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In the United States alone, bipolar disorder afflicts an estimated three million people. According to a report by the National Institutes of Mental Health, the disorder costs over $45 billion annually. The average age of onset of bipolar disorder is from adolescence through the early twenties. However, because of the complexity of the disorder, a correct diagnosis can be delayed for several years or more.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revised (DSM-IV-TR), the diagnostic standard for mental health professionals in the United States, defines four separate categories of bipolar disorder: bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified (NOS).

Bipolar I disorder is characterized by manic episodes, the "high" of the manic-depressive cycle. A bipolar patient experiencing mania often has feelings of self-importance, elation, talkativeness, increased sociability, and a desire to embark on goal-oriented activities, coupled with the characteristics of irritability, impatience, impulsiveness, hyperactivity, and a decreased need for sleep. Usually this manic period is followed by a period of depression, although a few bipolar I individuals may not experience a major depressive episode. Mixed states, where both manic or hypomanic symptoms and depressive symptoms occur at the same time, also occur fre-

Anticonvulsant medication—A medication that prevents convulsions or seizures; often prescribed in the treatment of epilepsy. Several anticonvulsant medications have been found effective in the treatment of bipolar disorder.

Antipsychotic medication—A medication used to treat psychotic symptoms of schizophrenia such as hallucinations, delusions and delirium. May be used to treat symptoms in other disorders, as well.

Benzodiazepines—A group of central nervous system depressants used to relieve anxiety or to induce sleep.

ECT—Electroconvulsive therapy is sometimes used to treat depression or mania when pharmaceutical treatment fails.

Hypomania—A milder form of mania which is characteristic of bipolar II disorder.

Mania—An elevated or euphoric mood or irritable state that is characteristic of bipolar I disorder. This state is characterized by mental and physical hyperactivity, disorganization of behavior, and inappropriate elevation of mood.

Mixed mania/mixed state—A mental state in which symptoms of both depression and mania occur simultaneously.

Neurotransmitter—A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to bipolar disorder.

Psychomotor retardation—Slowed mental and physical processes characteristic of a bipolar depressive episode.

quently with bipolar I patients (for example, depression with the racing thoughts of mania). Also, dysphoric mania is common (mania characterized by anger and irritability).

Bipolar II disorder is characterized by major depressive episodes alternating with episodes of hypomania, a milder form of mania. Bipolar depression may be difficult to distinguish from unipolar depression (depression without mania, as found in major depressive disorder). Patients with bipolar depression tend to have extremely low energy, retarded mental and physical processes, and more profound fatigue (for example, hypersomnia—a sleep disorder marked by a need for excessive sleep or sleepiness when awake) than people with unipolar depression.

tû Cyclothymia refers to the cycling of hypomanic

"I episodes with depression that does not reach major depres-

•Jg sive proportions. A third of patients with cyclothymia will

£ develop bipolar I or II disorder later in life.

JL A phenomenon known as rapid cycling occurs in up

M to 20% of bipolar I and II patients. In rapid cycling, manic and depressive episodes must alternate frequently—at least four times in 12 months—to meet the diagnostic definition. In some cases of "ultra-rapid cycling," the patient may bounce between manic and depressive states several times within a 24-hour period. This condition is very hard to distinguish from mixed states.

Bipolar NOS is a category for bipolar states that do not clearly fit into the bipolar I, II, or cyclothymia diagnoses.

Causes and symptoms

The source of bipolar disorder has not been clearly defined. Because two-thirds of bipolar patients have a family history of emotional disorders, researchers have searched for a genetic link to the disorder. Several studies have uncovered a number of possible genetic connections to the predisposition for bipolar disorder. There is significant evidence that correlates bipolar II with genetic causes. Studies have shown that identical twins have an 80% concordance rate (presence of the same disorder). Additionally, studies have demonstrated that the disorder is transmitted to children by autosomal dominant inheritance. This means that either affected parent (father or mother) has a 50% chance of having a child (regardless if the child is male or female) with the disorder.

