuse seems to begin before the onset of bipolar disorder, which is difficult to reconcile with the idea of self-medication (at least initially).

Severe depression or mania may be accompanied by symptoms of psychosis. These symptoms include: hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time. Mania is associated with unwarranted optimism, and depression with unwarranted pessimism.

Diagnostic criteria

Bipolar disorder takes two principal forms, neither of which requires plural "cycles". According to the DSM-IV-TR (p. 345), these two principal forms of Bipolar disorder are:

Bipolar I disorder, the diagnosis of which requires over the entire course of the individual's life at least one manic (or mixed state) episode which is usually (though not always) accompanied by episodes of Major Depressive disorder.
Bipolar II disorder, which over the course of the individual's life must involve at least one Major Depressive episode and must be accompanied by at least one hypomanic episode; i.e. there must be no full manic episodes at all. For if there were full manic episodes, the accurate diagnosis would be Bipolar I.

Therefore Bipolar disorder need not have both severe mania and depression and in certain cases has only episodes of the one type. There need be no "cycles" of mania and depression.

This is the reason why certain contemporary psychiatrists shy away from the original name, Manic Depression, i.e. because the latter name might suggest that all individuals have both mania and depression. It has nothing to do with the notion of equal distribution of cycles of mania and depression, since there need not be any cycles at all--in fact, even when there is one (or more) bout of both mania and depression over the course of an individual's life, the two episodes may be so unrelated to each other temporally and otherwise that this need not constitute a cycle. However, a significant portion of individuals with bipolar experience the classical alternating episodes (cycles) of mania and depression and therefore it is overstating the case to say that the classical alternation "rarely" occurs.

The DSM-IV treats these bipolar disorders as variants of mood or affective disorders. Others types include Major Depressive Disorder and Dysthymic Disorder. Bipolar and other mood disorders may have no identifiable medical, traumatic or other external cause (exogenous) or may be due to e.g. a medical condition (endogenous).

In order for a person to be properly diagnosed with bipolar, the mood episodes cannot be due to external medication, drugs or treatment for depression.

Cycles in bipolar disorder

Kraepelin included in his description of Manic Depression the phenomenon that episodes of acute illness, whether mania or depression, are usually punctuated by relatively symptom-free intervals during which the patient is able to function normally both at work and in social affairs.

The cycles of bipolar disorder may be long or short, and the ups and downs may be of different magnitudes: for instance, a person suffering from bipolar disorder may suffer a protracted mild depression followed by a shorter and intense mania. The manic episodes typically include euphoria, tirelessness, and impulsiveness; the depressed periods may seem much worse following a manic period.

Environmental factors affecting mood in bipolar disorder

In mid-2003, a twin study was published concerning environmental factors and bipolar disorder. The bipolar twin was found to be far more affected by changes in sunlight. Longer nights resulted in mood and sleep-length changes far greater than the healthy twin. Sunny days also did more to improve mood. In fact, natural light in general was found to have a profound positive effect upon the well-being of the bipolar twin.^[2]

Paradoxically, in the 2004 publication of a study using Tel Aviv's public psychiatric hospitals, it was found that "Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature".^[3] Unipolar depressed patient admission had no such correlation. High temperature points in the month, as well as high temperature months, were found to be correlated with depressive episodes in admissions

Bipolar disorder and childbirth

For many women with depression or bipolar disorder the postpartum period is a period of risk for developing illness. Episodes of bipolar disorder that follow childbirth are traditionally called puerperal psychosis (PP). Dr. Ian Jones of the Department of Psychological Medicine in Cardiff is researching this area.

Treatment of bipolar disorder

A variety of medications are used to treat bipolar disorder. Many people with bipolar disorder are on multiple medications, which may range between two and five. Some people with bipolar disorder add to or replace their western medication with herbal or holistic options. But even with optimal medication treatment, many people with the illness have some residual symptoms. Symptom management is considered one of the only useful non-medication treatments of bipolar disorder. This treatment teaches how to lessen the severity of mood swings by recognizing and managing triggering symptoms or events.

Medication

There is no cure for bipolar disorder, however their medications can be used to prevent a person from going out of control. Medications, called "mood stabilizers" can sometimes be used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are also sometimes treated with antidepressants, although this carries a risk of inducing mania (especially when no mood stabilizer is also prescribed). In severe cases where the mania or the depression is severe enough to cause psychosis (and recently sometimes in less severe cases as well, although this remains controversial), antipsychotic drugs may also be used. (See the end of the article for an external resource on psychopharmacology.)

