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 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, 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 (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 (Leiby,1988). 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 (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