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BIPOLAR DISORDER

by Beverly Chastain







Langston University
Nov 11, 1996 

Running Head:BIPOLAR DISORDER
Table of Contents
Chapter                                                                                                                      Page
               Cover Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1
	   Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 
	1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3                               
		Affective Disorders . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
		Demographics . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
		Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4
		Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4
		Prevalence and Age of Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5
		Mixed Episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5
	2.  Medical Treatments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7
		Lithium  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7
		Anti-convulsants  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8
		Neuroliptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8
		Anti-deppressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
	3.  Non-Medical Treatments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
		Light Therapy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10
		Shock Therapy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
		Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
                 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12 
Chapter One
The phenomenon of Bipolar Affective Disorder has been a mystery since the 16th and 17th century.  The Dutch painter Vincent Van Gogh was thought to of suffered from bipolar disorder.  It appears that there are an abundance of people with the disorder yet, no true causes or cures for the disorder.  Clearly the Bipolar disorder severely undermines their ability to obtain and sustain social and occupational success.  However, the journey for the causes and cures for the Bipolar disorder must continue.
Affective Disorders
Affective disorders are primarily characterized by depressed mood, elevated mood or (mania), or alternations of depressed and elevated moods.  The classical term is manic-depressive illness, a newer term is Bipolar disorder.  The two are interchangeable.  Milder forms of a depressive syndrome are called dysthymic disorder, mild forms of mania are hypomania and the milder expressions of Bipolar disorder are called cyclothymic disorders.
The use of the term primary affective disorder refers to the individuals who had no previous psychiatric disorders or else only episodes of mania or depression.  Secondary affective disorder refers to patients with preexisting psychiatric illness other than depression or mania (Goodwin, Guze. 1989, p.7 ).





Demographics
	Bipolar affective disorder affects approximately one percent or three million persons in the United States, afflicting both males and females.  Bipolar disorder involves episodes of mania and depression.  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 ). 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.
Symptoms
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 in a psychotic state are misdiagnosed as schizophrenic.  Speech patterns help distinguish between the two disorders (Lish, 1994).
  
	Prevalnce 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 begins with hypomania, which patients report that they are energetic, extroverted and assertive.  The hypomania state has let observers to feel that bipolar patients are "addicted" to their mania.  Hypomania progresses into mania as 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.
	
Mixed Episode
	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.














Chapter Two

Lithium
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.
	















Chapter Three

Light Therapy
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.
Shock Therapy
	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).  
Psychotherapy
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 medication management, 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).  Effects of Phototherapy on nonseasonal unipolar and bipolar depressive spectrum disorders.  Journal of Affective Disorders. 23: 231-237.
	Fawcett, Jan. (1994).  Bipolar depression highlights of the first international conference on bipolar disorder.  University of Pittsburgh, Pennsylvania.
	Forster, P.L.  Videoconference program synopsis.  Annenburg Center for Health Services at Eisenhower Rancho Mirage, C.A. (http://www.wpic.pitt.edu/research/stanley/othnws/vidtel12.htm).
	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 (1): 27-38.
	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: pp.281-294.
	Weisman, M.M., Livingston, B.M., Leaf, P.J., Florio, L.P., Holzer, C. (1991).  Psychiatric Disorders in America.  Affective Disorders. Free Press.
	University of Pittsburgh, Pennsylvania.  (1994).  Bipolar  depression highlights of 	the first international conference on bipolar disorder.  (http://www.wpic.pitt.edu/research/bipolar2.htm).   


















 
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