Bipolar disorder

Bipolar Affective Disorder

ICD-10	F31
ICD-9	296
OMIM	{{{OMIM}}}
DiseasesDB	{{{DiseasesDB}}}
MedlinePlus	001528
eMedicine	med/229
MeSH	{{{MeshNumber}}}

Bipolar disorder, also known as manic-depression, is a psychiatric diagnosis referring to a mental health condition defined by periods of extreme, often inappropriate, and sometimes unpredictable mood states.

Bipolar individuals generally experience mania, hypomania or mixed states alternating with clinical depression and euthymic or normal range of mood over varied periods of time. There are many variations of this disorder. A person with bipolar disorder generally tends to experience more extreme states of mood than other people. Moods can change quickly (many times a day) or last for months. Bipolar individuals tend to have very 'black and white' thinking, where everything in life is either a positive aspect or a negative. Mood patterns of this nature are associated with distress and disruption, and a relatively high risk of suicide. Bipolar disorder is also associated with a variety of cognitive deficits, in particular, difficulty in organizing and planning. The disorder may also skew the ability to judge others' emotion, and alter sense of awareness. Bipolar individuals can be overly observant and analytical of their environment, and in some cases paranoid of others.

Bipolar disorder is usually treated with medications that help to stabilize mood, and/or therapy and counselling.

Some studies have suggested that while bipolar disorder alters emotion, there may be a correlation between creativity and bipolar disorder, although it is unclear what the relationship is between the two.

Aspects of bipolar disorder

Bipolar disorder is commonly categorised as either Bipolar Type I, where an individual experiences full-blown mania, or Bipolar Type II, in which the hypomanic "highs" do not go to the extremes of mania. The latter is much more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression. Psychosis can occur, particularly in manic periods. There are also 'rapid cycling' subtypes. Because there is so much variation in the severity and nature of mood-related problems, the concept of a bipolar spectrum is often employed, which includes cyclothymia. There is no consensus as to how many 'types' of bipolar disorder exist (Akiskal and Benazzi, 2006). Many people with bipolar disorder experience severe anxiety and are very irritable (to the point of rage) when in a manic state, while others are euphoric and grandiose.

The Depressive Phase

Signs and symptoms of the depressive phase of bipolar disorder include (but in no way are limited to): persistent feelings of sadness, anxiety, guilt, anger, isolation and/or hopelessness, disturbances in sleep and appetite, fatigue and loss of interest in usually enjoyed activities, problems concentrating, loneliness, self-loathing, apathy or indifference, depersonalization, loss of interest in sexual activity, shyness or social anxiety, irritability, chronic pain (with or without a known cause), lack of motivation, and morbid/suicidal ideation].

Mania

Main article: Mania

People having a manic episode of mood can be elated, euphoric, irritated and/or suspicious. There will be an increase in physical and mental rate and quality. Increased energy and over-activity is common; speech can become racing. The need for sleep is reduced. Attention span is low and easily distracted. Unrealistic, grandiose or over optimistic ideas may be voiced or attempted. Social skills are impaired, and impractical ideas may lead to financial and relationship indiscretions.

Hypomania

Main article: Hypomania

Hypomania is generally a less destructive state than mania, and people in the hypomanic phase generally experience less of the symptoms of mania than those in a full-blown manic episode. The duration is usually also shorter than in mania. This is often a very 'artistic' state of the disorder, where there is a flight of ideas, extremely clever thinking, and an increase in energy.

Mixed state

Main article: Mixed state (psychiatry)

In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously (for example, agitation, anxiety, aggressiveness or belligerence, confusion, fatigue, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, persecutory delusions, pressured speech, racing thoughts, restlessness, and rage).

Mixed episodes can be the most volatile of the bipolar states, as moods can easily and quickly be triggered or shifted. Suicide attempts, substance abuse, and self-mutilation may occur during this state.

Rapid cycling

Rapid cycling, defined as having four or more episodes per year, is found in a significant fraction of patients with bipolar disorder. It has been associated with greater disability or a worse prognosis, due to the confusing changeability and difficulty in establishing a stable state. Rapid cycling can be induced or made worse by antidepressants.

