HOME WEB NEWS IMAGES CLASSIFIEDS YELLOW PAGESPOLLS - SURVEYS WIKI COUNTRIES PHOTOS US UK INDIA
Cities Stocks Weather Movies Coupons Travel Blogs Health Horoscope Maps ASIA EUROPE Classifieds Yellow Pages
 1
|
|
|
It has been suggested that Bipolar spectrum be merged into this article or section. (Discuss) |
"Manic depression" redirects here. For other uses, see Manic depression (disambiguation).
| Bipolar disorder Classification & external resources | |
| ICD-10 | F31. |
|---|---|
| ICD-9 | 296.80 |
| OMIM | 125480 309200 |
| DiseasesDB | 7812 |
| MedlinePlus | 001528 |
| eMedicine | med/229 |
| MeSH | D001714 |
Bipolar disorder is not a single disorder, but a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood, clinically referred to as mania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes which present with features of both mania and depression. These episodes are normally separated by periods of normal mood, but in some patients, depression and mania may rapidly alternate, known as rapid cycling. The disorder has been subdivided into bipolar I, bipolar II and cyclothymia based on the type and severity of mood episodes experienced.
Also called bipolar affective disorder until recently, the current name is of fairly recent origin and refers to the cycling between high and low episodes; it has replaced the older term manic-depressive illness coined by Emil Kraepelin (1856-1926) in the late nineteenth century.International Kraepelin Society The new term is designed to be neutral, to avoid the stigma in the non-mental health community that comes from conflating "manic" and "depression."
Onset of symptoms generally occurs in young adulthood. Diagnosis is based on the person\'s self-reported experiences, as well as observed behavior. Episodes of illness are associated with distress and disruption, and a relatively high risk of suicide. Ösby, U; Brandt, L & Correia, N et al. (2001), "Excess Mortality in Bipolar and Unipolar Disorder in Sweden", Archives of General Psychiatry 58 (9): 844-850, <http://archpsyc.ama-assn.org/cgi/content/abstract/58/9/844> Studies suggest that genetics, early environment, neurobiology, and psychological and social processes are important contributory factors. Psychiatric research is focused on the role of neurobiology, but a clear organic cause has not been found. Bipolar disorder is usually treated with medications and/or therapy or counseling. The mainstay of medication are a number of drugs termed \'mood stabilizers\', in particular lithium and sodium valproate; these are a group of unrelated medications used to prevent relapses of further episodes. Antipsychotic medications, sometimes called neuroleptics, in particular olanzapine, are used in the treatment of manic episodes and in maintenance. The benefits of using antidepressants in depressive episodes is unclear. In serious cases where there is risk to self and others involuntary hospitalization may be necessary; these generally involve severe manic episodes with dangerous behaviour or depressive episodes with suicidal ideation. Hospital stays are less frequent and for shorter periods than they were in previous years.
Some studies have suggested a significant correlation between creativity and bipolar disorder. However, the relationship between the disorder and creativity is still very unclear. Santosa et al. Enhanced creativity in bipolar disorder patients: A controlled study. J Affect Disord. 2006 23 November; PMID 17126406. Rihmer et al. Creativity and mental illness. Psychiatr Hung. 2006;21(4):288-94. PMID 17170470. Nowakowska et al. Temperamental commonalities and differences in euthymic mood disorder patients, creative controls, and healthy controls. J Affect Disord. 2005 Mar;85(1-2):207-15. PMID 15780691. One study indicated increased striving for, and sometimes attaining, goals and achievements.Johnson SL. (2005) Mania and dysregulation in goal pursuit: a review. Clin Psychol Rev. Feb;25(2):241-62. While the disorder affects people differently, individuals with bipolar disorder tend to be much more outgoing and daring than individuals without bipolar disorder. The disorder is also found in a large number of people involved in the arts. It is an ongoing study as to why many creative geniuses had bipolar disorder.
Contents |
Bipolar disorder is often a cyclic illness where people periodically exhibit elevated (manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting three to six months, although some will experience only a single mood episode. Kessler, RC; McGonagle, KA & Zhao, S et al. (1994), "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States", Archives of General Psychiatry 51 (1): 8-19, <http://archpsyc.ama-assn.org/cgi/content/abstract/51/1/8> Angst, J & Selloro, R (15 September 2000), "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry 48 (6): 445-457, DOI 10.1016/S0006-3223(00)00909-4 Late adolescence and early adulthood are peak years for the onset of the illness.Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ (1988). "(abstract) Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults". Am J Psychiatry 145: 971-975. Retrieved on 2007-07-01. Goodwin & Jamison. p121 These are critical periods in a young adult\'s social and vocational development, and they can be severely disrupted by disease onset.
