Bipolar Disorder General Description Diagnostic Criteria

Manic depression, with its two principal sub-types, bipolar disorder and major depression, was first clinically described near the end of the 19th century by psychiatrist Emil Kraepelin, who published his account of the disease in his Textbook of Psychiatry. As described below, there are several forms of bipolar disorder.

It should be noted that this disorder does not consist of mere "ups and downs". Ups and downs are experienced by virtually everyone and do not constitute a disorder. The mood swings of bipolar disorder are far more extreme than those experienced by most people. See cyclothymia for a milder version of this disorder.

Note: Bipolar disorder is also commonly called "manic depression" by laymen (and by some psychiatrists in the twentieth century), although this usage is now unpopular with psychiatrists, who have standardised on Kraepelin's usage of the term manic depression to describe the whole bipolar spectrum that includes both bipolar disorder and unipolar depression; they now use bipolar disorder to describe the bipolar form of manic depression.

1 General description

Bipolar disorder is a condition that causes extreme shifts in mood, energy, and functioning. In most populations it affects around 1 percent of the population. Men and women are equally likely to develop this often-disabling illness. The disorder typically emerges in adolescence or early adulthood, but in some cases appears in childhood. Cycles, or episodes, of depression, mania, or "mixed" manic and depressive symptoms typically recur and may become more frequent, often disrupting work, school, family, and social life.

There is a tendency to romanticize bipolar disorder, especially in artistic circles. Many artists, musicians, and writers have experienced its mood swings, and some credit the condition with their creativity. However, many lives are ruined by this disease, and it is associated with a greatly increased risk of suicide.

Especially early in the course of illness, the episodes may be separated by periods of wellness during which a person suffers few to no symptoms. When 4 or more episodes of illness occur within a 12-month period, the person is said to have bipolar disorder with rapid cycling. Bipolar disorder is often complicated by co-occurring alcohol or substance abuse.

Severe depression or mania may be accompanied by symptoms of psychosis. These symptoms include: hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time. Mania is associated with unwarranted optimism, and depression with unwarranted pessimismPessimism generally, describes a belief that things are bad, and tend to become worse; or that looks to the eventual triumph of evil over good; it contrasts with optimism, the contrary belief in the goodness and betterment of things generally. Philosophic.

2 Diagnostic criteria

Bipolar disorder takes two principal forms, neither of which requires plural "cycles". According to the DSM-IV-TR (p. 345), these two principal forms of Bipolar disorder are:

Bipolar I disorder, the diagnosis of which requires over the entire course of the patient's life at least one manic (or mixed state) episode which is usually (though not always) accompanied by episodes of Major Depressive disorder.
Bipolar II disorder, which over the course of the patient's life must involve at least one Major Depressive episode and must be accompanied by at least one hypomanic episode; i.e. there need be no full manic episodes at all.

Therefore Bipolar disorder need not have both severe mania and depression and in certain cases has only episodes of the one type. There need be no "cycles" of mania and depression.

This is the reason why certain contemporary psychiatrists shy away from the original name, Manic Depression, i.e. because the latter name might suggest that all patients have both mania and depression. It has nothing to do with the notion of equal distribution of cycles of mania and depression, since there need not be any cycles at all--in fact, even when there is one (or more) bout of both mania and depression over the course of a patient's life, the two episodes may be so unrelated to each other temporally and otherwise that this need not constitute a cycle. However, a significant portion of bipolar patients experience the classical alternating episodes (cycles) of mania and depression and therefore it is overstating the case to say that the classical alternation "rarely" occurs.

The DSM-IV treats these bipolar disorders as variants of mood or affective disorders. Others types include Major Depressive Disorder and Dysthymic DisorderDysthymia or dysthymic disorder is a form of the mood disorder of depression characterised by a lack of enjoyment/pleasure in life that continues for at least six months. It differs from clinical depression in the severity of the symptoms. While dysthymia. Bipolar and other mood disorders may have no identifiable medical, traumatic or other external cause (endogenous) or may be due to e.g. a medical condition (exogenous).