Cognition

Numerous studies show that bipolar disorder involves certain cognitive deficits or impairments, even in states of remission. Deborah Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has argued these deficits should be included as a core feature of bipolar disorder. According to McIntyre et al. (2006), "study results now press the point that neurocognitive deficits are a primary feature of BD; they are highly prevalent and persist in the absence of overt symptomatology. Although disparate neurocognitive abnormalities have been reported, disturbances in attention, visual memory, and executive function are most consistently reported."

Creativity

Main article: Creativity and mental illness

A number of recent studies have observed a correlation between creativity and bipolar disorder, although it is unclear in which direction the cause lies, or whether both conditions are caused by some third, unknown, factor. It has been hypothesized that temperament may be one such factor.

History

Main article: Bipolar disorder - History

Biological approaches

Main article: Bipolar disorder - Biological perspective

Main article: Bipolar disorder - Genetic perspective

Main article: Bipolar disorder - Evolutionary perspective

Theoretical approaches

Main article: Bipolar disorder - Theoretical approaches

Developmental aspect

Main article: Bipolar disorder - Developmental perspective

Epidemiology

Main article: Bipolar disorder - Epidemiology

Risk factors

Main article: Bipolar disorder - Risk factors

Causes

Main article: Bipolar disorder - Etiology

Comorbidity

Main article: Bipolar disorder - Comorbidity

Assessment

Main article: Bipolar disorder - Assessment

Treatment

Main article: Bipolar disorder - Treatment

User information

Main article: Personality disorder - User information

Carer information

Main article: Personality disorder - For their carers

Suicide risk

Although many people with bipolar disorder who attempt suicide never actually complete it, the annual average suicide rate in males and females with diagnosed bipolar disorder (0.4%) is 10 to more than 20 times that in the general population

Individuals with bipolar disorder tend to become suicidal, especially during mixed states such as dysphoric mania and agitated depression. Persons suffering from Bipolar II have high rates of suicide compared to persons suffering from other mental illnesses, including Major Depression. Major Depressive episodes are part of the Bipolar II experience, and some have speculated that sufferers of this disorder spend much of their life in the depressive phase of the illness.

Divorce rate

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According to Psychology Today , the divorce rate for couples where at least one spouse is bipolar is 90%. For comparison purposes, the general divorce rate is commonly held to be about half as much (around 50%), implying that this illness causes substantial additional burdens on married life.

Diagnosis

Diagnostic criteria

Main article: Current diagnostic criteria for bipolar disorder

Flux is the fundamental nature of bipolar disorder. Both within and between individuals with the illness, energy, mood, thought, sleep, and activity are among the continually changing biological markers of the disorder. The diagnostic subtypes of bipolar disorder are thus static descriptions—snapshots, perhaps—of an illness in continual change, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness. The DSM V, to be published in 2011, will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).

There are currently four types of bipolar illness. The Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) details four categories of bipolar disorder, Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Not Otherwise Specified).

For a diagnosis of Bipolar I disorder according to the DSM-IV-TR, there requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder but it frequently occurs.

Bipolar II, which occurs more frequently is usually characterized by at least one episode of hypomania and at least one depression.

A diagnosis of Cyclothymic Disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning.

If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified).

Although a patient will most likely be depressed when they first seek help, it is very important to find out from the patient or the patient's family or friends if a manic or hypomaniac episode has ever been present, using careful questioning. This will prevent misdiagnosis of Depressive Disorder and avoids the use of an antidepressant which may trigger a "switch" to hypomania or mania or induce rapid cycling. Recent screening tools such as the Hypomanic Check List Questionnaire (HCL-32) have been developed to assist the quite often difficult detection of Bipolar II disorders.

Research findings

The MRC eMonitoring Project, another research study based at the Institute of Psychiatry and Newcastle Universities, is conducting novel research on electronic monitoring methodologies (electronic mood diaries and actigraphy) for tracking bipolar symptom fluctuations in Bipolar individuals who are interested in self-managing their condition.

Medical imaging

Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the functional MRI and positron emission tomography. An important area of neuroimaging 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, and studies have found anatomical differences in areas such as the prefrontal cortex and hippocampus.

Better understanding of the neural circuits involved in regulating mood states, and genetic factors such as the cadherin gene FAT linked to bipolar disorder, may influence the development of new and better treatments, and may ultimately aid in early diagnosis and even a cure

New treatments

In late 2003, researchers at McLean Hospital found tentative evidence of improvements in mood during echo-planar magnetic resonance spectroscopic imaging (EP-MRSI), and attempts are being made to develop this into a form which can be evaluated as a possible treatment.

