Bipolar
disorder
Bipolar
disorder is a psychiatric condition defined as recurrent episodes
of significant disturbance in mood. These disturbances can occur
on a spectrum that ranges from debilitating depression to unbridled
mania. Individuals suffering from bipolar disorder typically
experience fluid states of mania, hypomania or what is referred
to as a mixed state in conjunction with depressive episodes.
These clinical states typically alternate with a normal range
of mood. The disorder has been subdivided into bipolar I, bipolar
II and cyclothymia, with both bipolar I and bipolar II potentially
presenting with rapid cycling.
Also
called bipolar affective disorder until recently, the current
name is of fairly recent origin and refers to the cycling between
high and low episodes; it has replaced the older term manic-depressive
illness coined by Emil Kraepelin (1856-1926) in the late nineteenth
century.[3] The new term is designed to be neutral, to avoid
the stigma in the non-mental health community that comes from
con?ating "manic" and "depression."
Onset
of symptoms generally occurs in young adulthood. Diagnosis is
based on the person's self-reported experiences, as well as
observed behavior. Episodes of illness are associated with distress
and disruption, and a relatively high risk of suicide.[1] Studies
suggest that genetics, early environment, neurobiology, and
psychological and social processes are important contributory
factors. Psychiatric research is focused on the role of neurobiology,
but a clear organic cause has not been found. Bipolar disorder
is usually treated with medications and/or therapy or counseling.
The mainstay of medication are a number of drugs termed 'mood
stabilizers', in particular lithium and sodium valproate ; these
are a group of unrelated medications used to prevent relapses
of further episodes. Antipsychotic medications, sometimes called
neuroleptics, in particular olanzapine, are used in the treatment
of manic episodes and in maintenance. The benefits of using
antidepressants in depressive episodes is unclear. In serious
cases where there is risk to self and others involuntary hospitalization
may be necessary; these generally involve severe manic episodes
with dangerous behaviour or depressive episodes with suicidal
ideation. Hospital stays are less frequent and for shorter periods
than they were in previous years.
Some
studies have suggested a significant correlation between creativity
and bipolar disorder. However, the relationship between the
disorder and creativity is still very unclear. One study indicated
increased striving for, and sometimes obtaining, goals and achievements.
Signs
and symptoms
Bipolar
disorder is a cyclic illness where people periodically exhibit
elevated (Manic) and depressive episodes. Most people will experience
a number of episodes, averaging 0.4 to 0.7 a year with each
lasting 3 to 6 months. Late adolescence and early adulthood
are peak years for the onset of the illness. These are critical
periods in a young adult's social and vocational development,
and they can be severely disrupted by disease onset.
Classification
Bipolar
disorder is commonly categorized as either bipolar type I, where
an individual experiences full-blown mania, or bipolar type
II, in which the hypomanic "highs" do not go to the
extremes of mania. The latter is much more difficult to diagnose,
since the hypomanic episodes may simply appear as a period of
successful high productivity and is reported less frequently
than a distressing depression. Psychosis can occur, particularly
in manic periods. There are also "rapid cycling" subtypes.
Because there is so much variation in the severity and nature
of mood-related problems, the concept of a bipolar spectrum
is often employed, which includes cyclothymia. There is no consensus
as to how many "types" of bipolar disorder exist.[10]
Many people with bipolar disorder experience severe anxiety
and are very irritable (to the point of rage) when in a manic
state, while others are euphoric and grandiose.
Depressive
phase
Signs
and symptoms of the depressive phase of bipolar disorder include:
persistent feelings of sadness, anxiety, guilt, anger, isolation
and/or hopelessness, disturbances in sleep and appetite, fatigue
and loss of interest in usually enjoyed activities, problems
concentrating, loneliness, self-loathing, apathy or indifference,
depersonalization, loss of interest in sexual activity, shyness
or social anxiety, irritability, chronic pain (with or without
a known cause), lack of motivation, and morbid/suicidal ideation.
Mania
Mania
is generally characterized by a distinct period of an elevated,
expansive or irritable mood state. People commonly experience
an increase in energy and a decreased need for sleep. A person's
speech may be pressured, with thoughts experienced as racing.
Attention span is low and a person in a manic state may be easily
distracted. Judgement may become impaired, the sufferer may
go on spending sprees or engage in behavior that is quite abnormal
for them. They may indulge in substance abuse, particularly
alcohol or other depressants, cocaine or other stimulants, or
sleeping pills. Their behavior may become aggressive or intrusive.
People may feel they have been "chosen", or are "on
a special mission", which are considered grandiose or delusional
ideas. Sexual drive may increase. At more extreme phases, a
person in a manic state can begin to experience psychosis, or
a break with reality, where thinking is affected along with
mood.