Further studies concerning the genetic correlations have revealed specific chromosomes (the structures that contain genes) that contain mutated genes. Susceptible genes are located in specific regions of chromosomes 13, 18, and 21. The building blocks of genes, called nucleotides, are normally arranged in a specific order and quantity. If these nucleotides are repeated, a genetic abnormality usually results. Recent evidence suggests that a special type of nucleotide repeat is observed in persons with bipolar II on chromosome 18. However, the presence of this sequence does not worsen the disorder or change the age of onset. It is currently thought that expression of bipolar II involves multiple mutated genes. Further research is ongoing to discover precise mechanisms and to develop genetic markers (gene tags) that would predict which individuals are at higher risk.

Another possible biological cause for bipolar disorder under investigation is the presence of an excessive calcium buildup in the cells. Also, dopamine and other neurochem-ical transmitters (the chemicals that transmit messages from nerve cell to nerve cell) appear to be implicated in bipolar disorder and these are under intense investigation.

Over half of patients diagnosed with bipolar disorder have a history of substance abuse. There is a high rate of association between cocaine abuse and bipolar disorder. Some studies have shown up to 30% of abusers meeting the criteria for bipolar disorder. The emotional and physical highs and lows of cocaine use correspond to the manic depression of the bipolar patient, making the disorder difficult to diagnose.

For some bipolar patients, manic and depressive episodes coincide with seasonal changes. Depressive episodes are typical during winter and fall, and manic episodes are more probable in the spring and summer months.

Symptoms of bipolar depressive episodes include low energy levels, feelings of despair, difficulty concentrating, extreme fatigue, and psychomotor retardation (slowed mental and physical capabilities). Manic episodes are characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. In extreme cases, mania can induce hallucinations and other psychotic symptoms such as grandiose delusions (ideas that the person affected is extremely important or has some unrecognized talent or insight).

Demographics

Manic-depression is a common psychological disorder that is difficult to detect. As stated, it is estimated that about three million people in the United States are affected. The disorder is more common among women than men. Women have been observed at increased risk of developing subsequent episodes in the period immediately following childbirth.

Diagnosis

Bipolar disorder is usually diagnosed and treated by a psychiatrist and/or a psychologist with medical assistance. In addition to an interview, several clinical inventories or scales may be used to assess the patient's mental status and determine the presence of bipolar symptoms. These include the Millon Clinical Multiaxial Inventory III (MCMI-III), Minnesota Multiphasic Personality Inventory II (MMPI-2), the Internal State Scale (ISS), the Self-Report Manic Inventory (SRMI), and the Young Mania Rating Scale (YMRS). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Psychologists and psychiatrists typically use the criteria listed in the DSM-IV-TR as a guideline for diagnosis of bipolar disorder and other mental illnesses. DSM-IV-TR describes a manic episode as an abnormally elevated or irritable mood lasting a period of at least one week that is distinguished by at least three of the mania symptoms: inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities that have a high potential for painful consequences. If the mood of the patient is irritable and not elevated, four of the symptoms are required.

Although many clinicians find the criteria too rigid, a hypomanic diagnosis requires a duration of at least four days with at least three of the symptoms indicated for manic episodes (four if mood is irritable and not elevated). DSM-IV-TR notes that unlike manic episodes, hypo-manic episodes do not cause a marked impairment in social or occupational functioning, do not require hospitalization, and do not have psychotic features (no delusions or hallucinations). In addition, because hypomanic episodes are characterized by high energy and goal-directed activities and often result in a positive outcome, or are perceived in a positive manner by the patient, bipolar II disorder can go undiagnosed.

Bipolar symptoms often appear differently in children and adolescents than they appear in adults. Manic episodes in these age groups are typically characterized by more psychotic features than in adults, which may lead to a mis-diagnosis of schizophrenia. Children and adolescents also tend toward irritability and aggressiveness instead of elation. Further, symptoms tend to be chronic, or ongoing, rather than acute, or episodic. Bipolar children are easily distracted, impulsive, and hyperactive, which can lead to a misdiagnosis of attention-deficit/hyperactivity disorder (ADHD). Furthermore, their aggression often leads to violence, which may be misdiagnosed as a conduct disorder.

Substance abuse, thyroid disease, and use of prescription or over-the-counter medication can mask or mimic the presence of bipolar disorder. In cases of substance abuse, the patient must ordinarily undergo a period of detoxification and abstinence before a mood disorder is diagnosed and treatment begins.

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