Essay/Term paper: Bipolar affective disorder

Essay, term paper, research paper:  Science Reports

Bipolar Affective Disorder


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 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 ).

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.

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).

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).

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.

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).

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.

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
(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 medication management, the need for
education and support for the interpersonal difficulties that arise during the
course of the disorder



References


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