In
order to be diagnosed with mania according to DSM-IV, a person
must experience this state of elevated or irritable mood as
well as other symptoms for at least one week or less if hospitalisation
is required. According to the National Institute of Mental Health,
"A manic episode is diagnosed if elevated mood occurs with
three or more of the other symptoms most of the day, nearly
every day, for 1 week or longer. If the mood is irritable, four
additional symptoms must be present."
Hypomania
Hypomania
is generally a less extreme state than mania, and people in
the hypomanic phase generally experience fewer of the symptoms
of mania than those in a full-blown manic episode. During an
episode of hypomania, one might feel an uncontrollable impulse
to laugh at things he or she does not normally find funny. The
duration is usually also shorter than in mania. This is often
a very "artistic" state of the disorder, where there
is a flight of ideas, extremely clever thinking, and an increase
in energy.
Mixed
state
In
the context of bipolar disorder, a mixed state is a condition
during which symptoms of mania and clinical depression occur
simultaneously (for example, agitation, anxiety, aggressiveness
or belligerence, confusion, fatigue, impulsiveness, insomnia,
irritability, morbid and/or suicidal ideation, panic, paranoia,
persecutory delusions, pressured speech, racing thoughts, restlessness,
and rage).
Mixed
episodes can be the most volatile of the bipolar states, as
moods can easily and quickly be triggered or shifted. Suicide
attempts, substance abuse, and self-mutilation may occur during
this state.
Rapid
cycling
Rapid
cycling, defined as having four or more episodes per year, is
found in a significant fraction of patients with bipolar disorder.
It has been associated with greater disability or a worse prognosis,
due to the confusing changeability and difficulty in establishing
a stable state. Rapid cycling can be induced or made worse by
antidepressants, unless there is adjunctive treatment with a
mood stabilizer.
The
definition of rapid cycling most frequently cited in the literature
is that of Dunner and Fieve: at least four major depressive,
manic, hypomanic or mixed episodes are required to have occurred
during a 12-month period. There are references that describe
very rapid (ultra-rapid) or extremely rapid (ultra-ultra or
ultraradian) cycling. One definition of ultra-ultra rapid cycling
is defining distinct shifts in mood within a 24–48-hour
period.
Cognition
Recent
studies have found that bipolar disorder involves certain cognitive
deficits or impairments, even in states of remission.
Deborah
Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has
argued these deficits should be included as a core feature of
bipolar disorder. According to McIntyre et al. (2006),
Study results now press the point that neurocognitive deficits
are a primary feature of BD; they are highly prevalent and persist
in the absence of overt symptomatology. Although disparate neurocognitive
abnormalities have been reported, disturbances in attention,
visual memory, and executive function are most consistently
reported.
However,
in the April-June 2007 issue of the Journal of Psychiatric Research,
Spanish researchers reported that people with bipolar 1 who
have a history of psychotic symptoms do not necessarily experience
an increase in cognitive impairment.
Creativity
A
number of recent studies have observed a correlation between
creativity and bipolar disorder, although it is unclear in which
direction the cause lies, or whether both conditions are caused
by some third, unknown, factor. It has been hypothesized that
temperament may be one such factor.
Diagnosis
Diagnosis
is based on the self-reported experiences of the patient as
well as abnormalities in behavior reported by family members,
friends or co-workers, followed by secondary signs observed
by a psychiatrist, nurse, social worker, clinical psychologist
or other clinician in a clinical assessment. There is a list
of criteria that must be met for someone to be so diagnosed.
These depend on both the presence and duration of certain signs
and symptoms.
An
initial assessment includes a comprehensive history and physical
examination by a physician. Although there are no biological
tests which confirm bipolar disorder, tests are carried out
to exclude medical illnesses which may rarely present with psychiatric
symptoms. These include blood tests measuring TSH to exclude
hypo- or hyperthyroidism, basic electrolytes and serum calcium
to rule out a metabolic disturbance, full blood count including
ESR to rule out a systemic infection or chronic disease, and
serology to exclude syphilis or HIV infection; two commonly
ordered investigations are EEG to exclude epilepsy, and a CT
scan of the head to exclude brain lesions. There are several
psychiatric illnesses which may present with similar symptoms;
these include schizophrenia, drug intoxication, brief drug-induced
psychosis, schizophreniform disorder and borderline personality
disorder.