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, unless there is adjunctive treatment with a mood stabilizer.Treatment of refractory and rapid-cycling bipolar disorder.Sachs, GS, MD, et al (2007) Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression New England Journal of Medicine, Volume 356:1711-1722 (Abstract)
The definition of rapid cycling most frequently cited in the literature is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period. Mackin, P & Young, AH (2004), "Rapid cycling bipolar disorder: historical overview and focus on emerging treatments", Bipolar Disorders 6 (6): 523–529, DOI 10.1111/j.1399-5618.2004.00156.x There are references that describe very rapid (ultra-rapid) or extremely rapid Papolos, DF; Veit, S & Faedda, GL et al. (1998), "Ultra-ultra rapid cycling bipolar disorder is associated with the low activity catecholamine-O-methyltransferase allele", Molecular Psychiatry 3 (4): 346-349, <http://www.nature.com/mp/journal/v3/n4/abs/4000410a.html> (ultra-ultra or ultradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24–48-hour period.
Signs and symptoms of the depressive phase of bipolar disorder include: 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.Bipolar Disorder: Signs and symptoms. Mayo Clinic. In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features.
Mania is generally characterized by a distinct period of an elevated, expansive or irritable mood state. People commonly experience an increase in energy and a decreased need for sleep. A person\'s speech may be pressured, with thoughts experienced as racing. Attention span is low and a person in a manic state may be easily distracted. Judgment may become impaired, the sufferer may go on spending sprees or engage in behavior that is quite abnormal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive or intrusive. People may feel they have been "chosen", or are "on a special mission", which are considered grandiose or delusional ideas. Sexual drive may increase. At more extreme phases, a person in a manic state can begin to experience psychosis, or a break with reality, where thinking is affected along with mood.NIMH · Bipolar Disorder · Complete Publication Many people in a manic state experience severe anxiety and are very irritable (to the point of rage), while others are euphoric and grandiose.
In order to be diagnosed with mania according to DSM-IV, a person must experience this state of elevated or irritable mood as well as other symptoms for at least one week or less if hospitalisation is required. According to the National Institute of Mental Health, "A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present."NIMH · Bipolar Disorder · Complete Publication
Hypomania is generally a less extreme state than mania, and people in the hypomanic phase generally experience fewer symptoms of mania than those in a full-blown manic episode. During an episode, one might feel an uncontrollable impulse to laugh at things he or she does not normally find funny. 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.
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).Bipolar Disorder: Complications. Mayo Clinic. Mixed episodes can be the most volatile of the bipolar states, as moods can easily and quickly be triggered or shifted.[citation needed] Suicide attempts, substance abuse, and self-mutilation may occur during this state.[citation needed]
Diagnosis is based on the self-reported experiences of the patient as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.
An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm bipolar disorder, tests are carried out to exclude medical illnesses which may rarely present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions.[citation needed] There are several psychiatric illnesses which may present with similar symptoms; these include schizophrenia,Pope HG (1983). Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports. Hospital and Community Psychiatry, 34: 322–328. drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder.
The last is important as both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months (notwithstanding Rapid Cycling variant of greater than four episodes a year). The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.Goodwin & Jamison. p108-110
The relationship between bipolar disorder and borderline personality disorder has been debated; some hold that the latter represents a subthreshold form of affective disorder,Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H (1985). "The nosologic status of borderline personality: Clinical and polysomnographic study". Am J Psychiatry 142: 192-198. Gunderson JG, Elliott GR (1985). "The interface between borderline personality disorder and affective disorder". Am J Psychiatry 142: 277-288. while others maintain the distinctness, though noting they often coexist.McGlashan, TH (1983). "The borderline syndrome:Is it a variant of schizophrenia or affective disorder?". Arch Gen Psychiatry 40: 1319-1323. Pope HG Jr, Jonas JM, Hudson JI, Cohen BM, Gunderson JG (1983). "The validity of DSM-III borderline personality disorder: A phenomenologic, family history, treatment response, and long term follow up study". Arch Gen Psychiatry 40: 23-30.
Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, lithium or valproate level to check compliance or toxicity with those medications, renal or thyroid function if lithium has been previously prescribed and taken regularly. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.[citation needed]
The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association\'s Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization\'s International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies.
There is no clear consensus as to how many types of bipolar disorder exist. Akiskal HS, Benazzi F (May 2006). "(abstract) The DSM-IV and ICD-10 categories of recurrent [major depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum.]". J Affect Disord. 92 (1): 45-54. Retrieved on 2007-06-29. In DSM-IV-TR and ICD-10, bipolar disorder is conceptualized as a spectrum of disorders occurring on a continuum. The DSM-IV-TR lists four types of mood disorders which fit into the bipolar categories: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Not Otherwise Specified).