Medications work differently in each person, and it takes considerable time to determine in any particular case whether any particular drug is effective at all since bipolar disorder is usually episodic, and patients may experience remissions and periods of normal functioning (which may last years) whether or not they receive treatment. Evaluation of patients is usually carried out using a "life chart" which graphs moods over a long period of time, ranging from weeks to years. It is also generally necessary to "titrate" the dosage of a drug, seeking to achieve the most effective treatment possible while minimizing side-effects. Most mood stabilizers have common side-effects which may range from inconvenient to having a major impact on quality of life; many also have potentially dangerous side-effects which make medical monitoring of patients undergoing drug treatment vitally important. For details of particular drugs, see the section below. Often a customized combination of medications are needed to stabilize moods.

Compliance with medications can be a major problem because some people becoming manic lose insight, or an awareness of having an illness, and discontinue medications; then they often suffer a manic episode and may suddenly find themselves initiating multiple projects often being scattered and ineffective, or may go on a spending spree or take a poorly planned trip landing them in an unfamiliar location without cash. The manic periods, euphoric as they may be, are often disastrous because of the impulsiveness and irrationality that comes with them. Contrary to the patient's wishes, the depression does not respond instantaneously to resumed medication, typically taking 2-6 weeks to respond. Other reasons cited by individuals for discontinuing medication are side effects, expense, and the stigma of having a psychiatric disorder. In a relatively small number of cases stipulated by law (varying by locality but typically, according to the law, only when a patient poses a strong threat to himself or others), patients who do not agree with their psychiatric diagnosis and treatment can legally be required to have treatment without their consent. Throughout North America and the United Kingdom, involuntary treatment laws exist for bipolar disorder and other mental illnesses.

While bipolar disorder can be one of the most severe and devastating medical conditions, fortunately many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Compared to patients with schizophrenia, persons with bipolar disorder are more likely to have periods of normal functioning in the absence of medication. Although schizophrenic patients may have remissions with relatively high levels of functioning, schizophrenic patients tend to suffer some impairment during these intervals in contrast to persons with bipolar disorder who often appear completely healthy when they are between mood swings.

Lithium salts

The use of lithium salts as a treatment of Bipolar Disorder was first discovered by Dr. John Cade.

Lithium salts have long been used as a first-line treatment for bipolar disorder. In ancient times, doctors would send their mentally ill patients to drink from "alkali springs" as a treatment. They did not know it, but they were really prescribing lithium, which was present in high concentration in the waters. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li⁺. The two lithium salts used for bipolar therapy are lithium carbonate (mostly) and lithium citrate (sometimes). Approved for the treatment of acute mania in 1970 by the FDA, lithium has been an effective mood-stabilizing medication for many people with bipolar disorder. Lithium is also noted for reducing the risk of suicide^[4]. Although lithium is among the most effective mood stabilizers, most persons taking it experience side effects similar to the effects of ingesting too much table salt, such as high blood pressure, water retention, and constipation. Regular blood testing is required when taking lithium to determine the correct lithium levels since the therapeutic dose is close to the toxic dose.

The mechanism of lithium salt treatment is believed to work as follows: some symptoms of bipolar disorder appear to be caused by the enzyme inositol monophosphatase (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. It is involved in signal transduction and is believed to create an imbalance in neurotransmitters in bipolar patients. The lithium ion is believed to produce a mood stabilizing effect by inhibiting IMPase by substituting for one of two magnesium ions in IMPase's active site, slowing down this enzyme.

Lithium orotate is used as an alternative treatment to lithium carbonate by some sufferers of bipolar disorder, mainly because it is available without a doctor's prescription. It is sometimes sold as "organic lithium" by nutritionists, as well as under a wide variety of brand names. There seems to be little evidence for its use in clinical treatment in preference to lithium carbonate. Self-treatment without medical monitoring is potentially dangerous.

