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Psychology Basics Bipolar Disorder TYPE OF PSYCHOLOGY: Biological bases of behavior; psychopathology; psychotherapy FIELDS OF STUDY: Biological treatments; depression Knowledge about bipolar disorder, a serious mental illness that is characterized by depressive episodes and manic episodes, has grown extensively since the 1970's. Advanced neurobiological research and assessment techniques have shown the biochemical origins and genetic element of this disorder. Recent research indicates the ways in which stress may play a role in precipitating recurrence of episodes. KEY CONCEPTS ∙ diathesis-stress model ∙ lithium carbonate ∙ mania ∙ melatonin ∙ neurotransmitter ∙ psychotic symptoms ∙ seasonal affective disorder (SAD) Although mood fluctuations are a normal part of life, individuals with bipolar affective disorder experience extreme mood changes. Bipolar affective disorder, or bipolar disorder (also called manic-depressive disorder), has been identified as a major psychiatric disorder characterized by dramatic mood and behavior changes. These changes, ranging from episodes of high euphoric moods to deep depressions, with accompanying behavioral and personality changes, are devastating to the victims of the disorder and perplexing to the loved ones of those affected. Prevalence rates have been estimated at about 1.6 (0.8 to 2.6) percent of the American population. The disorder is divided fairly equally between males and females. Clinical psychiatry has been effective in providing biochemical intervention in the form of lithium carbonate to stabilize or modulate the ups and downs of this illness. However, lithium treatment has only been effective for approximately 70 percent of those to whom it is administered. Mood-stabilizing anticonvulsant medications such as Depakote, Tegretol, and Lamictal, are showing promise in helping some people who were formerly referred to as lithium nonresponders. Psychotherapy is seen by most practitioners as a necessary adjunct to medication. SYMPTOMS In the manic phase of a bipolar episode, the individual may experience inappropriately good moods, or "highs," or may become extremely irritable. During a manic phase, the person may overcommit to work projects and meetings, social activities, or family responsibilities in the belief that he or she can accomplish anything; this is known as manic grandiosity. At times, psychotic symptoms such as delusions, severe paranoia, and hallucinations may accompany a manic episode. These symptoms may lead to a misdiagnosis of another psychotic disorder such as schizophrenia. However, skilled clinicians can make a differential diagnosis between schizophrenia and bipolar disorder. The initial episode of bipolar disorder is typically one of mania or elation, although in some people a depressive episode may signal the beginning of the disorder. Episodes of bipolar disorder can recur rapidly--within hours or days--or may have a much slower recurrence rate, even of years. The duration of each episode, whether it is depression or mania, varies widely among individuals but normally remains fairly consistent for each individual.
According to the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (rev. 4th ed., 2000), the diagnostic manual of the American Psychiatric Association, there are several types of bipolar disorder, which are categorized according to the extent of severity, the types of the symptoms, and the duration of the symptoms. Bipolar I disorder is characterized by alternating periods of mania and depression. At times, severe bipolar disorder may be accompanied by psychotic symptoms such as delusions and hallucinations. For this reason, Bipolar I disorder is also considered a psychotic disorder. Bipolar II disorder is characterized by alternating episodes of a milder form of mania (known as hypomania) and depression. Cyclothymia is a form of bipolar disorder in which hypomania alternates with a low-level, chronic depressive state. Seasonal affective disorder (SAD) is characterized by alternating mood episodes that vary according to seasonal patterns; the mood changes are thought to be related to changes in the amount of sunlight and accompanying effects on the levels of hormone melatonin. In the Northern Hemisphere, the typical pattern is associated with manic symptoms in the spring and summer and depression in the fall and winter. Manic episodes often have a shorter duration than the depressive episodes. Bipolar disorder must be differentiated from depressive disorders, which include major depression (unipolar depression) and dysthymia, a milder but chronic form of depression. CAUSES The causes of bipolar disorder are not fully understood, but genetic factors play a major role. Approximately 80 percent of individuals with bipolar disorder have a relative with some form of mood disorder, whether bipolar disorder or depression. It is not uncommon to see families in which several generations are affected by bipolar disorder. Serotonin, norepinephrine, and dopamine, brain chemicals known as neurotransmitters that regulate mood, arousal, and energy, respectively, may be altered in bipolar disorder.