In Bipolar I disorder, an individual has experienced one or more manic episodes with or without major depressive episodes. 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 disorder is characterized by hypomanic episodes as well as at least one major depressive episode. Hypomanic episodes do not go to the extremes of mania (i.e. do not cause social or occupational impairment, and without psychosis), and this can make Bipolar II 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. For both disorders, there are a number of specifiers that indicate the presentation and course of the disorder, including "chronic", "rapid cycling", "catatonic" and "melancholic".
Cyclothymia involves a presence or history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. 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.
Bipolar Disorder Not Otherwise Specified is a catch-all diagnosis that is used to indicate bipolar illness that does not fit into the other diagnostic categories. 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,[citation needed] it is important to find out from the patient or the patient\'s family or friends if a manic or hypomanic episode has ever occurred. 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.
The behavioral manifestations of bipolar disorder are often not understood by patients nor recognized by mental health professionals, so diagnosis may sometimes be delayed for 10 years or more.S. Nassir Ghaemi (2001). Bipolar Disorder: How long does it usually take for someone to be diagnosed for bipolar disorder?. Retrieved on 2007-02-20. That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Recent TV specials, for example the BBC\'s The Secret Life of the Manic Depressive,The Secret Life of the Manic Depressive. BBC (2006). Retrieved on 2007-02-20. MTV\'s True Life: I\'m Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby further raising public awareness. Despite this increased focus, individuals are still commonly misdiagnosed.Roy H. Perlis (2005). Misdiagnosis of Bipolar Disorder. Retrieved on 2007-02-20.
Children with bipolar disorder do not often meet the strict DSM-IV definition, tending to have rapid-cycling or mixed-cycling pattern.Kranowitz, C.S. & Post, R., (1996). Ultra-rapid and ultradian cycling in bipolar affective illness. British Journal of Psychiatry, 168, 314-323. The incidence in this age group has been traditionally held to be very rare.[citation needed] In September 2007, experts (from New York, Maryland and Madrid) found that the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, and it was increasing ever since. They concluded that doctors had been more aggressively applying the diagnosis to children, and not that the incidence of the disorder had increased. The study calculated the number of visits which increased, from 20,000 in 1994 to 800,000 in 2003, or 1% of the population under age 20.New York Times, Bipolar Illness Soars as a Diagnosis for the YoungMoreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. (September 2007) "National trends in the outpatient diagnosis and treatment of bipolar disorder in youth," Archives of General Psychiatry. 64(9):1032-9. PMID 17768268
Often other psychiatric conditions are diagnosed in bipolar children. These other diagnoses may be concurrent problems, or they may be misdiagnosed as bipolar disorder. Depression, ADHD, ODD, schizophrenia, and Tourette syndrome are common comorbid conditions. Furthermore some children with histories of abuse or neglect may have Bipolar I Disorder. There is a high comorbidity between Reactive attachment disorder and Bipolar I Disorder with about 50% of children in the Child Welfare System who have Reactive Attachment Disorder also have Bipolar I Disorder. Alston, J., (2000), Correlation between Childhood Biploar I Disorder and Reactive Attachment Disorder, Disinhibited Type. In Attachment Interventions, Edited ty T. Levy, 2000, Academic Press.
Flux is the fundamental nature of bipolar disorder.Depression and Bipolar Support Alliance: About Mood Disorders Individuals with the illness have continual changes in energy, mood, thought, sleep, and activity. The diagnostic subtypes of bipolar disorder are thus static descriptions — snapshots, perhaps — of an illness in continual flux, 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 (Goodwin & Jamison, 1990). The DSM V, to be published in 2011, will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).
Associated features are clinical phenomenon that often accompany the disorder, but are not part of the diagnostic criteria for the disorder.
