Untitled Essay, Research Paper

The phenomenon of Bipolar Affective Disorder has been a mystery since the

16th

and 17th century. The Dutch painter Vincent Van Gogh was thought to of suffered

from

bipolar disorder. It appears that there are an abundance of people with the

disorder yet,

no true causes or cures for the disorder. Clearly the Bipolar disorder severely

undermines

their ability to obtain and sustain social and occupational success. However,

the journey

for the causes and cures for the Bipolar disorder must continue. Affective disorders are primarily characterized by depressed

mood, elevated

mood or (mania), or alternations of depressed and elevated moods. The classical

term is

manic-depressive illness, a newer term is Bipolar disorder. The two are

interchangeable.

Milder forms of a depressive syndrome are called dysthymic disorder, mild

forms of

mania are hypomania and the milder expressions of Bipolar disorder are

called

cyclothymic disorders. The use of the term primary affective disorder refers

to the

individuals who had no previous psychiatric disorders or else only episodes

of mania or

depression. Secondary affective disorder refers to patients with preexisting

psychiatric

illness other than depression or mania (Goodwin, Guze. 1989, p.7 ).

Bipolar affective disorder affects approximately one percent

or three million

persons in the United States, afflicting both males and females. Bipolar

disorder involves

episodes of mania and depression. The manic episodes are characterized by

elevated or

irritable mood, increased energy, decreased need for sleep, poor judgment

and insight,

and often reckless or irresponsible behavior (Hollandsworth, Jr. 1990 ).

These episodes

may alternate with profound depressions characterized by a pervasive sadness,

almost

inability to move, hopelessness, and disturbances in appetite, sleep, in

concentrations and

driving.

Bipolar disorder is diagnosed if an episode of mania occurs

whether depression

has been diagnosed or not (Goodwin, Guze, 1989, p 11). Most commonly,

individuals

with manic episodes experience a period of depression. Mood is either elated,

expansive,

or irritable, hyperactivity, pressure of speech, flight of ideas, inflated

self esteem,

decreased need for sleep, distractibility, and excessive involvement in

activities with high

potential for painful consequences. Rarest symptoms were periods of loss

of all interest

and retardation or agitation (Weisman, 1991). As the National Depressive and Manic Depressive Association

(MDMDA) has

demonstrated, bipolar disorder can create substantial developmental delays,

marital and

family disruptions, occupational setbacks, and financial disasters. This

devastating

disease causes disruptions of families, loss of jobs and millions of dollars

in cost to

society. Many times bipolar patients report that the depressions are longer

and increase

in frequency as the individual ages. Many times bipolar in a psychotic state

are

misdiagnosed as schizophrenic. Speech patterns help distinguish between the

two

disorders (Lish, 1994). The onset of Bipolar disorder usually occurs between the

ages of 20 and 30 years

of age, with a second peak in the mid-forties for women. A typical bipolar

patient may

experience eight to ten episodes in their lifetime. However, those who have

rapid cycling

may experience more episodes of mania and depression that succeed each other

without a

period of remission (DSM III-R).

The three stages of mania begins with hypomania, which

patients report that they

are energetic, extroverted and assertive. The hypomania state has let observers

to feel

that bipolar patients are “addicted” to their mania. Hypomania progresses

into mania as

the transition is marked by loss of judgment. Often, euphoric grandiose

characters are

recognized as well as a paranoid or irritable character begins to manifest.

The third stage

of mania is evident when the patient experiences delusions with often paranoid

themes.

Speech is generally rapid and behavior manifests with hyperactivity and

sometimes

assaultiveness.When both manic and depressive symptoms occur at the same time it is called

a

mixed episode. These people are a special risk because of the combination

of

hopelessness, agitation and anxiety make them feel like they “could jump

out of their

skin”(Hirschfeld, 1995). Up to 50% of all patients with mania have a mixture

of

depressed moods. Patients report feeling very dysphoric, depressed and unhappy

yet

exhibit the energy associated with mania. Rapid cycling mania is yet

another

presentation of bipolar disorder. Mania may be present with four or more

distinct

episodes within a 12 month period. There is now evidence to suggest that

sometimes

rapid cycling may be a transient manifestation of the bipolar disorder. This

form of the

disease experiences more episodes of mania and depression than bipolar. Lithium has been the primary treatment of bipolar disorder

since its introduction

in the 1960’s. It is main function is to stabilize the cycling characteristic

of bipolar

disorder. In four controlled studies by F. K. Goodwin and K. R. Jamison,

the overall

response rate for bipolar subjects treated with Lithium was 78% (1990). Lithium

is also

the primary drug used for long- term maintenance of bipolar disorder. In

a majority of

bipolar patients, it lessens the duration, frequency, and severity of the

episodes of both

mania and depression.Unfortunately, there are up to 40% of bipolar patients

who are

either unresponsive to lithium or who cannot tolerate the side effects. Some

of the side

effects include thirst, weight gain, nausea, diarrhea, and edema. Patients

who are

unresponsive to lithium treatment are often those who experience dysphoric

mania,

mixed states, or rapid cycling bipolar disorder (those patients who experience

at least

four distinct episodes within one month period). Among the problems associated with lithium includes the