Anticonvulsant mood stabilizers

Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives or adjuncts to lithium in many cases. Valproate (Depakote and Depakene) was FDA approved for the treatment of acute mania in 1995, and is now considered by many to be the first line of therapy for bipolar disorder. It is preferable to lithium because its side effect profile seems to be less severe, compliance with the medication is better, and fewer breakthrough manic episodes occur. However, valproate is not as effective as lithium in preventing or managing depressive episodes, so patients taking valproate may also need an SSRI or other antidepressant as an adjunct medicinal therapy. Some research suggests that different combinations of lithium and anticonvulsants may be helpful. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, have been studied to determine their efficacy as mood stabilizers in bipolar disorder. Lamotrigine is particularly promising, as there is evidence it acts as a mood stabilizer and particularly helps bipolar persons with severe depression. ^[5] Topiramate has not done well in clinical trials, which may be because it seems to help a few patients very much but most not at all. Unfortunately, there are several controlled studies that show that gabapentin is very effective for certain types of epilepsy and has a mild side effect profile, but is ineffective for bipolar disorder. Nevertheless, many psychiatrists continue to prescribe topiramate and gabapentin for bipolar disorder, although this is becoming increasingly controversial.

According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician. It should be noted, however, that the therapeutic dose for a patient taking valproate for epilepsy is very different than the therapeutic dose of valproate for an individual with bipolar disorder.

Atypical antipsychotic drugs

In some cases, the newer atypical antipsychotic drugs such as risperidone, quetiapine and olanzapine may help relieve severe or refractory symptoms of bipolar disorder and prevent recurrences of mania. Several of the atypical antipsychotic drugs are now FDA approved for treatment of bipolar mania. However, more research is needed to establish the safety and efficacy of atypical antipsychotics as long-term treatments for this disorder.

Omega-3 fatty acids

Omega-3 fatty acids are also used as an alternative or additional treatment for bipolar disorder. Omega-3 fatty acids are polyunsaturated fatty acids which can be found in wild salmon, flaxseed and walnuts. To receive a significant dose, however, omega-3 fatty acids must usually be taken in the form of a fish oil supplement. It has been hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is eicosapentaenoic acid (EPA) and that supplements should be high in this compound to be beneficial.

Psychotherapy

Certain types of psychotherapy or psychosocial interventions, in combination with medication or instead of medication, often can provide tremendous additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family systems therapy, and psychoeducation.

Electroconvulsive therapy

Electroconvulsive therapy is sometimes used to treat severe bipolar depression.

Research findings

Heritability

Bipolar disorder appears to run in families. The rate of suicide is higher in people who have bipolar disorder than in the general population. In fact, people with bipolar disorder are about twice as likely to commit suicide as those suffering from major depression (12% to 6%). The rate of prevalence of bipolar disorder is roughly equal (around 1-1.5%) in men and women.

More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a heritable component. Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

Recent genetic research

Bipolar disorder is considered to be a result of complex interactions between genes and environment. The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Therefore, the genetic component makes up about 70% of the risk for the disorder. Relatives of persons with bipolar disorder also have an increased incidence of having unipolar depression.

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3, which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder.^[6]

Medical imaging

Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the functional MRI. An important area of imaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Better understanding of the neural circuits involved in regulating mood states may influence the development of new and better treatments, and may ultimately aid in diagnosis.

Personality types

An evolving literature exists concerning the nature of personality and temperament in Bipolar Disorder patients, compared to Major Depressive Disorder (unipolar) patients and normals. Such differences may be diagnostically relevant. Using MBTI continuum scores, bipolar patients were significantly more extroverted, intuitive and perceiving, and less introverted, sensing, and judging than were unipolar patients. This suggests that there might be a correlation between the Jungian extraverted intuiting process and bipolar disorder.

Research into new treatments

In late 2003, researchers at McLean Hospital in Belmont, Massachusetts found tentative evidence of improvements in mood during EP-MRSI imaging, and attempts are being made to develop this into a form which can be evaluated as a possible treatment.

It has been hypothesized that bipolar disorder may be the result of poor membrane conduction in the brain and that one possible cause may be a deficiency in omega-3 fatty acids. Following an encouraging small-scale study conducted by Andrew Stoll at Harvard University's McLean Hospital, the Stanley Foundation is sponsoring research regarding the beneficial claims, and several large scale trials of treatment using omega-3 fatty acids are under way.

NIMH has initiated a large-scale study at 20 sites across the U.S. to determine the most effective treatment strategies for people with bipolar disorder. This study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), will follow patients and document their treatment outcome for 5 to 8 years. For more information, visit the Clinical Trials page of the NIMH Web site.

