Going To Extremes: Bipolar Disorder
Bipolar Disorder
There is a tendency to romanticize bipolar disorder. Many artists, musicians, and
writers have suffered from its mood swings. But in truth, many lives are ruined by this
disease; and without effective treatment, the illness is associated with an increased
risk of suicide.1
Bipolar disorder, also known as manic-depressive illness, is a serious brain disease that
causes extreme shifts in mood, energy, and functioning. It affects approximately 2.3
million adult Americans-about 1.2 percent of the population.2 Men and women are
equally likely to develop this disabling illness. The disorder typically emerges in
adolescence or early adulthood, but in some cases appears in childhood.3 Cycles, or
episodes, of depression, mania, or “mlxed” manic and depressive symptoms typically
recur and may become more frequent, often disrupting work, school, family, and social
life.
Depression: Symptoms include a persistent sad mood; loss of interest or pleasure in
activities that were once enjoyed; significant change in appetite or body weight;
difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy;
feelings of worthlessness or inapproprlate guilt; difficulty thinking or concentrating;
and recurrent thoughts of death or suicide.
Mania: Abnormally and persistently elevated (high) mood or irritability accompanied
by at least three of the following symptoms: overly-inflated self-esteem; decreased
need for sleep; increased talkativeness; racing thoughts; distractibility; increased goaldirected
activity such as shopping; physical agitation; and excessive involvement in
risky behaviors or activities.
“Mixed” state: Symptoms of mania and depression are present at the same time. The
symptom picture frequently includes agitation, trouble sleeping, significant change in
appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic
activation.
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 four 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.4
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 typically reflect the extreme
mood state at the time.
Treatments
A variety of medications are used to treat bipolar disorder.5 But even with optimal
medication treatment, many people with the illness have some residual symptoms.
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 therapy, and
psychoeducation.6,7
Lithium has long been used as a first-line treatment for bipolar disorder. 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.
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 20.8 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.
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.
Research Findings
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.9 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 imaging techniques to examine brain function and
structure in people with bipolar disorder.10,ll An important area of imaging research
focuses on identifying and characterizing networks of interconnected nerve ceils 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 will influence the development of
new and better treatments, and will ultimately aid in diagnosis.
New Clinical Trial
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 Website.
References
1. Brown GK, Beck AT, Steer RA, et al. Risk factors for suicide in psychiatric
outpatients: a 20-year prospective study. Journal of Consulting and Clinical
Psychology, 2000; 68(3): 371-7.
2. Narrow WE. One-year prevalence of depressive disorders among adults 18 and over
in the U.S.: NIMH ECA prospective data. Population estimates based on U.S. Census
estimated residential population age 18 and over on July 1, 1998. Unpublished.
3. Geller B, Luby 3. 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.
4. Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic
Catchment Area Study. New York: The Free Press, 1991.
5. Sachs GS, Printz 03, Kahn DA, et al. The expert consensus guideline series:
medication treatment of bipolar disorder 2000. Postgraduate Medicine, 2000; Spec No:
l-104.
6. American Psychiatric Association. Practice guideline for the treatment of patients with
bipolar disorder. American Journal of Psychiatry, 1994; 151(12 Suppl): l-36.
7. Frank E, Hlastala S, Ritenour A, et al. Inducing lifestyle regularity in recovering
bipolar disorder patients: results from the maintenance therapies in bipolar disorder
protocol. Biological Psychiatry, 1997; 41(12): 1165-73.
8. Vainionpaa LK, Rattya J, Knip M, et al. Valproate-induced hyperandrogenism during
pubertal maturation in girls with epilepsy. Annals of Neurology, 1999; 45(4): 444-50.
9. NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-
4268. Rockville, MD: National Institute of Mental Health, 1998.
10. Soares JC, Mann JJ. The anatomy of mood disorders-review of structural
neuroimaging studies. Biological Psychiatry, 1997; 41(l): 86-106.
11. Soares JC, Mann 31. The functional neuroanatomy of mood disorders. Journal of
Psychiatric Research, 1997; 31(4): 393-432.
National Institutes of Health
NIH Publication No. 01-4595
2001
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