Thinking Essay, Research Paper

Bipolar Disorder

The phenomenon of bipolar affective disorder has been a mystery since

the 16th century. History has shown that this affliction can appear in

almost anyone. Even the great painter Vincent Van Gogh is believed to

have had bipolar disorder. It is clear that in our society many people

live with bipolar disorder; however, despite the abundance of people

suffering from the it, we are still waiting for definite explanations

for the causes and cure. The one fact of which we are painfully aware

is that bipolar disorder severely undermines its? victims ability to

obtain and maintain social and occupational success. Because bipolar

disorder has such debilitating symptoms, it is imperative that we remain

vigilant in the quest for explanations of its causes and treatment.

Affective disorders are characterized by a smorgasbord of symptoms

that can be broken into manic and depressive episodes. The depressive

episodes are characterized by intense feelings of sadness and despair

that can become feelings of hopelessness and helplessness. Some of the

symptoms of a depressive episode include anhedonia, disturbances in

sleep and appetite, psycomoter retardation, loss of energy, feelings of

worthlessness, guilt, difficulty thinking, indecision, and recurrent

thoughts of death and suicide (Hollandsworth, Jr. 1990 ). 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 ). Bipolar

affective disorder affects approximately one percent of the population

(approximately three million people) in the United States. It is

presented by both males and females. Bipolar disorder involves episodes

of mania and depression. 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. Symptoms include elated, expansive, or irritable mood,

hyperactivity, pressure of speech, flight of ideas, inflated self

esteem, decreased need for sleep, distractibility, and excessive

involvement in reckless activities (Hollandsworth, Jr. 1990 ). 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 states

and psychotic states are misdiagnosed as schizophrenia. 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 begin with hypomania, in which patients

report that they are energetic, extroverted and assertive (Hirschfeld,

1995). The hypomania state has led observers to feel that bipolar

patients are “addicted” to their mania. Hypomania progresses into mania

and the transition is marked by loss of judgment (Hirschfeld, 1995).

Often, euphoric grandiose characteristics are displayed, and paranoid or

irritable characteristics begin to manifest. The third stage of mania

is evident when the patient experiences delusions with often paranoid

themes. Speech is generally rapid and hyperactive behavior manifests

sometimes associated with violence (Hirschfeld, 1995).

When both manic and depressive symptoms occur at the same time it

is called a mixed episode. Those afflicted are a special risk because

there is a combination of hopelessness, agitation, and anxiety that

makes 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 dysphoric, depressed, and unhappy; yet,

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

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

exhibits 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, as many as 40% of bipolar patients are either

unresponsive to lithium or can not 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.

One of the problems associated with lithium is 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 experienced 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 have been

unresponsive to it in the past. The American Psychiatric Association’s

guidelines suggest the next line of treatment to be Anticonvulsant

drugs 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

(SSRI?s) 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 (1992). This study is

controversial however, because conflicting research shows that SSRI?s

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 patients. Patients were 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

bright morning light treatment for patients with seasonal affective

disorder and 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 (Baur,

Kurtz, Rubin, and Markus, 1994). 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 has called

attention to the value of support groups, and challenged 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, and the need for education and support for the

interpersonal difficulties that arise during the course of the disorder.

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Mood and

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