The
last is important as both diagnoses involve symptoms commonly
known as "mood swings". In bipolar disorder, the term
refers to the cyclic episodes of elevated and depressed mood
which generally last weeks or months (notwithstanding Rapid
Cycling variant of greater than four episodes a year). The term
in borderline personality refers to the marked lability and
reactivity of mood, known as emotional dysregulation, due to
response to external psychosocial and intrapsychic stressors;
these may arise or subside suddenly and dramatically and last
for seconds, minutes, hours or days. A bipolar depression is
generally more pervasive with sleep, appetite disturbance and
nonreactive mood, whereas the mood in dysthymia of borderline
personality remains markedly reactive and sleep disturbance
not acute.
The
relationship between bipolar disorder and borderline personality
disorder has been debated; some hold that the latter represents
a subthreshold form of affective disorder, while others maintain
the distinctness, though noting they often coexist.
Investigations
are not generally repeated for relapse unless there is a specific
medical indication. These may include serum BSL if olanzapine
has previously been prescribed, lithium or valproate level to
check compliance or toxicity with those medications, renal or
thyroid function if lithium has been previously prescribed and
taken regularly. Assessment and treatment are usually done on
an outpatient basis; admission to an inpatient facility is considered
if there is a risk to self or others.
The
most widely used criteria for diagnosing bipolar disorder are
from the American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders, the current version being DSM-IV-TR,
and the World Health Organization's International Statistical
Classification of Diseases and Related Health Problems, currently
the ICD-10. The latter criteria are typically used in European
countries while the DSM criteria are used in the USA or the
rest of the world, as well as prevailing in research studies.
Diagnostic
criteria
Flux
is the fundamental nature of bipolar disorder.[citation needed]
Both within and between individuals with the illness, energy,
mood, thought, sleep, and activity are among the continually
changing biological markers of the disorder. The diagnostic
subtypes of bipolar disorder are thus static descriptions—snapshots,
perhaps—of an illness in continual change, with a great
diversity of symptoms and varying degrees of severity. Individuals
may stay in one subtype, or change into another, over the course
of their illness. The DSM V, to be published in 2011 , will
likely include further and more accurate sub-typing (Akiskal
and Ghaemi, 2006).
There
are four types of bipolar illness. The Diagnostic and Statistical
Manual of Mental Disorders-IV-TR (DSM-IV-TR) details four categories
of bipolar disorder, Bipolar I, Bipolar II, Cyclothymia, and
Bipolar Disorder NOS (Not Otherwise Specified).
For
a diagnosis of Bipolar I disorder according to the DSM-IV-TR,
there requires one or more manic or mixed episodes. A depressive
episode is not required for the diagnosis of Bipolar I disorder
but it frequently occurs.
Bipolar
II, which occurs more frequently is usually characterized by
at least one episode of hypomania and at least one depression.
A
diagnosis of Cyclothymic Disorder requires the presence of numerous
hypomanic episodes, intermingled with depressive episodes that
do not meet full criteria for major depressive episodes. The
main idea here is that there is a low-grade cycling of mood
which appears to the observer as a personality trait, but interferes
with functioning.
If
an individual clearly seems to be suffering from some type of
bipolar disorder but does not meet the criteria for one of the
subtypes above, he or she receives a diagnosis of Bipolar Disorder
NOS (Not Otherwise Specified).
Although
a patient will most likely be depressed when they first seek
help, it is very important to find out from the patient or the
patient's family or friends if a manic or hypomanic episode
has ever been present, using careful questioning. This will
prevent misdiagnosis of Depressive Disorder and avoids the use
of an antidepressant which may trigger a "switch"
to hypomania or mania or induce rapid cycling. Recent screening
tools such as the Hypomanic Check List Questionnaire (HCL-32)
have been developed to assist the quite often difficult detection
of Bipolar II disorders.
Delay
in diagnosis
The
behavioral manifestations of bipolar disorder are often not
understood by patients nor recognized by mental health professionals,
so people may suffer unnecessarily for over 10 years in some
cases before receiving proper treatment.
That
treatment lag is apparently not decreasing, even though there
is now increased public awareness of this mental health condition
in popular magazines and health websites. Recent TV specials,
for example the BBC's The Secret Life of the Manic Depressive,
MTV's True Life: I'm Bipolar, talk shows, and public radio shows,
and the greater willingness of public figures to discuss their
own bipolar disorder, have focused on psychiatric conditions
thereby further raising public awareness. Despite this increased
focus, individuals are still commonly misdiagnosed.
Children
Children
with bipolar disorder do not often meet the strict DSM-IV definition.
In pediatric cases, the cycling can occur very quickly (see
section above on rapid cycling).
Children
with bipolar disorder tend to have rapid-cycling or mixed-cycling.