In order for a person to be properly diagnosed with bipolar, the mood episodes cannot be due to external medication, drugs or treatment for depression.

3 Cycles in bipolar disorder

Kraepelin included in his description of Manic Depression the phenomenon that episodes of acute illness, whether mania or depression, are usually punctuated by relatively symptom-free intervals during which the patient is able to function normally both at work and in social affairs.

The cycles of bipolar disorder may be long or short, and the ups and downs may be of different magnitudes: for instance, a person suffering from bipolar disorder may suffer a protracted mild depression followed by a shorter and intense mania. The manic periods typically include euphoria, tirelessness, and impulsiveness; the depressed periods may seem much worse following a manic period.

The name bipolar disorder is used to distinguish the condition from unipolar depression, and bipolar disorder is in turn divided into two forms, "Bipolar I" and the "Bipolar II" form, considered by some as a 'milder' version of the disorder. However, other doctors believe there is no sound basis for the blanket statement that Bipolar II is "milder" than Bipolar I.

4 Environmental factors affecting mood in bipolar disorder

In mid-2003, a twin study was published concerning environmental factors and bipolar disorder. The bipolar twin was found to be far more affected by changes in sunlight. Longer nights resulted in mood and sleep-length changes far greater than the healthy twin. Sunny days also did more to improve mood. In fact, natural light in general was found to have a profound positive effect upon the well-being of the bipolar twin (Hakkarainen, 2003).

Paradoxically, in the 2004 publication of a study using Tel Aviv's public psychiatric hospitals, it was found that "Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature" (Shapira, 2004). Unipolar depressed patient admission had no such correlation. High temperature points in the month, as well as high temperature months, were found to be correlated with depressive episodes in admissions.

5 Bipolar disorder and childbirth

For many women with depression or bipolar disorder the postpartum period is a period of risk for developing illness. Episodes of bipolar disorder that follow childbirth are traditionally called puerperal psychosis (PP) Dr Ian Jones of the Department of Psychological Medicine in Cardiff is researching this area.

6 Treatment of bipolar disorder

A variety of medications are used to treat bipolar disorder. But even with optimal medication treatment, many people with the illness have some residual symptoms. In contrast to schizophrenia, insight-oriented psychotherapy is also considered useful in the treatment of bipolar disorder.

6.1 Medication

Medications, called " mood stabilizers" can sometimes be used to prevent or mitigate manic or depressive episodes. Periods of depression can also be treated with antidepressants. In extreme cases where the mania or the depression is severe enough to cause psychosis, antipsychotic drugs may also be used. (See the end of the article for an external resource on psychopharmacology.)

Particular drugs may not work in all patients, or work sometimes in others, and it takes considerable time to determine in any particular case whether any particular drug is effective at all since bipolar disorder is usually episodic, and patients may experience remissions and periods of virtually normal functioning whether or not they receive treatment. Evaluation of patients is usually carried out using a "life chart" which graphs moods over a long period of time, ranging from weeks to years. It is also generally necessary to "titrate" the dosage of a drug, seeking to achieve the most effective treatment possible whilst minimising side-effects. Most mood stabilizers have common minor side-effects which are merely inconvenient, but many also have potential serious side-effects which make medical monitoring of patients undergoing drug treatment vitally important. For details of particular drugs, see the section below.

Compliance with medications can be a major problem because some people becoming manic lose insight, or an awareness of having an illness, and discontinue medications; then they often suffer a manic episode and may suddenly find themselves initiating multiple projects often being scattered and ineffective, or may go on a spending spree or take a poorly planned trip landing them in an unfamiliar location without cash. The manic periods, euphoric as they may be, are often disastrous because of the impulsiveness and irrationality that comes with them. Contrary to the patient's wishes, the depression does not respond instantaneously to resumed medication, typically taking 2-6 weeks to respond.

While bipolar disorder can be one of the most severe and devastating medical conditions, many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Compared to patients with schizophrenia, persons with bipolar disorder are more likely to have periods of normal functioning in the absence of medication. Although schizophrenic patients may have remissions with relatively high levels of functioning, schizophrenic patients tend to suffer some impairment during these intervals, if they are not medicated, in contrast to persons with bipolar disorder who often appear completely normal when they are between mood swings.

