BIPOLAR DISORDER

DEFINITION

Bipolar disorder is a mental condition that usually involves extreme mood swings. A person with the condition may feel happy and excited at one moment and depressed the next. The disorder was once called manic-depression. Mania is a mental disorder characterized by great excitement and sometimes uncontrolled, violent behavior. Depression (see depressive disorders entry) is characterized by persistent and long-term sadness or despair.

DESCRIPTION

Bipolar disorder affects about two million Americans. The average age at which the disorder first appears is between adolescence and the midtwenties. Sometimes a correct diagnosis of the disorder is not made for years. It is complex and difficult to identify. In one study of bipolar disorder patients, half said that they saw three or more doctors before receiving a correct diagnosis. Over one third waited more than ten years before their condition was recognized.

Psychiatrists list four types of bipolar disorder. The four types differ largely on three factors. One factor is whether mania (the highs) or depression (the lows) is more common in the patient. The second factor is how serious each condition is. The third factor is how fast the patient alternates between stages.

Patients with bipolar I disorder, for example, have extreme high periods with relatively moderate periods of depression. By contrast, those with bipolar II disorder are more likely to have severe depression, separated by relatively modest periods of mania.

A third type of bipolar disorder is called cyclothymia (pronounced siekluh-THIE-mee-uh). Patients with this condition have relatively moderate periods of both mania and depression. They may almost appear to be without either symptom for long periods of time. The fourth type of bipolar disorder is called rapid cycling. In this condition, a patient changes from periods of great energy to periods of depression fairly often, usually at least four times in a single year.

CAUSES

The cause of bipolar disorder has not yet been discovered. Many researchers believe that heredity is an important factor. Two-thirds of bipolar patients have a family history of mental disorders. Some research studies claim to have found a genetic link for bipolar disorder. Genes are the chemical units present in all cells that tell cells what functions to perform. Genes are passed down from parents to children.

Some researchers also believe that abnormal levels of certain chemicals in the body can cause bipolar disorder. For example, some studies have shown that people with bipolar disorder have abnormal levels of dopamine in their brains. Dopamine is a neurotransmitter, a chemical that carries messages in the brain.

Drug abuse may be associated with bipolar disorder also. Up to 30 percent of those who abuse cocaine also have bipolar disorder. Researchers are not sure about this connection, however. It may be that bipolar disorder leads to drug abuse, or that drug abuse leads to bipolar disorder. Or it may be that both conditions are caused by some abnormal condition in a person's body.

Bipolar disorder has also been shown to be associated with the seasons. Some patients experience mania during the summer months and depression during the winter months.

SYMPTOMS

The symptoms of bipolar disorder vary depending on the part of the cycle a patient is experiencing. During a low period, the patient has low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and slower mental and physical functions.

The manic, or high, part of a cycle is characterized by feelings of happiness and well-being, lack of restraint, talkativeness, racing thoughts, reduced need for sleep, and irritability. In extreme cases, mania can be expressed in the form of hallucinations and other mental fantasies.

DIAGNOSIS

Bipolar disorder is usually diagnosed by a psychiatrist, a doctor who specializes in mental conditions. One set of tools that is often used is a series of tests of a person's mental condition. Some examples of these tests include the Millon Clinical Multiaxial Inventory III (MCMI-III), the Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), and the Self-Report Manic Inventory (SRMI). These tests may be either verbal or written and are conducted in a hospital or a doctor's office.

Psychiatrists rely on a book called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), in diagnosing bipolar disorder. DSM-IV is the standard reference manual for all kinds of mental disorders. It describes the conditions for which a psychiatrist should look in diagnosing a condition. The guidelines set down in DSM-IV are very clear and specific for each condition.

