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 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 itsí
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, psychomotor 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 (Leiby,1988). 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 (Gurman,

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
(Turner,1989). 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 variety 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% (Turner,1998). 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 (Gurman,1991). Pregnant women experience another
problem associated with the use of lithium. 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 (Leiby,1988). 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 (SSRIís) 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 (Leiby,1988). This study is controversial however, because conflicting
research shows that SSRIís 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 (Turner,1998). 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 (Hollandsworth,

Jr. 1990). 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 (Gurman,1991). A final type of
therapy 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.

Bibliography

Gurman, A.Ph.D. (1991) Questions and answers in the practice of family
therapy. New York: Brunner/Mazel. Hirschfeld, R.M. (1995) Psychiatric Diagnosis
(S.Hutchinson, Ed.) (Vol. IV) Oxford University Press. Hollandsworth, J. G.
(1990). Recent development in clinical aspects of bipolar disorders. National

Alliance for the mentally ill: Vol. II (p.4-87) Leiby,J. (1988) A history of
social welfare and social work in the U.S..New York: Columbia University Press.

Turner, F (1989) Social work treatment. New York: The Free Press