Rapid cycling occurs when the cycles between depression and
mania occur quickly, sometimes within the same day or the same
hour. When the symptoms of both mania and depression occur simultaneously,
mixed cycling occurs.
Often
other psychiatric conditions are diagnosed in bipolar children.
These other diagnoses may be concurrent problems, or they may
be misdiagnosed as bipolar disorder. Depression, ADHD, ODD,
schizophrenia, and Tourette syndrome are common comorbid conditions.
Furthermore some children with histories of abuse or neglect
may have Bipolar I Disorder. There is a high comorbidity between
Reactive attachment disorder and Bipolar I Disorder with about
50% of children in the Child Welfare System who have Reactive
Attachment Disorder also have Bipolar I Disorder.
Misdiagnosis
can lead to incorrect medication.
On
September, 2007, experts (from New York, Maryland and Madrid)
found that the number of American children and adolescents treated
for bipolar disorder increased 40-fold from 1994 to 2003, and
it was increasing ever since. However, the increase was due
to the fact that doctors more aggressively applied the diagnosis
to children, and not that the incidence of the disorder had
increased. The study calculated the number of visits which increased,
from 20,000 in 1994 to 800,000 in 2003, or 1% of the population
under age 20.
Epidemiology
Clinical
depression and bipolar disorder are classified as separate illnesses.
Some researchers increasingly view them as part of an overlapping
spectrum that also includes anxiety and psychosis.
According
to Hagop Akiskal, M.D., at the one end of the spectrum is bipolar
type schizoaffective disorder, and at the other end is unipolar
depression (recurrent or not recurrent), with the anxiety disorders
present across the spectrum. Also included in this view is premenstrual
dysphoric disorder, postpartum depression, and postpartum psychosis.
This view helps to explain why many people who have the illness
do not have first-degree relatives with clear-cut "bipolar
disorder", but who have family members with a history of
these other disorders.
In
a 2003 study, Hagop Akiskal M.D. and Lew Judd M.D. re-examined
data from the landmark Epidemiologic Catchment Area study from
two decades before. The original study found that 0.8 percent
of the population surveyed had experienced a manic episode at
least once (the diagnostic threshold for bipolar I) and 0.5
a hypomanic episode (the diagnostic threshold for bipolar II).
By
tabulating survey responses to include sub-threshold diagnostic
criteria, such as one or two symptoms over a short time-period,
the authors arrived at an additional 5.1 percent of the population,
adding up to a total of 6.4 percent of the entire population
who can be thought of as having a bipolar spectrum disorder.
This and similar recent studies have been interpreted by some
prominent bipolar disorders researchers as evidence for a much
higher prevalence of bipolar conditions in the general population
than previously thought.
However
these re-analyses should be interpreted cautiously because of
substantive as well as methodological study limitations. Indeed,
prevalence studies of bipolar disorder are carried out by lay
interviewers (that is, not by expert clinicians/psychiatrists
who are more costly to employ) who follow fully structured/fixed
interview schemes; responses to single items from such interviews
may suffer limited validity.
Furthermore,
a well-known statistical problem arises when ascertaining disorders
and conditions with a relatively low population prevalence or
base-rate, such as bipolar disorder: even assuming that lay
interviews diagnoses are highly accurate in terms of sensitivity
and specificity and their corresponding area under the ROC curve
(that is, AUC, or area under the receiver operating characteristic
curve), a condition with a relatively low prevalence or base-rate
is bound to yield high false positive rates, which exceed false
negative rates; in such a circumstance a limited positive predictive
value, PPV, yields high false positive rates even in presence
of a specificity which is very close to 100%. To simplify, it
can be said that a very small error applied over a very large
number of individuals (that is, those who are *not affected*
by the condition in the general population during their lifetime;
for example, over 95%) produces a relevant, non-negligible number
of subjects who are incorrectly classified as having the condition
or any other condition which is the object of a survey study:
these subjects are the so-called false positives; such reasoning
applies to the 'false positive' but not the 'false negative'
problem where we have an error applied over a relatively very
small number of individuals to begin with (that is, those who
are *affected* by the condition in the general population; for
example, less than 5%). Hence, a very high percentage of subjects
who seem to have a history of bipolar disorder at the interview
are false positives for such a medical condition and apparently
never suffered a fully clinical syndrome (that is, bipolar disorder
type I): the population prevalence of bipolar disorder type
I, which includes at least a lifetime manic episode, continues
to be estimated at 1%. "Mild-to-severe versions of bipolar
disorder afflict nearly 4 percent of adults at some time in
their lives."
