Bipolar

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.

A smorgasbord of symptoms that can be broken into manic and depressive episodes characterizes affective disorders. 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. Both males and females present it. 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 (Goodwin, Guze, 1989, p 11). 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). The 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 states and psychotic states are misdiagnosed as schizophrenia. 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 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. A 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 mixture of depressed moods. Patients report feeling dysphonic, 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% (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 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 dysphonic 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 (Bauer et al., 1990). Pregnant women experience another problem associated with the use of lithium. Its use during pregnancy has been associated with birth defects, particularly Epstein's anomaly. Based on current data, the risk of a child with Epstein'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 have been unresponsive to it in the past. The American Psychiatric Association's