A diathesis-stress model can also account for some of the recurrent episodes of mania in bipolar disorder. Investigators suggest that positive life events, such as the birth of a baby or a job promotion, as well as negative life events, such as divorce or the loss of a job, may trigger the onset of episodes in individuals with bipolar disorder. Stressful life events and the social rhythm disruptions that they cause can have adverse effects on a person's circadian rhythms. Circadian rhythms are normal biologic rhythms that govern such functions as sleeping and waking, body temperature, and oxygen consumption. Circadian rhythms affect hormonal levels and have significant effects on both emotional and physical well-being. For those reasons, many clinicians encourage individuals with bipolar disorder to work toward maintaining consistency in their social rhythms. More recently, investigators have compared the course of bipolar disorder to kindling, a process in which epileptic seizures increase the likelihood of further seizures. According to the kindling hypothesis, triggered mood episodes may leave the individual's brain in a sustained sensitized state that makes the person more vulnerable to further episodes. After a while, external factors are less necessary for a mood episode to be triggered. Episode sensitization may also account for rapid-cycling states, in which the individual shifts from depression to mania over the course of a few hours or days. IMPACT The impact of bipolar disorder is considerable. Some believe that the illness puts people on an "emotional roller coaster" in which their ups and downs are so severe that resulting behavior can have its own disastrous consequences. For example, people suffering from episodes of mania sometimes use drugs, alcohol, money, or sex to excess, then later have to deal with an additional set of problems and trauma brought about by their behavior and impulsiveness. Organizations such as the National Alliance for the Mentally Ill (NAMI) and support groups such as the Depressive and Manic Depressive Association (DMDA) have provided a way for people with bipolar disorder to share their pain as well as to triumph over the illness. Many people have found comfort in knowing that others have suffered from the mood shifts, and they can draw strength from one another. Family members and friends can be the strongest supporters and advocates for those who have bipolar disorder or other psychiatric illnesses. Many patients have credited their families' constant, uncritical support, in addition to competent effective treatment including medications and psychotherapy, with pulling them through the devastating effects of the illness. TREATMENT APPROACHES Medications have been developed to aid in correcting the biochemical imbalances thought to be part of bipolar disorder. Lithium carbonate is usually effective for approximately 70 percent of those who take it. Many brilliant and successful people have reportedly suffered from bipolar disorder and have been able to function successfully with competent and responsible treatment. Some people who have taken lithium for bipolar disorder, however, have complained that it robs them of their energy and creativity and said that they actually miss the energy associated with manic phases of the illness. This perceived loss, some of it realistic, can be a factor in relapse associated with lithium noncompliance. Other medications have been developed to help those individuals who are considered lithium nonresponders or who find the side effects of lithium intolerable. Anticonvulsant medications, such as Depakote (valproic acid), Tegretol (carbamazepine), and Lamictal (lamotrigine), which have been found to have mood-stabilizing effects, are often prescribed to individuals with bipolar disorder. During the depressive phase of the disorder, electroconvulsive (shock) therapy (ECT) has also been administered to help restore the individual's mood to a normal level. Phototherapy is particularly useful for individuals who have SAD . Psychotherapy, especially cognitive-behavioral therapy or interpersonal social rhythm therapy, is viewed by most practitioners as a necessary adjunct to medication. Indeed, psychotherapy has been found to assist individuals with bipolar disorder in maintaining medication compliance. Local mental health associations are able to recommend psychiatric treatment by board-certified psychiatrists and licensed psychologists who specialize in the treatment of mood disorders. Often, temporary hospitalization is necessary for complete diagnostic assessment, initial mood stabilization, and intensive treatment, medication adjustment, or monitoring of an individual who feels suicidal. As many as 15 percent of those with bipolar disorder commit suicide. This frightening reality makes early intervention, relapse prevention, and treatment of the disorder necessary to prevent such a tragic outcome. SOURCES FOR FURTHER STUDY Goldberg, J., and Martin Harrow, eds. Bipolar Disorders: Clinical Course and Outcome. Washington, D.C.: American Psychiatric Press, 1999. This edited volume summarizes recent research regarding the course and outcome of bipolar disorder. Chapters are written by experts in the field. Goodwin, Frederick K., and Kay R. Jamison. Manic Depressive Illness. New York: Oxford University Press, 1990. This comprehensive book on bipolar disorder provides information on diagnosis, theories regarding the etiology of the disorder, and treatment options. Jamison, Kay R. An Unquiet Mind. New York: A. A. Knopf, 1995. An insightful first-person account of a psychiatrist's experience with bipolar disorder. Offers descriptions of mania as well as depression and discusses relevant issues such as the genetic basis of the disorder. Johnson, Sheri L., and John E. Roberts. "Life Events and Bipolar Disorder: Implications from Biological Theories." Psychological Bulletin 117, no. 3 (1995): 434-449. This theoretical article was written for psychologists but is readily accessible to laypeople. The authors review research and accounts for ways in which life events, both positive and negative ones, may trigger the onset of episodes in individuals with bipolar disorder. Diane C. Gooding and Karen Wolford See AlsoAnxiety Disorders; Attention-Deficit Hyperactivity Disorder (ADHD); Clinical Depression; Depression; Drug Therapies; Madness: Historical Concepts; Obsessive-Compulsive Disorder; Personality Disorders; Schizophrenia: Background, Types, and Symptoms; Schizophrenia: Theoretical Explanations. |
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