Bipolar Affective Disorder Essay, Research Paper

Bipolar Affective 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 definate explanations for the causes and cure. The one fact

of which we are pianfully aware4 is that bipolar disorder severely undermines

its’ victoms ability to obtain and maintain social and occupational success.

Because bipolar disorder has such debilitating symptoms, it is imperitive that

we remain vigilent 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 guilt and worthlessness, guilt,

difficulty thinking, indecision, and recurrent thoughts of death and suicide.

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 (approximatly 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. 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).

Effects

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 schizophrenic.

Speech patterns help distinguish between the two disorders (Lish, 1994).

Prevalence and Age of Onset

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. 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.

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).

Anti-convulsants

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.

Neuropletics

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.

Anti-depressants

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 medicationmanagement, the need for

education and support for the interpersonal difficulties that arise during the

course of the disorder.

References

Bauer, M.S., Kurtz, J.W., Rubin, L.B., and Marcus, J.G. (1994). Mood and

Behavioral effects of four-week light treatment in winter depressives and

controls. Journal of Psychiatric Research. 28, 2: 135-145.

Bauer, M.S., Whybrow, P.C. and Winokur, A. (1990). Rapid Cycling Bipolar

Affective Disorder: I. Association with grade I hypothyroidism. Archives of

General Psychiatry. 47: 427-432.

Black, D.W., Winokur, G., and Nasrallah, A. (1987). Treatment of Mania: A

naturalistic study of electroconvulsive therapy versus lithium in 438 patients.

Journal of Clinical Psychiatry. 48: 132-139.

Deltito, J.A., Moline, M., Pollak, C., Martin, L.Y. and Maremani, I. (1991).

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