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Essay/Term paper: Bipolar affective disorder

Essay, term paper, research paper:  Social Issues

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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 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, psycomoter
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 (Goodwin, Guze, 1989, p 11). 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 (Weisman, 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 (Lish, 1994).
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 mixture 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% (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
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 (Bauer et al., 1990). Another
problem associated with the use of lithium is experienced 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).
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 (1992). 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 (Hopkins and Gelenberg,
1994). 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 (Baur, Kurtz, Rubin, and Markus, 1994). 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 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.


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.
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.


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