NIMH has initiated a large-scale study at 20 sites across the United States 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 5-8 years. For more information, visit the Clinical Trials page of the NIMH Web site.

Transcranial magnetic stimulation is another fairly new technique being studied.

Pharmaceutical research is extensive and ongoing, as seen at clinicaltrials.gov.

Mortality

"Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD. The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder.".

References

• Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.

Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(9): 1168-76.

• Hyman SE, Rudorfer MV. Depressive and bipolar mood disorders. In: Dale DC, Federman DD, eds. Scientific American®; Medicine. Vol. 3. New York: Healtheon/WebMD Corp., 2000; Sect. 13, Subsect. II, p. 1.
• Hyman SE. Introduction to the complex genetics of mental disorders. Biological Psychiatry, 1999; 45(5): 518-21.
• Huxley NA, Parikh SV, Baldessarini RJ. Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harvard Review of Psychiatry, 2000; 8(3): 126-40.
• Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
• Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher FC, Vidaver R, Auciello P, Foy DW. Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 1998; 66(3): 493-9.
• NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.
• Sachs GS, Thase ME. Bipolar disorder therapeutics: maintenance treatment. Biological Psychiatry, 2000; 48(6): 573-81.
• Soares JC, Mann JJ. The anatomy of mood disorders—review of structural neuroimaging studies. Biological Psychiatry, 1997; 41(1): 86-106.
• Soares JC, Mann JJ. The functional neuroanatomy of mood disorders. Journal of Psychiatric Research, 1997; 31(4): 393-432.
• Stoll AL, Severus WE, Freeman MP, Rueter S, Zboyan HA, Diamond E, Cress KK, Marangell LB. Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-controlled trial. Archives of General Psychiatry, 1999; 56(5): 407-12.

Further reading

Contemporary first-person accounts on this subject include

• Jamison, Kay Redfield. 1995. An Unquiet Mind: A Memoir of Moods and Madness. New York: Knopf. ISBN 0-330-34651-2.
• Simon, Lizzie. 2002. Detour: My Bipolar Road Trip in 4-D. New York: Simon and Schuster. ISBN 0-7434-4659-3.
• Behrman, Andy. 2002. Electroboy: A Memoir of Mania. New York: Random House, 2002. ISBN 0-375-50358-7.

For a practical guide to living with bipolar disorder from the perspective of the sufferer, see

• Kelly, Madeleine Bipolar and the Art of Roller-coaster Riding. Strathbogie: Two Trees Media 2005 ISBN 0-646-44939-7

For a critique of genetic explanations of bipolar disorder, see

• Joseph, J. 2006. The Missing Gene: Psychiatry, Heredity, and the Fruitless Search for Genes. New York: Algora.

For readings regarding bipolar disorder in children, see:

• Raeburn, Paul. 2004. Acquainted with the Night: A Parent's Quest to Understand Depression and Bipolar Disorder in His Children.
• Earley, Pete. Crazy. 2006. New York: G. P. Putnam's Sons. ISBN 0-399-15313-6. A father's account of his son's bipolar disorder.
• About Pediatric Bipolar Disorder: www.bpkids.org/site/PageServer?pagename=lrn_about
• The Child and Adolescent Bipolar Foundation: www.bpkids.org
• Time Magazine checklist for childhood/adolescent bipolarity: www.time.com/time/covers/1101020819/worksheet/
• A Model IEP for a bipolar child's medication that works correctly: http://www.bipolarchild.com/iep.html

Classic works on this subject include

• Kraepelin, Emil. 1921. Manic-depressive Insanity and Paranoia ISBN 0-405-07441-7 (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. ISBN 0-19-503934-3 (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: ISBN 0-684-83183-X
• Mind Over Mood: Cognitive Treatment Therapy Manual for Clients by Christine Padesky, Dennis Greenberger. ISBN 0-89862-128-3

See also

• Mood (psychology)
• Emotion
• List of people believed to have been affected by bipolar disorder
• List of songs about bipolar disorder
• Bipolar spectrum
• Seasonal affective disorder
• Oppositional Defiance Disorder
• Emotional dysregulation
• Creativity and bipolar disorder
• Bipolar disorders research
• Visit Bipolar4all

External links

Bipolar Disorder at the Open Directory Project