Recent studies have found that bipolar disorder involves certain cognitive deficits or impairments, even in states of remission. Martínez-Arán, A; Vieta, E & Reinares, M et al. (February 2004), "Cognitive Function Across Manic or Hypomanic, Depressed, and Euthymic States in Bipolar Disorder", American Journal of Psychiatry 161 (2): 262-270, <http://ajp.psychiatryonline.org/cgi/content/abstract/161/2/262> Rossi, A; Arduini, L & Daneluzzo, E et al. (July 2000), "Cognitive function in euthymic bipolar patients, stabilized schizophrenic patients, and healthy controls", Journal of Psychiatric Research 34 (4-5): 333-339, DOI 10.1016/S0022-3956(00)00025-X "Second Biennial Conference of the International Society for Bipolar Disorders, 2–4 August 2006, Edinburgh, Scotland, Thursday, August 3, 09:00-10:00, Cognitive Function in BD", Bipolar Disorders 8 (Supplement 1): 2–3, August 2006, DOI 10.1111/j.1399-5618.2006.00379_2.x Zubieta, J-K; Huguelet, P & O\'Neil, RL et al. (10 May 2001), "Cognitive function in euthymic Bipolar I Disorder", Psychiatry Research 102 (1): 9-20, DOI 10.1016/S0165-1781(01)00242-6
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.17 November>Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski (2006). "Bipolar Disorder: Defining Remission and Selecting Treatment". Psychiatric Times. .However, in the April-June 2007 issue of the Journal of Psychiatric Research, Spanish researchers reported that people with bipolar 1 who have a history of psychotic symptoms do not necessarily experience an increase in cognitive impairment.[citation needed]
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.
Clinical depression and bipolar disorder are classified as separate illnesses. Some researchers increasingly view them as part of an overlapping spectrum that also includes anxiety and psychosis.
According to Hagop Akiskal, M.D., at the one end of the spectrum is bipolar type schizoaffective disorder, and at the other end is unipolar depression (recurrent or not recurrent), with the anxiety disorders present across the spectrum. Also included in this view is premenstrual dysphoric disorder, postpartum depression, and postpartum psychosis. This view helps to explain why many people who have the illness do not have first-degree relatives with clear-cut "bipolar disorder", but who have family members with a history of these other disorders.
In a 2003 study, Hagop Akiskal M.D. and Lew Judd M.D. re-examined data from the landmark Epidemiologic Catchment Area study from two decades before.Judd, Lewis L.; Hagop S. Akiskal (January 2003). "The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases". Journal of Affective Disorders 73 (1-2): 123-131. doi:10.1016/S0165-0327(02)00332-4. The original study found that 0.8 percent of the population surveyed had experienced a manic episode at least once (the diagnostic threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for bipolar II).
By tabulating survey responses to include sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, the authors arrived at an additional 5.1 percent of the population, adding up to a total of 6.4 percent of the entire population who can be thought of as having a bipolar spectrum disorder. This and similar recent studies have been interpreted by some prominent bipolar disorders researchers as evidence for a much higher prevalence of bipolar conditions in the general population than previously thought.
However these re-analyses should be interpreted cautiously because of substantive as well as methodological study limitations. Indeed, prevalence studies of bipolar disorder are carried out by lay interviewers (that is, not by expert clinicians/psychiatrists who are more costly to employ) who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity.
Furthermore, a well-known statistical problem arises when ascertaining disorders and conditions with a relatively low population prevalence or base-rate, such as bipolar disorder: even assuming that lay interviews diagnoses are highly accurate in terms of sensitivity and specificity and their corresponding area under the ROC curve (that is, AUC, or area under the receiver operating characteristic curve), a condition with a relatively low prevalence or base-rate is bound to yield high false positive rates, which exceed false negative rates; in such a circumstance a limited positive predictive value, PPV, yields high false positive rates even in presence of a specificity which is very close to 100%.Baldessarini, Ross J.; Finklestein S., Arana G. W. (May 1983). "The predictive power of diagnostic tests and the effect of prevalence of illness". Archives of General Psychiatry 40 (5): 569-573. To simplify, it can be said that a very small error applied over a very large number of individuals (that is, those who are *not affected* by the condition in the general population during their lifetime; for example, over 95%) produces a relevant, non-negligible number of subjects who are incorrectly classified as having the condition or any other condition which is the object of a survey study: these subjects are the so-called false positives; such reasoning applies to the \'false positive\' but not the \'false negative\' problem where we have an error applied over a relatively very small number of individuals to begin with (that is, those who are *affected* by the condition in the general population; for example, less than 5%). Hence, a very high percentage of subjects who seem to have a history of bipolar disorder at the interview are false positives for such a medical condition and apparently never suffered a fully clinical syndrome (that is, bipolar disorder type I): the population prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, continues to be estimated at 1%.Soldani, Federico; Sullivan P. F. Pedersen N. L. (Apr 2005). "Mania in the Swedish Twin Registry: criterion validity and prevalence". Australian and New Zealand of Psychiatry 39 (4): 235-243. "Mild-to-severe versions of bipolar disorder afflict nearly 4 percent of adults at some time in their lives."Bipolar Surprise, Science News, March 31 2007, vol. 171, #13, p.196
A different but related problem in evaluating the public health significance of psychiatric conditions has been highlighted by Robert Spitzer of Columbia University: fulfillment of diagnostic criteria and the resulting diagnosis do not necessarily imply need for treatment.Spitzer, Robert (Feb 1998). "Diagnosis and need for treatment are not the same". Archives of General Psychiatry 55 (2): 120. As a consequence, subjects who experience bipolar symptoms but not a full-blown, impairing bipolar syndrome should not be automatically considered as patients in need of treatment.