6.1.1 Lithium salts

The use of Lithium as a treatment of Bipolar Disorder was first discovered by Dr. John Cade.

Lithium salts have long been used as a first-line treatment for bipolar disorder. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li⁺. Approved for the treatment of acute mania in 1970 by the U.S. Food and Drug Administration (FDA), lithium has been an effective mood-stabilizing medication for many people with bipolar disorder. Lithium is also noted for reducing the risk of suicide in major affective disorders, such as bipolar disorder: suicide risk on the whole drops to below the average level for society (Baldessarini, 2003).

The mechanism of lithium salt tratment is believed to work as follows: some symptoms of bipolar disorder appear to be caused by the enzyme inositol monophosphatase (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. It is involved in signal transduction and is believed to create an imbalance in neurotransmitters in bipolar patients. The lithium ion is believed to produce a a mood stabilizing effect by inhibiting IMPase by substituting for one of two magnesium ions in IMPase's active site, slowing down this enzyme.

6.1.2 Anticonvulsant mood stabilizers

Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives to lithium in many cases. Valproate was FDA approved for the treatment of acute mania in 1995. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, are being studied to determine their efficacy as mood stabilizers in bipolar disorder. Some research suggests that different combinations of lithium and anticonvulsants may be helpful.

According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician.

During a depressive episode, people with bipolar disorder commonly require additional treatment with antidepressant medication. Typically, lithium or anticonvulsant mood stabilizers are prescribed along with an antidepressant to protect against a switch into mania or rapid cycling. The comparative efficacy of various antidepressants in bipolar disorder is currently being studied.

6.1.3 Atypical antipsychotic drugs

In some cases, the newer atypical antipsychotic drugs such as clozapine or olanzapine may help relieve severe or refractory symptoms of bipolar disorder and prevent recurrences of mania. More research is needed to establish the safety and efficacy of atypical antipsychotics as long-term treatments for this disorder.

6.2 Psychotherapy

Certain types of psychotherapy or psychosocial interventions, in combination with medication, often can provide additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy , family systems therapy, and psychoeducation .

6.3 Electroconvulsive therapy

Electroconvulsive therapy (ECT) was an accepted treatment in the past, and is still used today when other treatments have failed. There is current research work on transcranial magnetic stimulation as an alternative to ECT.

7 "Alternative" treatments

Lithium orotate is used as an alternative treatment to lithium carbonate by some sufferers of Bipolar Disorder, mainly because it is available without a doctor's prescription. It is sometimes sold as "organic lithium" by nutritionists, as well as under a wide variety of brand names. There seems to be little evidence for its use in clinical treatment in preference to lithium carbonate. Self-treatment without medical monitoring is potentially dangerous. [1]

8 Research into new treatments

In late 2003, researchers at McLean Hospital in Belmont, Massachusetts have found tentative evidence of improvements in mood during EP-MRSI imaging, and attempts are being made to develop this into a form which can be evaluated as a possible treatment.

It has been hypothesized that bipolar disorder may be the result of poor membrane conduction in the brain and that one possible cause may be a deficiency in omega-3 polyunsaturated fatty acids. Following an encouraging small-scale study, several large scale trials of treatment using omega-3 fatty acids are under way.

NIMH has initiated a large-scale study at 20 sites across the U.S. to determine the most effective treatment strategies for people with bipolar disorder. This study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), will follow patients and document their treatment outcome for 5 to 8 years. For more information, visit the Clinical Trials page of the NIMH Web site.

There are reports that Omega-3 fatty acids may be beneficial in the treatment of bipolar disorder. A significant study was conducted by Dr Andrew L Stoll at Harvard University's McLean Hospital. The Stanley Foundation is sponsoring research regarding the benficial claims.

9 Research findings

Bipolar disorder appears to run in families, that is, a vulnerability for bipolar disorder may be inherited. The rate of suicide is higher in people who have bipolar disorder than in the general population. The rate of prevalence of bipolar disorder is roughly equal (around 1%) in men and women.

