Bipolar Disorder

Introduction

What would you think if your best friend started acting a little funny? Let's say it started with unusual shopping sprees. She bought everything in sight whether or not it was needed; 5 pairs of pajamas in the same color, 10 pair of jeans, and 20 pairs of shoes. Then, on the way home from the store, she starts driving a little erratically and ends up wrecking and hitting a tree. She bumps her head on the steering wheel and is bleeding. You suggest calling an ambulance. Your friend cannot sit still and wants to drive off and leave the scene of the accident and even mentions going to get something to eat as the bump on her head turns colors and gets bigger. Would you chalk it up to a bad day or is it something more? As the weeks go by you notice these episodes of complete restlessness, hyperactivity, and erratic behavior continue. Then she seems to have disappeared, you cannot reach her and she isn't trying to contact you. When you finally go and check on her, she has locked herself inside her house and hasn't left, let alone showered or combed her hair in days. You even begin to wonder if your friend is experimenting with drugs or alcohol due to the strangeness of her behavior. What else could be causing her to act so strangely? Your friend could be suffering from a psychiatric disorder known as bipolar disorder.

What is it?

Bipolar disorder (also known as manic depression) is a psychiatric disorder that involves cycling between depressive and manic episodes as described in the introduction of this health condition.

A major depressive episode lasts greater than two weeks and is associated with a depressed mood or a loss of pleasure or interest in ordinary activities. Patients experiencing a major depressive episode must also have five or more of the symptoms listed in the section: "What are the Symptoms?"

A manic episode involves a persistent and abnormally elevated mood lasting for at least one week. It also involves the patient having at least three of the symptoms listed in the section: "What are the Symptoms?"

A hypomanic episode lasts at least four days. Symptoms are similar for manic and hypomanic episodes: the difference being that hypomanic symptoms are milder than manic symptoms, and some people may even feel more productive during this time and deny anything is wrong. However without treatment, hypomania can develop into severe mania, so family members and caregivers need to be aware and help the person seek treatment.

Individuals can also experience a mixed episode. A mixed episode lasts for at least one week and consists of symptoms of both manic and depressive episodes.

There are two major classes of bipolar disorder: bipolar I and bipolar II. Bipolar I disorder is characterized by at least one manic episode with or without previous episodes of depression. Bipolar II disorder is characterized by one or more major depressive episodes accompanied by one or more hypomanic episodes.

The duration and intensity of mood states varies widely among people with bipolar disorder. Fluctuating from one mood state to the next is called "cycling". Mood swings can cause impaired or improved functioning. There can be changes in one's energy level, sleep pattern, activity level, social rhythms and mental performance. Left untreated, bipolar disorder can be a disabling and life-threatening condition.

During these times, some people may have marked impairment in judgment which may require hospitalization to prevent harm to themselves or others, especially if they have symptoms of psychosis.

Symptoms of psychosis include:

  • Hallucinations (seeing, hearing, feeling or smelling things that are not actually there)
  • Having paranoid beliefs or thoughts
  • Jumbled thought process
  • Difficulty writing or speaking
  • Delusions (a false belief, that even when faced with fact is not realized to be false)

The symptoms of psychosis often reflect the mood that the individual is in. For example, a feeling of being invincible and having special powers and therefore engaging in dangerous behavior may be associated with a manic episode. On the other hand, a feeling of worthlessness and deserving to suffer may be associated with a depressive episode. Sometimes, when individuals with bipolar disorder have symptoms of psychosis, they are misdiagnosed as having another mental illness, schizophrenia.

What causes it?

The causes of bipolar disorder are not fully known.

Genes:

  • Results from studies looking at twins and children that were adopted are consistent with the theory that bipolar disorder has a genetic component. For instance, those persons with a 1st degree relative (e.g. a parent or sibling) with bipolar disorder have a 15 to 35% greater risk of developing bipolar disorder.

Biochemical:

  • There are also theories that biological factors, particularly changing levels of neurotransmitters are possible causes of bipolar disorder. One such theory is the monoamine theory which states that depressive episodes are caused by deficiencies in norepinephrine, serotonin, and dopamine. In addition, the theory states that manic episodes are caused by increasing levels of norepinephrine and dopamine. Two other neurotransmitters that may also play a part in bipolar disorder are GABA and glutamate.

  • There can also be problems with regulation of hormones, which may induce episodes of bipolar disorder. For instance, individuals with an overactive thyroid gland may be more prone to manic episodes, while those with an underperforming thyroid gland may be more susceptible to depressive episodes.

Environmental:

  • Another possible cause of bipolar disorder is the kindling phenomenon. Kindling occurs when a psychosocial stressor precedes the 1st episode of bipolar disorder. A psychosocial stressor could be as varied as working in a stressful workplace or driving in a heavy traffic jam. Future episodes occur spontaneously due to an increased sensitivity in the central nervous system, CNS, caused by the initial stressor.