A
different but related problem in evaluating the public health
significance of psychiatric conditions has been highlighted
by Robert Spitzer of Columbia University: fulfillment of diagnostic
criteria and the resulting diagnosis do not necessarily imply
need for treatment. As a consequence, subjects who experience
bipolar symptoms but not a full-blown, impairing bipolar syndrome
should not be automatically considered as patients in need of
treatment.
Recent
studies have indicated that at least 50% of adult sufferers
report manifestation of symptoms before the age of 17. Moreover,
there is a growing consensus that bipolar disorder originates
in childhood. In young children the illness is now referred
to as pediatric bipolar disorder. Today about 0.5% of children
under 18 are believed to have the condition. For children, the
main concern is that bipolar disorder needs to be diagnosed
correctly and treated properly because it can look like unipolar
depression, ADHD, or conduct disorder. Young children, adolescents
and adults each express the condition differently according
to child and adolescent bipolar disorders expert Demitri Papolos
M.D. and the Child and Adolescent Bipolar Foundation. There
is, however, controversy about this last point.
Bipolar
disorder manifests in late life as well. Some individuals with
"hyperthymic" temperament (or "hypomanic"
personality style) who experience depression in later life appear
to have a form of bipolar disorder. Much more needs to be elucidated
about late-life bipolar disorder.
Approximately
50% of children in the U.S. child welfare system who have reactive
attachment disorder also have comorbid Bipolar I disorder according
to research by John Alston, MD.
Etiology
According
to the U.S. government's National Institute of Mental Health
(NIMH), "There is no single cause for bipolar disorder—rather,
many factors act together to produce the illness." "Because
bipolar disorder tends to run in families, researchers have
been searching for specific genes passed down through generations
that may increase a person's chance of developing the illness."
"In addition, findings from gene research suggest that
bipolar disorder, like other mental illnesses, does not occur
because of a single gene.
It
is well established that bipolar disorder is a genetically influenced
condition which can respond very well to medication (Johnson
& Leahy, 2004; Miklowitz & Goldstein, 1997; Frank, 2005).
(See treatment of bipolar disorder for a more detailed discussion
of treatment.)
Psychological
factors also play a strong role in both the psychopathology
of the disorder and the psychotherapeutic factors aimed at alleviating
core symptoms, recognizing episode triggers, reducing negative
expressed emotion in relationships, recognizing prodromal symptoms
before full-blown recurrence, and, practising the factors that
lead to maintenance of remission (Lam et al, 1999; Johnson &
Leahy, 2004; Basco & Rush, 2005; Miklowitz & Goldstein,
1997; Frank, 2005). Modern evidence based psychotherapies designed
specifically for bipolar disorder when used in combination with
standard medication treatment increase the time the individual
stays well significantly longer than medications alone (Frank,
2005). These psychotherapies are interpersonal and social rhythm
therapy for bipolar disorder, family focused therapy for bipolar
disorder, psychoeducation, cognitive therapy for bipolar disorder,
and prodrome detection. All except psychoeducation and prodrome
detection are available as books.
Abnormalities
in brain function have been related to feelings of anxiety and
lower stress resilience. When faced with a very stressful, negative
major life event, such as a failure in an important area, an
individual may have his first major depression. Conversely,
when an individual accomplishes a major achievement he may experience
his first hypomanic or manic episode. Individuals with bipolar
disorder tend to experience episode triggers involving either
interpersonal or achievement-related life events. An example
of interpersonal-life events include falling in love or, conversely,
the death of a close friend. Achievement-related life events
include acceptance into an elite graduate school or by contrast,
being fired from work (Miklowitz & Goldstein, 1997). Childbirth
can also trigger a postpartum psychosis for bipolar women, which
can lead in the worst cases to infanticide.
The
"kindling" theory asserts that people who are genetically
predisposed toward bipolar disorder can experience a series
of stressful events, each of which lowers the threshold at which
mood changes occur. Eventually, a mood episode can start (and
becomes recurrent) by itself. Not all individuals experience
subsequent mood episodes in the absence of positive or negative
life events, however.
Individuals
with late-adolescent/early adult onset of the disorder will
very likely have experienced childhood anxiety and depression.
Some argue that childhood-onset bipolar disorder should be treated
early.
A
family history of bipolar spectrum disorders can impart a genetic
predisposition towards developing a bipolar spectrum disorder.
Since bipolar disorders are polygenic (involving many genes),
there are apt to be many unipolar and bipolar disordered individuals
in the same family pedigree. This is very often the case (Barondes,
1998). Anxiety disorders, clinical depression, eating disorders,
premenstrual dysphoric disorder, postpartum depression, postpartum
psychosis and/or schizophrenia may be part of the patient's
family history and reflects a term called "genetic loading".