For example, DSM-IV defines mania as a period of abnormally intense excitement that lasts for a period of at least one week. The patient must also demonstrate at least three specific symptoms from the following list:

• Inflated self-esteem
• Decreased need for sleep
• Talkativeness
• Racing thoughts
• Becoming distracted easily
• Increase in desire to get specific jobs done
• Unusual interest in activities that can lead to painful results

The symptoms of bipolar disorder are often different in children and adolescents. For example, their symptoms may be considerably more severe than in adults. A psychiatrist may diagnose schizophrenia (pronounced skit-suh-FREE-nee-uh, see schizophrenia entry), a severe and disabling mental disorder, rather than bipolar disorder. The symptoms of bipolar disorder in those under the age of twenty lead to many incorrect diagnoses, including attention-deficit/hyperactivity (ADHD; see attention-deficit/hyperactivity disorder entry) or conduct disorder.

Other conditions can also produce symptoms similar to those of bipolar disorder. Drug abuse is one such condition. A drug abuser cannot be examined for possible bipolar disorder until he or she has stopped using drugs. Disorders of the thyroid gland and the use of prescribed and over-the-counter medication can also produce bipolar-like symptoms.

TREATMENT

Bipolar disorder is usually treated with some form of medication. Some drugs help to elevate a person's moods during the low part of a bipolar cycle. Others help to calm the person down during the high part of a cycle. Some examples of commonly used drugs include:

• Lithium. The common name for a group of chemicals that contain the chemical element lithium. These chemicals are among the oldest and most frequently prescribed of all drugs for the treatment of bipolar disorder. While they do not work equally well for all forms of the disorder, they can be very effective for many patients when taken according to the schedule prescribed by a doctor. Some side effects of lithium drugs include weight gain, thirst, nausea, and hand tremors (shaking). Long-term use sometimes leads to hyperthyroidism. Hyperthyroidism is a condition caused by an overactive thyroid gland. It can result in a variety of symptoms, both mild and serious.

While counseling cannot cure bipolar disorder, patients can sometimes better understand the nature of their condition and learn to adjust to it. (© 1995

Peter Berndt

, M.D., P.A. Reproduced by permission of

Custom Medical Stock Photo

.)

• Carbamazepine. Carbamazepine (pronounced KAHR-buh-MAZ-uh-peen) is an anticonvulsant drug used to prevent convulsions (spasms). It is often prescribed to patients for whom lithium treatment is ineffective. Blurred vision and other eye problems are possible side effects of carbamazepine use.
• Valproate. Used primarily for the treatment of patients with rapid cycling bipolar disorder. These patients often do not respond to treatment with lithium. Side effects of valproate use include stomach cramps, indigestion, diarrhea, hair loss, appetite loss, nausea, and unusual weight loss or gain.
• Antidepressants. Sometimes used to treat bipolar disorder on a short-term basis. An antidepressant is a drug that tends to overcome a person's depression and lift his or her spirits. Antidepressants are not used on a long-term basis because they may intensify the manic period in a person's bipolar cycle. That is, the person may not be depressed, but he or she may become more manic. Some examples of antidepressants used to treat bipolar disorder are the drugs known as selective serotonin (pronounced sihr-uh-TOE-nun) reuptake inhibitors (SSRIs), monoamine (pronounced mon-oh-AM-een) oxidase inhibitors (MAO inhibitors), and tricyclic antidepressants.

Electroconvulsive Shock Therapy

Bipolar disorder is sometimes treated with electroconvulsive shock therapy, or ECT. ECT is a procedure in which intense electrical shocks are administered through electrodes attached to the patient's head. The patient is first given anaesthesia (pronounced an-is-THEE-zhuh) and a muscle relaxant. The muscle relaxant prevents the patient from going into convulsions that would cause broken bones and strained muscles.

No one knows how electric shocks affects the patient's brain. In some cases, however, the treatment is able to relieve the conditions of bipolar disorder. The side effects of ECT include headaches, muscle soreness, nausea, confusion, and memory loss.

