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Back to Psychiatry Diseases
Bipolar disorder
As categorized by the DSM-IV, bipolar disorder is a form of mood
disorder characterised by a variation of mood between a phase of manic
or hypomanic elation, hyperactivity and hyper imagination, and a
depressive phase of inhibition, slowness to conceive ideas and move, and
anxiety or sadness. Together these form what is commonly known as manic
depression.
Manic depression with its two principal sub-types, bipolar disorder and
major depression, was first clinically described near the end of the
19th century by psychiatrist Emil Kraepelin, who published his account
of the disease in his Textbook of Psychiatry. As described below, there
are several forms of bipolar disorder.
It should be noted that this disease does not consist of mere "ups and
downs". Ups and downs are experienced by virtually everyone and do not
constitute a disease. The mood swings of bipolar disorder are far more
extreme than those experienced by most people.
Note: Bipolar disorder is also commonly called "manic depression" by
laymen (and by some psychiatrists in the twentieth century), although
this usage is now unpopular with psychiatrists, who have standardised on
Kraepelin's usage of the term manic depression to describe the whole
bipolar spectrum that includes both bipolar disorder and unipolar
depression; they now use bipolar disorder to describe the bipolar form
of manic depression.
General description
Bipolar disorder is a condition that causes extreme shifts in mood,
energy, and functioning. In most populations it affects around 1 percent
of the population. Men and women are equally likely to develop this
often-disabling illness. The disorder typically emerges in adolescence
or early adulthood, but in some cases appears in childhood. Cycles, or
episodes, of depression, mania, or "mixed" manic and depressive symptoms
typically recur and may become more frequent, often disrupting work,
school, family, and social life.
There is a tendency to romanticize bipolar disorder, especially in
artistic circles. Many artists, musicians, and writers have experienced
its mood swings, and some credit the condition with their creativity.
However, many lives are ruined by this disease, and it is associated
with a greatly increased risk of suicide.
Depression: Symptoms include a persistent sad mood; loss of interest or
pleasure in activities that were once enjoyed; significant change in
appetite or body weight; difficulty sleeping or oversleeping; physical
slowing or agitation; loss of energy; feelings of worthlessness or
inappropriate guilt; difficulty thinking or concentrating; and recurrent
thoughts of death or suicide.
Mania: Abnormally and persistently elevated (high) mood or irritability
accompanied by at least three of the following symptoms: overly-inflated
self-esteem; decreased need for sleep; increased talkativeness; racing
thoughts; distractibility; increased goal-directed activity such as
shopping; physical agitation; hypersexuality and excessive involvement
in risky behaviors or activities.
"Mixed" state: Symptoms of mania and depression are present at the same
time. The symptom picture frequently includes agitation, trouble
sleeping, significant change in appetite, psychosis, and suicidal
thinking. Depressed mood accompanies manic activation. Also known as
dysphoric mania (from Greek 'dysphoria', 'dys', difficulty, 'phor?',
bearer, and 'mania', mania, insanity).
Especially early in the course of illness, the episodes may be separated
by periods of wellness during which a person suffers few to no symptoms.
When 4 or more episodes of illness occur within a 12-month period, the
person is said to have bipolar disorder with rapid cycling. Bipolar
disorder is often complicated by co-occurring alcohol or substance
abuse.
Severe depression or mania may be accompanied by symptoms of psychosis.
These symptoms include: hallucinations (hearing, seeing, or otherwise
sensing the presence of stimuli that are not there) and delusions (false
personal beliefs that are not subject to reason or contradictory
evidence and are not explained by a person's cultural concepts).
Psychotic symptoms associated with bipolar disorder typically reflect
the extreme mood state at the time.
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Diagnostic criteria
Bipolar disorder takes two principal forms, neither of which requires
plural "cycles". According to the DSM-IV-TR (p. 345), these two
principal forms of Bipolar disorder are:
Bipolar I disorder, the diagnosis of which requires over the entire
course of the patient's life at least one manic (or mixed state) episode
which is usually (though not always) accompanied by episodes of Major
Depressive disorder.
Bipolar II disorder, which over the course of the patient's life must
involve at least one Major Depressive episode and must be accompanied by
at least one hypomanic episode; i.e. there need be no full manic
episodes at all.
Therefore Bipolar disorder need not have both severe mania and
depression and in certain cases has only episodes of the one type. There
need be no "cycles" of mania and depression.
This is the reason why certain contemporary psychiatrists shy away from
the original name, Manic Depression, i.e. because the latter name might
suggest that all patients have both mania and depression. It has nothing
to do with the notion of equal distribution of cycles of mania and
depression, since there need not be any cycles at all--in fact, even
when there is one (or more) bout of both mania and depression over the
course of a patient's life, the two episodes may be so unrelated to each
other temporally and otherwise that this need not constitute a cycle.
However, a significant portion of bipolar patients does experience the
classical alternating episodes (cycles) of mania and depression and
therefore it is overstating the case to say that the classical
alternation "rarely" occurs.
