FREE ESSAY ON BIPOLAR DISORDER

BIPOLAR 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 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, psychomotor 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 (Leiby,1988). 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 (Gurman, 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 (Turner,1989). 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 variety 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% (Turner,1998). 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 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
(Gurman,1991). Pregnant women experience another problem associated with the use of
lithium. 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 (Leiby,1988). 
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 (Leiby,1988). 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 (Turner,1998).
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 (Hollandsworth, Jr.
1990). 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 (Gurman,1991).
A final type of therapy 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. 
References
Gurman, A.Ph.D. (1991) Questions and answers in the practice of family therapy. New York:
Brunner/Mazel.
Hirschfeld, R.M. (1995) Psychiatric Diagnosis (S.Hutchinson, Ed.) (Vol. IV) Oxford
University Press.
Hollandsworth, J. G. (1990). Recent development in clinical aspects of bipolar disorders.
National Alliance for the mentally ill: Vol. II (p.4-87) 
Leiby,J. (1988) A history of social welfare and social work in the U.S..New York:
Columbia University Press.
Turner, F (1989) Social work treatment. New York: The Free Press