The phenomenon of Bipolar Affective Disorder has been a mystery since the 16th
and 17th century. The Dutch painter Vincent Van Gogh was thought to of suffered from
bipolar disorder. It appears that there are an abundance of people with the disorder yet,
no true causes or cures for the disorder. Clearly the Bipolar disorder severely undermines
their ability to obtain and sustain social and occupational success. However, the journey
for the causes and cures for the Bipolar disorder must continue.
Affective disorders are primarily characterized by depressed mood, elevated
mood or (mania), or alternations of depressed and elevated moods. The classical term is
manic-depressive illness, a newer term is Bipolar disorder. The two are interchangeable.
Milder forms of a depressive syndrome are called dysthymic disorder, mild forms of
mania are hypomania and the milder expressions of Bipolar disorder are called
cyclothymic disorders. The use of the term primary affective disorder refers to the
individuals who had no previous psychiatric disorders or else only episodes of mania or
depression. Secondary affective disorder refers to patients with preexisting psychiatric
illness other than depression or mania (Goodwin, Guze. 1989, p.7 ).
Bipolar affective disorder affects approximately one percent or three million
persons in the United States, afflicting both males and females. Bipolar disorder involves
episodes of mania and depression. 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 ). 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
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. Mood is either elated, expansive,
or irritable, hyperactivity, pressure of speech, flight of ideas, inflated self esteem,
decreased need for sleep, distractibility, and excessive involvement in activities with high
potential for painful consequences. 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 in a psychotic state are
misdiagnosed as schizophrenic. 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 begins with hypomania, which patients report that they
are energetic, extroverted and assertive. The hypomania state has let observers to feel
that bipolar patients are "addicted" to their mania. Hypomania progresses into mania as
the transition is marked by loss of judgment. Often, euphoric grandiose characters are
recognized as well as a paranoid or irritable character begins to manifest. The third stage
of mania is evident when the patient experiences delusions with often paranoid themes.
Speech is generally rapid and behavior manifests with hyperactivity and sometimes
When both manic and depressive symptoms occur at the same time it is called a
mixed episode. These people are a special risk because of the combination of
hopelessness, agitation and anxiety make 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 very dysphoric, depressed and unhappy yet
exhibit the energy associated with mania. Rapid cycling mania is yet 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 experiences 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, there are up to 40% of bipolar patients who are
either unresponsive to lithium or who 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 dysphoric mania,
mixed states, or rapid cycling bipolar disorder (those patients who experience at least
four distinct episodes within one month period).
Among the problems associated with lithium includes 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). Another problem associated with the use of
lithium is its use by pregnant women. 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
(Jacobson et al., 1992).
There are other effective treatments for bipolar disorder that are used in cases
where the patients cannot tolerate lithium or can become unresponsive to it in the past.
The American Psychiatric Association's guidelines suggest the next line of to be
anticonvulsant 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 (SSRIs)
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. This study is
controversial, however, because conflicting research shows that SSRIs 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 depresses patients. Patients are 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
(Hopkins and Gelenberg, 1994). Another study involved a four week treatment of
morning bright light treatment of patients with seasonal affective disorder, including
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. 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
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 (Black et al., 1987).
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 have called attention to the value of support groups, challenging mental
health professionals to take a more serious look at group therapy for the bipolar
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, the need for education and support for the interpersonal
difficulties that arise during the course of the disorder
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