The DSM-IV treats these bipolar disorders as variants of mood or
affective disorders. Others types include Major Depressive Disorder and
Dysthymic Disorder. Bipolar and other mood disorders may have no
identifiable medical, traumatic or other external cause (endogenous) or
may be due to e.g. a medical condition (exogenous).
Cycles in bipolar disorder
Kraepelin included in his description of Manic Depression the phenomenon
that episodes of acute illness, whether mania or depression, are usually
punctuated by relatively symptom-free intervals during which the patient
is able to function normally both at work and in social affairs.
The cycles of bipolar disorder may be long or short, and the ups and
downs may be of different magnitudes: for instance, a person suffering
from bipolar disorder may suffer a protracted mild depression followed
by a shorter and intense mania. The manic periods typically include
euphoria, tirelessness, and impulsiveness; the depressed periods may
seem much worse following a manic period.
The name bipolar disorder is used to distinguish the condition from
unipolar depression, and bipolar disorder is in turn divided into two
forms, "Bipolar I" and the "Bipolar II" form, considered by some as a
'milder' version of the disorder. However, other doctors believe there
is no sound basis for the blanket statement that Bipolar II is "milder"
than Bipolar I.
Environmental factors affecting mood in bipolar disorder
In mid-2003, a twin study was published concerning environmental factors
and bipolar disorder. The bipolar twin was found to be far more affected
by changes in sunlight. Longer nights resulted in mood and sleep-length
changes far greater than the healthy twin. Sunny days also did more to
improve mood. In fact, natural light in general was found to have a
profound positive effect upon the well-being of the bipolar twin (Hakkarainen,
2003).
Treatment of bipolar disorder
Medications, called "mood stabilizers" can sometimes be used to prevent
manic or depressive episodes. Periods of depression can also be treated
with antidepressants. In extreme cases where the mania or the depression
is severe enough to cause psychosis, antipsychotic drugs may also be
used. (See the end of the article for an external resource on
psychopharmacology.) In contrast to schizophrenia, insight-oriented
psychotherapy may be of some use in treating bipolar disorder.
These drugs do not work in all patients, work sometimes in others, and
it is very difficult to determine in any particular case whether they
are effective at all since bipolar disorder is mostly transient or
episodic, and patients experience remissions and periods of virtually
normal functioning whether or not they receive treatment.
It is not clear how it would even be possible to determine that
medications prevent such episodes. Tens of millions of patients have
severe mood disorders and if any medication could prevent episodes, such
diseases as bipolar disorder would be rare indeed. There is some
evidence that they may be effective for some patients, some of the time
but the evidence for their efficacy is at best statistical and it is
virtually impossible to say that any particular patient was benefited
by any particular treatment. In discussing these medications one must
also take into account the fact that many patients experience severe
side effects. Until recently, one might reasonably question whether the
enormously harmful side effects and the tendency to abuse psychotropic
drugs outweighed any possible benefits (real or imagined). The
anti-psychotic drug Navane, became notorious after several people using
it committed violent homicides, attributing to the drug a share of
responsibility for destabilizing them.
Compliance with medications can be a major problem because some people
becoming manic lose insight, or an awareness of having an illness, and
discontinue medications; then they often suffer a manic episode and may
suddenly find themselves initiating multiple projects often being
scattered and ineffective, or may go on a spending spree or take a
poorly planned trip landing them in an unfamiliar location without cash.
The manic periods, euphoric as they may be, are often disastrous because
of the impulsiveness and irrationality that comes with them. Contrary to
the patient's wishes, the depression does not respond instantaneously to
resumed medication, typically taking 2-6 weeks to respond.
Whilst bipolar disorder can be one of the most severe and devastating
medical conditions, many individuals with bipolar disorder can also live
full and mostly happy lives with correct management of their condition.
Compared to patients with schizophrenia, persons with bipolar disorder
are more likely to have periods of normal functioning in the absence of
medication. Although schizophrenic patients may have remissions with
relatively high levels of functioning, schizophrenic patients tend to
suffer some impairment during these intervals, if they are not
medicated, in contrast to persons with bipolar disorder who often appear
completely normal when they are between mood swings.
Research into new treatments
Electroconvulsive therapy (ECT) was an accepted treatment in the past,
and is still used today when other treatments have failed. There is
current research work on transcranial magnetic stimulation as an
alternative to ECT. In late 2003, researchers at McLean Hospital in
Belmont, Massachusetts have found tentative evidence of improvements in
mood during EP-MRSI imaging, and attempts are being made to develop this
into a form which can be evaluated as a possible treatment.
Lithium Orotate is used as an alternative treatment to lithium carbonate
by some sufferers of Bipolar Disorder, mainly because it is available
without a doctor's prescription, and because it can be taken at lower
non-toxic dosages. It should be noted that there are few human studies
involving lithium orotate, and that self-treatment of bipolar disorder
entails risks.
