Bipolar affective disorder has been a mystery since the 16th century. History has shown that this disorder 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 amount of people suffering from it, we are still waiting for explanations for the causes and cure. The one fact of which we are 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 important that we keep looking for explanations of its causes and for more ways to treat this disorder.
Bipolar has a large variety of symptoms, divided in two categories. One is the manic episodes, the other is depressive. The depressive episodes are characterized by intense feelings of sadness and despair that can turn into feelings of hopelessness and helplessness. Some of the symptoms of a depressive episode include disturbances in sleep and appetite, loss of energy, feelings of worthlessness, guilt, difficulty thinking, indecision, and reoccurring 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. These episodes may alternate with profound depressions characterized by a deep sadness, almost inability to move, hopelessness, and disturbances in appetite, sleep, problems with concentrations and driving.
Bipolar affective disorder affects approximately one percent of the population (approximately three million people) in the United States. It occurs in both males and females. Bipolar disorder is diagnosed if an episode of mania occurs whether depression has been diagnosed or not. Most commonly, individuals with manic episodes do experience a period of depression. Symptoms include elated, excited, or irritable mood, hyperactivity, pressure of speech, flight of ideas, inflated self-esteem, decreased need for sleep, distractibility, and excessive involvement in reckless activities.
As the National Depressive and Manic Depressive Association (MDMDA) has found out in their research, bipolar disorder can create marital and family disruptions, occupational setbacks, and financial disasters.
Many times, bipolar patients report that the depressions are longer and increase in frequency as the person ages. Many times's bipolar states and psychotic states are misdiagnosed as schizophrenia.
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 follow each other without a period of remission.
The three stages of mania begin with hypomania, in which patients report that they are energetic, extroverted and assertive. Hypomania progresses into mania and the transition is marked by extreme loss of judgment. Often, euphoric grandiose characteristics are displayed, and paranoid or irritable characteristics begin. The third stage of mania is evident when the patient experiences paranoid delusions. Speech is generally rapid and hyperactive behavior sometimes turns into violence.
Sometimes both manic and depressive symptoms occur at the same time. This is called a mixed episode. Those affected are at special risk because there is a combination of hopelessness, agitation, and anxiety that make them feel like they "could jump out of their skin". Up to 50% of all patients with mania have a mixture of depressed moods. Patients report feeling dysphoric, depressed, and unhappy; yet, they have the energy associated with mania. Rapid cycling mania is another form of bipolar disorder. Mania may be present with four or more episodes within a 12 month period. This form of the disease has more episodes of mania and depression than bipolar disorder, although this is believed to be a branch of actual bipolar disorder.
Lithium has been the primary treatment of bipolar disorder since its introduction in the 1960's. Its 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, as many as 40% of bipolar patients are either unresponsive to lithium or can not handle 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. Evidence also suggests that hypothyroidism may actually lead to rapid-cycling. Pregnant women experience another problem associated with the use of lithium. Its use during pregnancy has been associated with birth defects.
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 best treatment to be Anticonvulsant drugs such as valproate and carbamazepine. These drugs are useful as antimanic drugs, 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 do not wish to take lithium, experience rapid cycling, or abuse drugs or alcohol.
Neuroleptics such as Haldol or Thorazine have also been used to help stabilize manic patients who are highly agitated or psychotic. Use of these drugs is often necessary because the responses 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.
Some doctors as treatment for bipolar disorder have also used antidepressants such as the selective serotonin reuptake inhibitors (SSRI's) Luvox and Elavil. There are studies that say these help, but these are controversial however, because conflicting research shows that SSRI's and other antidepressants can actually cause manic episodes. Most doctors can see the usefulness of antidepressants when used 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 electro-convulsive shock therapy. ECT is the preferred treatment for severely manic patients and patients who are homicidal, psychotic, catatonic, or severely suicidal. In one study, researchers found 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.
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 medication compliance, insight regarding the illness, and awareness of 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 difficulties that arise during the course of the disorder.
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