Bipolar
disorder is not either environmental or physiological, it is
multifactorial; that is, many genes and environmental factors
conspire to create the disorder (Johnson & Leahy, 2004).
Since
bipolar disorder is so heterogeneous, it is likely that people
experience different pathways towards the illness (Miklowitz
& Goldstein, 1997).
Recent
research done in Japan indicates a hypothesis of dysfunctional
mitochondria in the brain (Stork & Renshaw, 2005).
Heritability
or inheritance
The
disorder runs in families. More than two-thirds of people with
bipolar disorder have at least one close relative with the disorder
or with unipolar major depression.
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.
Genetic
research
There
is increasing evidence for a genetic component in the causation
of bipolar disorder, provided by a number of twin studies and
gene linkage studies.
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. Dizygotic twins have
a 23% concordance rate. These concordance rates are not universally
replicated in the literature; recent studies have shown rates
of around 40% for monozygotic and <10% for dizygotic twins
(see Kieseppa, 2004 and Cardno, 1999).
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.
A
2007 gene-linkage study by an international team coordinated
by the NIMH has identified a number of genes as likely to be
involved in the etiology of bipolar disorder, suggesting that
bipolar disorder may be a polygenic disease. The researchers
at NIMH have found a correlation between DGKH (diacylglycerol
kinase eta) and bipolar disorder. The portion of the genome
that encodes DGKH, a key protein in the lithium-sensitive phosphatidyl
inositol pathway.
Treatment
Bipolar
disorder cannot be cured, instead the emphasis of treatment
is on effective management of acute episodes and prevention
of further episodes by use of pharmacological and psychotherapeutic
techniques.
Hospitalization
may occur, especially with manic episodes. This can be voluntary
or (if mental health legislation allows it) involuntary (called
civil or involuntary commitment). Long-term inpatient stays
are now less common due to deinstitutionalization, although
can still occur. Following (or in lieu of) a hospital admission,
support services available can include drop-in centers, visits
from members of a community mental health team or Assertive
Community Treatment team, supported employment and patient-led
support groups.
Medication
The
mainstay of treatment is a mood stabilizer medication; these
comprise several unrelated compounds which have been shown to
be effective in preventing relapses of manic, or in the one
case, depressive episodes. The first known and "gold standard"
mood stabilizer is lithium, while almost as widely used is sodium
valproate, originally used as an anticonvulsant. Other anticonvulsants
used in bipolar disorder include carbamazepine, reportedly more
effective in rapid cycling bipolar disorder, and lamotrigine,
which is the first one to be shown to be of benefit in bipolar
depression.
Treatment
of the agitation in acute manic episodes has often required
the use of antipsychotic medications, such as Quetiapine, Olanzapine
and Chlorpromazine. More recently, Olanzapine and Quetiapine
have been approved as effective monotherapy for the maintenance
of bipolar disorder. A head-to-head randomized control trial
in 2005 has also shown olanzapine monotherapy to be as effective
and safe as lithium in prophylaxis.
The
use of antidepressants in bipolar disorder has been debated,
with some studies reporting a worse outcome with their use triggering
manic, hypomanic or mixed episodes, especially if no mood stabiliser
is used. However, most mood stabilizers are of limited effectiveness
in depressive episodes.
Research
The
following studies are ongoing, and are recruiting volunteers:
The
Maudsley Bipolar Twin Study, based at the Institute of Psychiatry
in London is conducting research about the genetic basis of
bipolar disorder using twin methodology. Currently recruiting
volunteers: identical and non-identical twins pairs, where either
one or both twins has a diagnosis of bipolar I or II.
The
Maudsley Bipolar eMonitoring Project, another research study
based at the Institute of Psychiatry in London, is conducting
novel research on electronic monitoring methodologies (electronic
mood diaries and actigraphy) for tracking bipolar symptom fluctuations
in Bipolar individuals who are interested in self-managing their
condition. The study is currently recruiting volunteers from
all over the world (see Remote eMonitoring)
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 and positron emission tomography. An
important area of neuroimaging 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, and studies have
found anatomical differences in areas such as the prefrontal
cortex and hippocampus.
Better
understanding of the neural circuits involved in regulating
mood states, and genetic factors such as the cadherin gene FAT
linked to bipolar disorder, may influence the development of
new and better treatments, and may ultimately aid in early diagnosis
and even a cure.
New
treatments
In
late 2003, researchers at McLean Hospital found tentative evidence
of improvements in mood during echo-planar magnetic resonance
spectroscopic imaging (EP-MRSI), and attempts are being made
to develop this into a form which can be evaluated as a possible
treatment.