  • Substance abuse and sleep deprivation can also bring about manic episodes.

Who has it?

According to the National Institute of Mental Health, approximately 2.6%, or 5.7 million adults in America are afflicted with some type of bipolar disorder. The incidence of bipolar disorder increases during late adolescence into early adulthood. Both males and females are affected equally with Bipolar I disorder, however Bipolar II disorder does affect a larger number of women.

What are the risk factors?

There are a number of risk factors for the development of bipolar disorder including:

  • Family history of bipolar disorder
  • Extremely high levels of stress
  • Substance abuse
  • Patient non-compliance with antidepressant medications

What are the symptoms?

During manic and hypomanic episodes, symptoms include:

  • Extreme euphoria (happiness or joy)
  • Extreme irritability
  • Inability to sleep
  • Being easily distracted by sights and sounds
  • Engaging in unsafe sexual practices
  • Having difficulty concentrating due to having racing thoughts
  • Being extremely talkative
  • Inflated self-esteem
  • Excessive spending
  • Excessive makeup
  • Hallucinations

    During depressive episodes, symptoms include:

  • Feelings of guilt
  • Loss of interest in normal activities
  • Feeling very anxious
  • Feelings of worthlessness
  • Significant weight gain or weight loss
  • Fatigue or loss of energy nearly every day
  • Getting too little or too much sleep
  • Finding it difficult to concentrate
  • Agitation
  • Significant increase or decrease in appetite
  • Crying spells
  • Suicidal thoughts or attempts

    How is it treated?

    There are number of different options available for the treatment of bipolar disorders, consisting of drug and non-drug therapies. Many experts feel the best treatment is a combination of medications and psychosocial treatment and aim for similar goals to help guide in the treatment of individuals with bipolar disorder. Some of these goals include:

    • Eliminate manic and depressive episodes and symptoms associated with those.

    • Prevent relapses of manic and depressive episodes

    • Find a therapy that will treat the symptoms, but also have the fewest adverse effects and fewest drug interactions.

    • Treat substance abuse and use that may be present in addition to the disorder.

    • Avoid stressors or substances that may lead to a manic or depressive episode.

    Different classes of medications are used to treat bipolar disorder. Most of the medications used treat either mania or depression associated with bipolar disorder. There are a few drugs that have been shown to treat both types effectively.

    One group of medications commonly used for the treatment of bipolar disorder are mood stabilizers. This group includes drugs such as lithium, divalproex, carbamazepine, and lamotrigine. Lithium is one of the most widely used mood stabilizers to treat bipolar disorder and is often considered as first-line treatment for many individuals with mania. Lithium is also considered a miscellaneous antidepressant.

    Divalproex, carbamazepine and lamotrigine were originally used only as anti-convulsant medications for the treatment of seizures, but are now also used to help treat various components of bipolar disorder. For example, divalproex and carbamazepine are used to help treat the symptoms of mania, while lamotrigine is used to help treat the symptoms of depression. More research is being done on other anticonvulsant medications to see if they have value in the treatment of bipolar disorders.

    Newer anti-psychotics are the next group of medications that can be used to treat bipolar disorders. They include olanzapine, risperidone, quetiapine, aripiprazole, and ziprasidone. These medications are most effective for short-term treatment, especially for sudden manic episodes. Quetiapine (brand name: Seroquel), has been approved by the FDA for treatment of manic and depressive episodes.

    Individuals who have manic episodes, who may or may not be receiving treatment for bipolar disorder, may need to be given additional medications for faster relief of manic symptoms and to help with sleep. Benzodiazepines are commonly used for this purpose. Some examples include lorazepam, alprazolam, and clonazepam.

    Due to the possible teratogenic effects (causing developmental malformations in a fetus) of most of the medications used to treat bipolar disorder, finding treatment for women who are pregnant or breastfeeding may be difficult. Sometimes a class of drug called, calcium channel blockers are used. They have a lower teratogenic effect and have been shown to have some mood stabilizing properties.

    Electroconvulsive therapy, ECT, is another option that is available for bipolar disorder treatment. ECT is usually reserved when more severe symptoms are present that are not effectively treated with medication or psychotherapy. It can also be used in situations where the risks of drug therapy are greater than the benefits the patient would get (i.e. pregnancy).

    Psychotherapy (the treatment of mental and emotional disorders using a variety of psychological techniques) may also provide benefit in addition to medication therapy. Psychological techniques include enrolling in self-help and support groups, instruction on using coping skills, and education on how to recognize the early symptoms of manic or depressive episodes.

    Finally, bipolar disorder can often be better controlled with good, regular sleep habits, proper nutrition and regular exercise. Additionally, learning to spot stressors (the events or conditions that cause stress) in order to effectively manage them may be beneficial.

