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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
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
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.,
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
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.
Bauer, M.S., Kurtz, J.W., Rubin, L.B., and Marcus, J.G. (1994).
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.
Gasperini, M., Gatti, F., Bellini, L., Anniverno, R., Smeralsi,
E., (1992). Perspectives in clinical psychopharmacology of
amitriptyline and fluvoxamine. Pharmacopsychiatry. 26:186-192.
Goodwin, F.K., and Jamison, K.R. (1990). Manic Depressive
Illness. New York: Oxford University Press.
Goodwin, Donald W. and Guze, Samuel B. (1989). Psychiatric
Diagnosis. Fourth Ed. Oxford University. p.7.
Hirschfeld, R.M. (1995). Recent Developments in Clinical
Aspects of Bipolar Disorder. The Decade of the Brain. National
Alliance for the Mentally Ill. Winter. Vol. VI. Issue II.
Hollandsworth, James G. (1990). The Physiology of Psychological
Disorders. Plenem Press. New York and London. P.111.
Hopkins, H.S. and Gelenberg, A.J. (1994). Treatment of Bipolar
Disorder: How Far Have We Come? Psychopharmacology Bulletin. 30
Jacobson, S.J., Jones, K., Ceolin, L., Kaur, P., Sahn, D.,
Donnerfeld, A.E., Rieder, M., Santelli, R., Smythe, J., Patuszuk, A.,
Einarson, T., and Koren, G., (1992). Prospective multicenter study of
pregnancy outcome after lithium exposure during the first trimester.
Laricet. 339: 530-533.
Lish, J.D., Dime-Meenan, S., Whybrow, P.C., Price, R.A. and
Hirschfeld, R.M. (1994). The National Depressive and Manic Depressive
Association (DMDA) Survey of Bipolar Members. Affective Disorders. 31:
Weisman, M.M., Livingston, B.M., Leaf, P.J., Florio, L.P.,
Holzer, C. (1991). Psychiatric Disorders in America. Affective
Disorders. Free Press.
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