Essay/Term paper: Bipolar affective disorder

Essay, term paper, research paper:  Social Issues

Bipolar Affective 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 the it, we are
still waiting for definate explanations for the causes and cure. The one fact
of which we are pianfully aware4 is that bipolar disorder severely undermines
its' victoms ability to obtain and maintain social and occupational success.
Because bipolar disorder has such debilitating symptoms, it is imperitive that
we remain vigilent 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 guilt and worthlessness, guilt,
difficulty thinking, indecision, and recurrent thoughts of death and suicide.
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 (approximatly 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. 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 states and psychotic states are misdiagnosed as schizophrenic.
Speech patterns help distinguish between the two disorders (Lish, 1994).

Prevalence 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 begin with hypomania, in which patients report
that they are energetic, extroverted and assertive. 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.
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.
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.
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.
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.
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).
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 medicationmanagement, 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
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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.
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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.
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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
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(http://www.wpic.pitt.edu/research/ bipolar2.htm).