    Helping Yourself

    Individuals with bipolar disorder are not helpless when it comes to treating this disease. There are a few things that you can do to help aid in the treatment of this disorder.

    • Learn Your Triggers: Many times people with bipolar disorder notice that periods of mania or depression are usually preceded by certain events. Certain stressors, or "triggers" are often associated with the onset of manic and depressive episodes in patients. Keeping a journal can help to identify the triggers associated with these episodes.

    • Get Help: Most communities have self-help, support groups, and educational materials. It can be very reassuring to talk to others going through the same thing. Here are some examples of some organizations that can help:

    1. Depression and Bipolar Support Alliance: www.dbsalliance.org, 1-800-826-3632

    2. National Mental Health Association: www.nmha.org, 1-800-969- 6642

    3. National Institue of Mental Health: www.nimh.nih.gov, 1-866- 615-6464

    What is on the horizon?

    Researchers are currently trying to find the best drug therapy for the different types of bipolar disorder and the symptoms associated with bipolar disorder. Trials are underway to compare different types of conventional therapy to see if any one drug is superior.

    Some researchers are beginning to look at the effects of another drug class, anti-depressants in the treatment of bipolar disorder with major depression. Often anti-depressants are not considered for treatment in individuals with bipolar disorder because of the risk of increased episodes of mania. One trial is underway to compare the effectiveness of a certain type of anti-depressant, a Selective Serotonin Reuptake Inhibitor, or SSRI, with standard mood stabilizer therapy in individuals with major depressive episodes. The results of this trial could lead to more tailored therapy for individuals with this type of bipolar disorder.

    The STEP-BD is a large, federally-funded treatment study designed to find out which treatments, or combinations of treatments, are most effective for treating episodes of depression and mania and for preventing recurrent episodes in people with bipolar disorder. STEP-BD is a long-term outpatient study that enrolled more than 4,000 patients from 1998 to 2005. It is a broad research program that includes several different studies, each aimed at a different aspect of treatment for bipolar disorder. In addition to determining effectiveness of treatments, STEP-BD researchers will also evaluate the cost-effectiveness of treatments and how treatments affect a person's quality of life. DNA collected from patients in the study will be used by researchers to examine how genes may affect bipolar disorder. Many different findings will be published as researchers analyze the data obtained from this group of studies. Researchers are using the extensive data from STEP-BD to help determine the best treatments for individuals with various features of the disorder (for example, bipolar I vs. bipolar II, manic, depressive, or mixed episodes, or rapid cycling) and prevent recurrence.

    One preliminary evaluation of some of the results of this study looked at the effects of different types of psychosocial therapy in conjunction with medication therapy. These results suggest that intensive psychosocial therapy in conjunction with medication therapy yield better results in the stabilization of mood than less intensive therapy in conjunction with medication therapy.

    While many questions have been answered concerning the causes and treatment for bipolar disorder, there is still much more to discover about this disease and what the best treatment is.

    References

    1. Fankhauser MP, Freeman MP. Bipolar Disorder. In: Dipiro JT, et al. Pharmacotherapy: A Pathophysiologic Approach. 6th ed., 1257-1284.

    2. Borovicka MC, Love RC. Mood Disorders II: Bipolar Disorder. In: Koda-Kimble MA, et al. Applied Therapeutics: The Clinical Use of Drugs. 8th ed., 80-1 to 80-19.

    3. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

    4. National Institutes of Mental Health. Bipolar Disorder. National Institutes of Health. Updated January 2007; http://www.nimh.nih.gov/healthinformation/bipolarmenu.cfm. Accessed March 2007 and February 2008.

    5. Muller-Oerlinghausen B, et al. (2002). Bipolar disorder. Lancet, 359(9302): 241-247.

    6. Perugi G, et al. (July 2001). Adjunctive dopamine agonists in treatment-resistant bipolar II depression: an open case series. Pharmacopsychiatry. 34(4): 137-41.

    7. MDF The Bipolar Organisation. Accessed March 2007 and February 2008. http://www.mdf.org.uk/

    8. American Psychiatric Association: Bipolar Disorders. Accessed March 2007 and February 2008. http://www.healthyminds.org/multimedia/bipolardisorder.pdf

    9. Clinicaltrials.gov. Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Available at: http://www.clinicaltrials.gov/ct/show/NCT00012558?order=1. Accessed March 2007 and February 2008.

    10. Mayoclinc.com. Bipolar Disorder. Updated Jan 4 2008. http://www.mayoclinic.com/health/bipolar-disorder/DS00356#. Accessed February 2008.

    11. Clinicaltrials.gov. Comparing the Safety and Effectiveness of a Mood Stabilizing Medication, an Antidepressant Medication, and a Combination of Both Medications to Treat Symptoms of Bipolar Type II Depression. http://www.clinicaltrials.gov/show/NCT00276965. Accessed February 2008.

    Bipolar Disorder Health Condition Last Updated: February 2008

    Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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