Some doctors are reluctant to use ECT unless all other treatments fail. The procedure has many critics who regard it as inhumane. Most cases of bipolar disorder now respond to some form of drug treatment, making ECT unnecessary.

Other Drugs

A variety of drugs are available for treating other aspects of bipolar disorder. For example, some patients have very severe episodes of mania or depression. They may need to have drugs to get them through the worst parts of these episodes. One group of drugs, known as benzodiazepines (pronounced ben-zo-die-A-zuh-peenz), can be used to calm a patient who is having a severe attack of mania. The drug known as clozapine (pronounced KLO-zuh-peen) can also be used to help prevent manic episodes and to treat patients who do not respond to other drugs designed to stabilize their moods.

Counseling

Counseling can also be of some help with bipolar disorder. While it cannot cure the disorder because mania and depression are caused by biological factors, patients can sometimes better understand the nature of their condition and learn to adjust to it. Perhaps most important, counseling can help patients and their families to understand the need for a person to stay on a strict schedule of drug therapy.

Alternative Treatment

Bipolar patients can often benefit from some simple suggestions, such as maintaining a calm environment, avoiding over-simulation, getting plenty of rest and regular exercise, and eating a proper diet. Some practitioners believe that Chinese herbs can soften mood swings. Biofeedback can sometimes help patients control their symptoms, such as irritability, poor self-control, racing thoughts, and sleep problems. During biofeedback a patient watches the brain waves produced when he or she is behaving a certain way. The patient than learns to adjust that behavior to produce correct brain waves. A diet high in vitamin C is thought by some to help reduce depression.

PROGNOSIS

Most patients benefit to some extent from treatment, however responses vary widely from complete recovery to no improvement at all with any form of treatment. One of the most difficult problems is to find the right drug, the right combination of drugs, and the right dosage for any one patient. Bipolar disorder is a chronic condition. That is, most patients experience the condition throughout their lives and require lifelong treatment and observation.

Suicide is common among people with severe bipolar disorder who do not receive prompt or adequate treatment. The suicide rate is 15 to 25 percent among these individuals. With proper and early diagnosis and treatment, however, it is possible for bipolar patients to live normal lives.

PREVENTION

There is currently no known way to prevent bipolar disorder, but the chances of stabilizing the condition improves considerably with proper treatment. Educating the patient about the disorder is also important. He or she can learn to recognize the signs of mania and depression and be taught how to respond to those signs.

FOR MORE INFORMATION

Books

Mondimore, Francks Mark. Bipolar Disorder: A Guide for Parents and Families. Baltimore: Johns Hopkins Press, 1999.

Whybrow, Peter C. A Mood Apart. New York: Harper Collins, 1997.

Organizations

American Psychiatric Association. Office of Public Affairs. 1400 K Street NW, Washington, DC 20005. (202) 682–6119. http://www.psych.org.

National Alliance for the Mentally Ill. 200 North Glebe Road, Suite 1015, Arlington, VA 22203–3754. (800) 950–6264. http://www.nami.org.

National Depressive and Manic-Depressive Association. 730 North Franklin Street, Suite 501, Chicago, IL 60610. (800) 826–3632. http://www.ndmda.org.

National Institute of Mental Health. 5600 Fishers Lane, Room 7C–02, Bethesda, MD 20857. (301) 443–4513. http://www.nimh.nih.gov.

Web sites

"Ask NOAH About: Bipolar Disorders." NOAH: New York Online Access to Health [Online]. http://www.noah.cuny.edu/mentalhealth/mental.html#BipolarDisorder (accessed on October 7, 1999).

Bowden, Charles L. "Choosing the Appropriate Therapy for Bipolar Disorder." Medscape Mental Health. [Online] http://www.medscape.com (accessed on October 7, 1999).

Bowden, Charles L. "Update on Bipolar Disorder: Epidemiology, Etiology, Diagnosis, and Prognosis." [Online] Medscape Mental Health, http://www.medscape.com (accessed on October 7, 1999).