NIMH
has initiated a large-scale study at 20 sites across the United
States 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
5-8 years. For more information, visit the Clinical Trials page
of the NIMH Web site.Transcranial magnetic stimulation is another
fairly new technique being studied.Pharmaceutical research is
extensive and ongoing, as seen at clinicaltrials.gov.
Prognosis
A
good prognosis results from good treatment, which, in turn,
results from an accurate diagnosis. Because bipolar disorder
continues to have a high rate of both under-diagnosis and misdiagnosis,
it is often difficult for individuals with the condition to
receive timely and competent treatment.
Bipolar
disorder can be a severely disabling medical condition. However,
with appropriate treatment, many individuals with bipolar disorder
can live full and satisfying lives. Persons with bipolar disorder
are likely to have periods of normal or near normal functioning
between episodes.
Ultimately
one's prognosis depends on many factors, which are, in fact,
under the individual's control: the right medicines; the right
dose of each; a very informed patient; a good working relationship
with a competent medical doctor; a competent, supportive and
warm therapist; a supportive family or significant other; and
a balanced lifestyle including a regulated stress level, regular
exercise and regular sleep and wake times.
There
are obviously other factors that lead to a good prognosis as
well, such as being very aware of small changes in one's energy,
mood, sleep and eating behaviors, as well as having a plan in
conjunction with one's doctor for how to manage subtle changes
that might indicate the beginning of a mood swing. Some people
find that keeping a log of their moods can assist them in predicting
changes.
Recurrence
Even
when on medication, some people may still experience weaker
episodes, or have a complete manic or depressive episode. In
fact, a recent study found bipolar disorder to be "characterized
by a low rate of recovery, a high rate of recurrence, and poor
interepisodic functioning." Worse, the study confirmed
the seriousness of the disorder as "the standardized all-cause
mortality ratio among patients with BD is increased approximately
2-fold." Bipolar disorder is currently regarded "as
possibly the most costly category of mental disorders in the
United States."
The
following behaviors can lead to depressive or manic recurrence:
- Discontinuing or lowering one's dose of medication, without
consulting one's physician.
- Being under- or over-medicated. Generally, taking a lower
dosage of a mood stabilizer can lead to relapse into mania.
Taking a lower dosage of an antidepressant, may cause the patient
to relapse into depression, while higher doses can cause destabilization
into mixed-states or mania.
- Taking hard drugs—recreationally or not—such as
cocaine, alcohol, amphetamines, or opiates. These can cause
the condition to worsen.
- An inconsistent sleep schedule can destabilize the illness.
Too much sleep (possibly caused by medication) can lead to depression,
while too little sleep can lead to mixed states or mania.
- Caffeine can cause destabilization of mood toward irritability,
dysphoria, and mania. Anecdotal evidence seems to suggest that
lower dosages of caffeine can have effects ranging from anti-depressant
to mania-inducing.
- Inadequate stress management and poor lifestyle choices. If
unmedicated, excessive stress can cause the individual to relapse.
Medication raises the stress threshold somewhat, but too much
stress still causes relapse.
- Often bipolar individuals are subject to self-medication,
the most common drugs being alcohol, and marijuana. Sometimes
they may also turn to hard drugs. Studies show that tobacco
smoking induces a calming effect on most bipolar people, and
a very high percentage suffering from the disorder smoke.
Recurrence
can be managed by the sufferer with the help of a close friend,
based on the occurrence of idiosyncratic prodromal events This
theorizes that a close friend could notice which moods, activities,
behaviours, thinking processes, or thoughts typically occur
at the outset of bipolar episodes. They can then take planned
steps to slow or reverse the onset of illness, or take action
to prevent the episode from being damaging.
Mortality
"Mortality
studies have documented an increase in all-cause mortality in
patients with BD. A newly established and rapidly growing database
indicates that mortality due to chronic medical disorders (eg,
cardiovascular disease) is the single largest cause of premature
and excess deaths in BD. The standardized mortality ratio from
suicide in BD is estimated to be approximately 18 to 25, further
emphasizing the lethality of the disorder."
Although
many people with bipolar disorder who attempt suicide never
actually complete it, the annual average suicide rate in males
and females with diagnosed bipolar disorder (0.4%) is 10 to
more than 20 times that in the general population.
Individuals
with bipolar disorder may become suicidal, especially during
mixed states such as dysphoric mania and agitated depression.[citation
needed] Persons suffering from Bipolar II have high rates of
suicide compared to persons suffering from other mental health
conditions, including Major Depression. Major Depressive episodes
are part of the Bipolar II experience, and there is evidence
that sufferers of this disorder spend proportionally much more
of their life in the depressive phase of the illness than their
counterparts with Bipolar I Disorder (Akiskal & Kessler,
2007).