fact the long-term

lithium treatment has been associated with decreased thyroid functioning

in patients with

bipolar disorder. Preliminary evidence also suggest that hypothyroidism may

actually

lead to rapid-cycling (Bauer et al., 1990). Another problem associated with

the use of

lithium is its use by pregnant women. Its use during pregnancy has been

associated with

birth defects, particularly Ebstein’s anomaly. Based on current data, the

risk of a child

with Ebstein’s anomaly being born to a mother who took lithium during her

first trimester

of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general

population

(Jacobson et al., 1992). There are other effective treatments for bipolar disorder

that are used in cases

where the patients cannot tolerate lithium or can become unresponsive to

it in the past.

The American Psychiatric Association’s guidelines suggest the next line of

to be

anticonvulsant such as valproate and carbamazepine. These drugs are useful

as

antimanic agents, especially in those patients with mixed states. Both of

these

medications can be used in combination with lithium or in combination with

each other.

Valproate is especially helpful for patients who are lithium noncompliant,

experience

rapid-cycling, or have comorbid alcohol or drug abuse.Neuroleptics such as haloperidol or chlorpromazine have also been used to

help

stabilize manic patients who are highly agitated or psychotic. Use of these

drugs is often

necessary because the response to them are rapid, but there are risks involved

in their use.

Because of the often severe side effects, benzodiazepines are often used

in their place.

Benzodiazepines can achieve the same results as Neuroleptics for most patients

in terms

of rapid control of agitation and excitement, without the severe side

effects. Antidepressants such as the selective serotonin reuptake

inhibitors (SSRIs)

fluovamine and amitriptyline have also been used by some doctors as treatment

for

bipolar disorder. A double-blind study by M. Gasperini, F. Gatti, L.

Bellini,

R.Anniverno, and E. Smeraldi showed that fluvoxamine and amitriptyline are

highly

effective treatments for bipolar patients experiencing depressive episodes.

This study is

controversial, however, because conflicting research shows that SSRIs and

other

antidepressants can actually precipitate manic episodes. Most doctors can

see the

usefulness of antidepressants when used in conjunction with mood

stabilizing

medications such as lithium. In addition to the mentioned medical treatments of bipolar

disorder, there are

several other options available to bipolar patients, most of which are used

in conjunction

with medicine. One such treatment is light therapy. One study compared the

response to

light therapy of bipolar patients with that of unipolar depresses patients.

Patients are free

of psychotropic and hypnotic medications for at least one month before treatment.

Bipolar patients in this study showed an average of 90.3% improvement in

their

depressive symptoms, with no incidence of mania or hypomania. They all continued

to

use light therapy, and all showed a sustained positive response at a three

month follow-up

(Hopkins and Gelenberg, 1994). Another study involved a four week treatment

of

morning bright light treatment of patients with seasonal affective disorder,

including

bipolar patients. This study found a statistically significant decrement

in depressive

symptoms, with the maximum antidepressant effect of light not being reached

until week

four. Hypomanic symptoms were experienced by 36% of bipolar patients in this

study.

Predominant hypomanic symptoms included racing thoughts, deceased sleep and

irritability. Surprisingly, one-third of controls also developed symptoms

such as those

mentioned above. Regardless of the explanation of the emergence of

hypomanic

symptoms in undiagnosed controls, it is evident from this study that light

treatment may

be associated with the observed symptoms. Based on the results, careful

professional

monitoring during light treatment is necessary, even for those without a

history of major

mood disorders. Another popular treatment for bipolar disorder is

electro-convulsive shock

therapy. ECT is the preferred treatment for severely manic pregnant patients

and patients

who are homicidal, psychotic, catatonic, medically compromised, or severely

suicidal. In

one study, researchers found marked improvement in 78% of patients treated

with ECT,

compared to 62% of patients treated only with lithium and 37% of patients

who received

neither, ECT or lithium (Black et al., 1987).

A final type of therapy that I found is outpatient group

psychotherapy. According

to Dr. John Graves, spokesperson for The National Depressive and Manic

Depressive

Association have called attention to the value of support groups, challenging

mental

health professionals to take a more serious look at group therapy for the

bipolar

population.

Research shows that group participation may help increase

lithium compliance,

decrease denial regarding the illness, and increase awareness of both external

and

internal stress factors leading to manic and depressive episodes. Group therapy

for

patients with bipolar disorders responds to the need for support and

reinforcement of

medication management, the need for education and support for the

interpersonal

difficulties that arise during the course of the disorder

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