More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a heritable component. Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

Researchers are using advanced medical imaging techniques to examine brain function and structure in people with bipolar disorder. An important area of imaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Better understanding of the neural circuits involved in regulating mood states may influence the development of new and better treatments, and may ultimately aid in diagnosis.

An evolving literature exists concerning the nature of personality and temperament in Bipolar Disorder patients, compared to Major Depressive Disorder (unipolar) patients and normals. Such differences may be diagnostically relevant. Using MBTI continuum scores, bipolar patients were significantly more extroverted, intuitive, and perceiving, and less introverted, sensing and judging than were unipolar patients. This suggests that there might be a correlation between the Jungian extraverted iNtuiting process and bipolar disorder.

10 Bipolar disorder, talent and famous people

Many famous people are believed to have been affected by bipolar disorder, based on evidence in their own writings and contemporaneous accounts by those who knew them. See list of people believed to have been affected by bipolar disorder.

There is no definitive scientific basis for classifying dead people as having had bipolar disorder, though they may very well have suffered from severe and even recurrent bouts of disordered mood. Until very recently there were no diagnostic systems with any degree of reliability. Even with the development of tools such as DSM-IV, there is a great deal of diagnostic uncertainty with living patients who have been intensively studied for decades, and there is no reason to think that it is any easier to diagnose individuals in their graves. For these reasons, some doctors regard psycho-history of this sort as a dubious endeavour.

There appears to be an association between bipolar disorder and artistic talent in many cases - this is documented in Jamison's book "Touched With Fire: Manic-Depressive Illness and the Artistic Temperament".

Some also believe that the manic state is a type of universal connection which provides creativity and intelligence but comes with the price of the depressive low.

11 Recent genetic research

Bipolar Disorder is considered to be primarily a genetically caused disorder. The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Relatives of persons with Bipolar Disorder also have an increased incidence of having unipolar depression.

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3 , which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder.

12 Sources

Material from public domain text copied from http://www.nimh.nih.gov/publicat/manic.cfm which states: "All material in this fact sheet is in the public domain and may be copied or reproduced without permission from the Institute. Citation of the source is appreciated."
Baldessarini RJ, et al. (2003). Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64 (Suppl 5), 44-52.
Hakkarainen R, et al. (2003). Seasonal changes, sleep length and circadian preference among twins with bipolar disorder. BMC Psychiatry 3 (1), 6.
Shapira A, et al. (2004). Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature. Bipolar Disord. Feb;6 (1), 90-3.

13 References

Classic works on this subject include

"Manic-depressive insanity and paranoia" by Emil Kraepelin., 1921. BooksEnthsiast.com (English translation of the original German from the earlier Eighth Edition of Kraepelin's Textbook -- now outdated, but a work of major historical importance).
"Manic-Depressive Illness" by Frederick K. Goodwin and Kay Redfield Jamison. BooksEnthsiast.com (The standard, very lengthy, medical reference on bipolar disorder.)
"Touched With Fire: Manic-Depressive Illness and the Artistic Temperament" by Kay Redfield Jamison (The Free Press: Macmillian, Inc., New York, 1993) 1996 reprint: BooksEnthsiast.com
"An Unquiet Mind: A Memoir of Moods and Madness" by Kay Redfield Jamison (Knopf, New York, 1995) (An excellent autobiographical work about what it's like to have bipolar disorder, by the woman who is also one of the medical world's experts on it.)
"Mind Over Mood: Cognitive Treatment Therapy Manual for Clients" by Christine Padesky, Dennis Greenberger. BooksEnthsiast.com

14 See also

15 External links

15.1 Support groups

15.2 Research

Mood Disorder Research Group (UK)

15.3 Evidence-based medicine

15.4 Other resources

15.5 Links about famous people with unipolar or bipolar disorder

A list of famous people believed to have bipolar disorder can be found at http://www.nami.org/helpline/peoplew.htm

15.6 About Emil Kraeplin

Detailed information concerning Emil Kraepelin, the discoverer of Manic Depression

15.7 News stories

Mood disorders

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