Bipolar disorder, talent and famous people

Many famous people are believed to have been affected by bipolar disorder, based on evidence in their own writings and contemporaneous accounts by those who knew them. Bipolar disorder is found in disproportionate numbers in people with creative talent such as artists, musicians, authors, poets, and scientists, and it has been speculated that the mechanisms which cause the disorder may be related to those responsible for creativity in these persons. (Many of the historical creative talents commonly cited as bipolar were "diagnosed" retrospectively after their deaths and thus the diagnoses are unverifiable; however, in cases diagnosed in recent decades there does seem to be at least some correlation between bipolar disorder and creativity.) The possible explanation for this is that hypomanic phases of the illness allow for heightened concentration on activities and the manic phases allow for around-the-clock work with minimal need for sleep. See list of people believed to have been affected by bipolar disorder.

Sources

Material from public domain text copied from http://www.nimh.nih.gov/publicat/manic.cfm which states: "All material in this fact sheet is in the public domain and may be copied or reproduced without permission from the Institute. Citation of the source is appreciated."
1, 2, 3 and 4 Links and references showing that gabapentin (Neurontin) is an inappropriate and ineffective medication for bipolar disorder.
Suicide rate of persons with bipolar disorder

References

^ Link and reference involving kindling theory
^ Hakkarainen R, et al. (2003). Seasonal changes, sleep length and circadian preference among twins with bipolar disorder. BMC Psychiatry 3 (1), 6.
^ Shapira A, et al. (2004). Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature. Bipolar Disorder Feb;6 (1), 90-3.
^ Baldessarini RJ, et al. (2003). Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64 (Suppl 5), 44-52.
^ 1 and 2 Links and references showing the promise of lamotrigine (Lamictal) in the treatment of bipolar depression.
^ Barrett TB, Hauger RL, Kennedy JL, Sadovnick AD, Remick RA, Keck PE, McElroy SL, Alexander M, Shaw SH, Kelsoe JR. Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder. Mol Psychiatry. 2003 May;8(5):546-57.

External links

Support groups

Research

Evidence-based medicine

Other resources

Benefits of Fish Oil Blog News and commentary on the use of fish oil and omega-3 fatty acids to treat bipolar disorder and other conditions.
Bipolar Happens An excellent resource written by a person suffering with bipolar disorder for over 20 years. Focuses on how a person can manage bipolar disorder.
Bipolar Proven techniques to help co-manage and cope with bipolar disorder in a loved one. Compiled by a certified NAMI faculty member from thousands of bipolar victims and co-victims.
Depression Guide: Bipolar Disorder
Depression Release Manage Bipolar Depression

Links about famous people with unipolar or bipolar disorder

A list of famous people believed to have bipolar disorder can be found at http://www.nami.org/helpline/peoplew.htm

About Emil Kraeplin

Detailed information concerning Emil Kraepelin, who first classified manic depression.

News stories

UCSD Researchers Identify Gene Involved In Bipolar Disorder
Unique Type Of MRI Scan Shows Promise In Treating Bipolar Disorder
Two mental diseases appear to be linked: reports on apparent link of protein kinase C to both bipolar disorder and schizophrenia

@@ Line 92: / Line 92: @@
 ==== Omega-3 fatty acids ====
-Omega-3 fatty acids are also used as an alternative or additional treatment for bipolar disorder. Omega-3 fatty acids are polyunsaturated fatty acids which can be found in wild salmon, flaxseed and even walnuts. To receive a significant dose, however, omega-3 fatty acids must usually be taken in the form of a fish oil supplement. It has been hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is eicosapentaenoic acid (EPA) and that supplements should be high in this ingredient to be beneficial.
+[[Omega-3 fatty acid]]s are also used as an alternative or additional treatment for bipolar disorder. Omega-3 fatty acids are [[polyunsaturated]] [[fatty acid]]s which can be found in wild [[salmon]], [[flaxseed]] and [[walnuts]]. To receive a significant dose, however, omega-3 fatty acids must usually be taken in the form of a [[fish oil]] [[dietary supplement|supplement]]. It has been hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is [[eicosapentaenoic acid]] (EPA) and that supplements should be high in this compound to be beneficial.
 ===Psychotherapy===