History
Varying
moods and energy levels have been a part of the human experience
since time immemorial. The words "melancholia" (an
old word for depression) and "mania" have their etymologies
in Ancient Greek. The word melancholia is derived from melas/µe?a?,
meaning "black", and chole/????, meaning "bile"
or "gall", indicative of the term’s origins in
pre-Hippocratic humoral theories. Within the humoral theories,
mania was viewed as arising from an excess of yellow bile, or
a mixture of black and yellow bile. The linguistic origins of
mania, however, are not so clear-cut. Several etymologies are
proposed by the Roman physician Caelius Aurelianus, including
the Greek word ‘ania’, meaning to produce great mental
anguish, and ‘manos’, meaning relaxed or loose, which
would contextually approximate to an excessive relaxing of the
mind or soul (Angst and Marneros 2001). There are at least five
other candidates, and part of the confusion surrounding the
exact etymology of the word mania is its varied usage in the
pre-Hippocratic poetry and mythologies (Angst and Marneros 2001).
The
idea of a relationship between mania and melancholia can be
traced back to at least the 2nd century AD.[citation needed]
Soranus of Ephesus (98-177 AD) described mania and melancholia
as distinct diseases with separate etiologies[5]; however, he
acknowledged that “many others consider melancholia a form
of the disease of mania” (Cited in Mondimore 2005 p.49).
A
clear understanding of bipolar disorder as a mental illness
was recognized by early Chinese authors. The encyclopedist Gao
Lian (c. 1583) describes the malady in his Eight Treatises on
the Nurturing of Life (Ts'un-sheng pa-chien).
The
earliest written descriptions of a relationship between mania
and melancholia are attributed to Aretaeus of Cappadocia. Aretaeus
was an eclectic medical philosopher who lived in Alexandria
somewhere between 30 and 150 AD (Roccatagliata 1986; Akiskal
1996). Aretaeus is recognized as having authored most of the
surviving texts referring to a unified concept of manic-depressive
illness, viewing both melancholia and mania as having a common
origin in ‘black bile’ (Akiskal 1996; Marneros 2001).The
contemporary psychiatric conceptualisation of manic-depressive
illness is typically traced back to the 1850s. Marneros (2001)
describes the concepts emerging out of this period as the “rebirth
of bipolarity in the modern era”. On January 31, 1854,
Jules Baillarger described to the French Imperial Academy of
Medicine a biphasic mental illness causing recurrent oscillations
between mania and depression. Two weeks later, on February 14,
1854, Jean-Pierre Falret presented a description to the Academy
on what was essentially the same disorder. This illness was
designated folie circulaire (‘circular insanity’)
by Falret, and folie à double forme (‘dual-form
insanity’) by Baillarger (Sedler 1983).
Emil
Kraepelin (1856-1926), a German psychiatrist categorized and
studied the natural course of untreated bipolar patients long
before mood stabilizers were discovered. Describing these patients
in 1902, he coined the term manic depressive psychosis. He noted
in his patient observations that intervals of acute illness,
manic or depressive, were generally punctuated by relatively
symptom-free intervals in which the patient that was able to
function normally.
After
World War II, Dr. John Cade, an Australian psychiatrist, was
investigating the effects of various compounds on veteran patients
with manic depressive psychosis. In 1949 , Cade discovered that
lithium carbonate could be used as a successful treatment of
manic depressive psychosis. Because there was a fear that table
salt substitutes could lead to toxicity or death, Cade's findings
did not immediately lead to treatments. In the 1950s, U.S. hospitals
began experimenting with lithium on their patients. By the mid-'60s,
reports started appearing in the medical literature regarding
lithium's effectiveness. The U.S. Food and Drug Administration
did not approve of lithium's use until 1970.
The
term "manic-depressive reaction" appeared in the first
American Psychiatric Association Diagnostic Manual in 1952,
influenced by the legacy of Adolf Meyer who had introduced the
paradigm illness as a reaction of biogenetic factors to psychological
and social influences. Subclassification of bipolar disorder
was first proposed by German psychiatrist Karl Leonhard in 1957;
he was also the first to introduce the terms bipolar (for those
with mania) and unipolar (for those with depressive episodes
only).
In
1968, both the newly revised classification systems ICD-8 and
DSM-II termed the condition "manic-depressive illness"
as biological thinking came to the fore.
The
current nosology, bipolar disorder, became popular only recently,
and some individuals prefer the older term because it provides
a better description of a continually changing multi-dimensional
illness.