It has been hypothesized that bipolar disorder may be the result of poor
membrane conduction in the brain and that one possible cause may be a
deficiency in omega-3 polyunsaturated fatty acids. Following an
encouraging small-scale study, several large scale trials of treatment
using omega-3 fatty acids are under way.
Treatments (from NIH public domain article and assorted publications)
A variety of medications are used to treat bipolar disorder. But even
with optimal medication treatment, many people with the illness have
some residual symptoms. Certain types of psychotherapy or psychosocial
interventions, in combination with medication, often can provide
additional benefit. These include cognitive-behavioral therapy,
interpersonal and social rhythm therapy, family therapy, and
psychoeducation.
Lithium has long been used as a first-line treatment for bipolar
disorder. Approved for the treatment of acute mania in 1970 by the U.S.
Food and Drug Administration (FDA), lithium has been an effective
mood-stabilizing medication for many people with bipolar disorder.
Lithium is also noted for reducing the risk of suicide in major
affective disorders, such as bipolar disorder: suicide risk on the whole
drops to below the average level for society (Baldessarini, 2003).
Anticonvulsant medications, particularly valproate and carbamazepine,
have been used as alternatives to lithium in many cases. Valproate was
FDA approved for the treatment of acute mania in 1995. Newer
anticonvulsant medications, including lamotrigine, gabapentin, and
topiramate, are being studied to determine their efficacy as mood
stabilizers in bipolar disorder. Some research suggests that different
combinations of lithium and anticonvulsants may be helpful.
According to studies conducted in Finland in patients with epilepsy,
valproate may increase testosterone levels in teenage girls and produce
polycystic ovary syndrome in women who began taking the medication
before age 20. Increased testosterone can lead to polycystic ovary
syndrome with irregular or absent menses, obesity, and abnormal growth
of hair. Therefore, young female patients taking valproate should be
monitored carefully by a physician.
During a depressive episode, people with bipolar disorder commonly
require additional treatment with antidepressant medication. Typically,
lithium or anticonvulsant mood stabilizers are prescribed along with an
antidepressant to protect against a switch into mania or rapid cycling.
The comparative efficacy of various antidepressants in bipolar disorder
is currently being studied.
In some cases, the newer, atypical antipsychotic drugs such as clozapine
or olanzapine may help relieve severe or refractory symptoms of bipolar
disorder and prevent recurrences of mania. More research is needed to
establish the safety and efficacy of atypical antipsychotics as
long-term treatments for this disorder.
Research findings
Bipolar disorder appears to run in families, that is, a vulnerablility
for bipolar disorder may be inherited. The rate of suicide is higher in
people who have bipolar disorder than in the general population. The
rate of prevalence of bipolar disorder is roughly equal (around 1%) in
men and women.
More than two-thirds of people with bipolar disorder have at least one
close relative with the disorder or with unipolar major depression,
indicating that the disease has a heritable component. Studies seeking
to identify the genetic basis of bipolar disorder indicate that
susceptibility stems from multiple genes. Scientists are continuing
their search for these genes using advanced genetic analytic methods and
large samples of families affected by the illness. The researchers are
hopeful that identification of susceptibility genes for bipolar
disorder, and the brain proteins they code for, will make it possible to
develop better treatments and preventive interventions targeted at the
underlying illness process.
Researchers are using advanced medical imaging techniques to examine
brain function and structure in people with bipolar disorder. An
important area of imaging research focuses on identifying and
characterizing networks of interconnected nerve cells in the brain,
interactions among which form the basis for normal and abnormal
behaviors. Researchers hypothesize that abnormalities in the structure
and/or function of certain brain circuits could underlie bipolar and
other mood disorders. Better understanding of the neural circuits
involved in regulating mood states may influence the development of new
and better treatments, and may ultimately aid in diagnosis.
New clinical trials
NIMH has initiated a large-scale study at 20 sites across the U.S. to
determine the most effective treatment strategies for people with
bipolar disorder. This study, the Systematic Treatment Enhancement
Program for Bipolar Disorder (STEP-BD), will follow patients and
document their treatment outcome for 5 to 8 years. For more information,
visit the Clinical Trials page of the NIMH Web site.
There are reports that Omega-3 fatty acids may be beneficial in the
treatment of bipolar disorder. A significant study was conducted by Dr
Andrew L Stoll at Harvard University's McLean Hospital. The Stanley
Foundation is sponsoring research regarding the beneficial claims.
Recent genetic research
Bipolar Disorder is considered to be primarily a genetically caused
disorder. The monozygotic concordance rate for the disorder is 70%. This
means that if a person has the disorder, an identical twin has a 70%
likelihood of having the disorder as well. Relatives of persons with
Bipolar Disorder also have an increased incidence of having unipolar
depression.
In 2003, a group of American and Canadian researchers published a paper
that used gene linkage techniques to identify a mutation in the GRK3
gene as a possible cause of up to 10% of cases of bipolar disorder. This
gene is associated with a kinase enzyme called G protein receptor kinase
3, which appears to be involved in dopamine metabolism, and may provide
a possible target for new drugs for bipolar disorder.
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