Recent studies have indicated that at least 50% of adult sufferers report manifestation of symptoms before the age of 17. Moreover, there is a growing consensus that bipolar disorder originates in childhood. In young children the illness is now referred to as pediatric bipolar disorder. Today about 0.5% of children under 18 are believed to have the condition. For children, the main concern is that bipolar disorder needs to be diagnosed correctly and treated properly because it can look like unipolar depression, ADHD, or conduct disorder. Young children, adolescents and adults each express the condition differently according to child and adolescent bipolar disorders expert Demitri Papolos M.D. and the Child and Adolescent Bipolar Foundation. There is, however, controversy about this last point.Bipolar Disorder in Children and Adolescents: a Caution. psycheducation.org.
Bipolar disorder manifests in late life as well. Some individuals with "hyperthymic" temperament (or "hypomanic" personality style) who experience depression in later life appear to have a form of bipolar disorder. Much more needs to be elucidated about late-life bipolar disorder.
Approximately 50% of children in the U.S. child welfare system who have reactive attachment disorder also have comorbid Bipolar I disorder according to research by John Alston, MD.
A debate rages in the medical community on the prevalence of bipolar disorders.» Bipolar Controversy - Psych Central News Concerns have arisen about the potential for overdiagnosis of BD.Bipolar Disorder: Particle or Wave? DSM Categories or Spectrum Dimensions? One controversy has been the validity of the construct of a mental disorder across different cultural perspectives (Lopez & Guarnaccia 2000, Sher & Trull 1996).http://www.dr-rock.com/SWG606IJ02.pdf Culture-bound syndromes represent recurrent patterns of maladaptive behaviors and/or troubling experiences specifically associated with different cultures or localities (APA, 1994b).Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder It can be difficult to distinguish between age-appropriate restlessness, the fidgeting of children with ADHD, and the purposeful busy activity of mania (Harrington & Myatt, 2003).Log In Problems Further complicating the diagnosis: Abused or traumatized children can seem to have bipolar disorder when they are actually reacting to horrors in their lives.Bipolar labels for children stir concern - The Boston Globe Assumptions regarding behavior, particularly in regard to diagnosing bipolar disorder, ADHD, and mania in children and adolescents, have raised considerable questions regarding unnecessary treatment. Antipsychotic drugs prescribed for the treatment of BD may increase risk to health including heart problems, diabetes, liver failure, and death.USATODAY.com - New antipsychotic drugs carry risks for children "Consequences of overdiagnosis … include exposure to a greater medication burden (in some cases requiring additional monitoring) as well as lesser likelihood of clinical improvement."http://www.ajmc.com/files/articlefiles/A127_05octPerlisS271toS274.pdf When checking for a misdiagnosis of Bipolar disorder or confirming a diagnosis of Bipolar disorder, it is useful to consider what other medical conditions might be possible misdiagnoses or other alternative conditions relevant to diagnosis.Misdiagnosis of Bipolar disorder - WrongDiagnosis.com
According to the U.S. government\'s National Institute of Mental Health (NIMH), "There is no single cause for bipolar disorder — rather, many factors act together to produce the illness." "Because bipolar disorder tends to run in families, researchers have been searching for specific genes passed down through generations that may increase a person\'s chance of developing the illness." "In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.".NIMH. What Causes Bipolar Disorder?.
It is well established that bipolar disorder is a genetically influenced condition which can respond very well to medication (Johnson & Leahy, 2004; Miklowitz & Goldstein, 1997; Frank, 2005). (See treatment of bipolar disorder for a more detailed discussion of treatment.)
Psychological factors also play a strong role in both the psychopathology of the disorder and the psychotherapeutic factors aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and, practising the factors that lead to maintenance of remission (Lam et al, 1999; Johnson & Leahy, 2004; Basco & Rush, 2005; Miklowitz & Goldstein, 1997; Frank, 2005). Modern evidence based psychotherapies designed specifically for bipolar disorder when used in combination with standard medication treatment increase the time the individual stays well significantly longer than medications alone (Frank, 2005). These psychotherapies are interpersonal and social rhythm therapy for bipolar disorder, family focused therapy for bipolar disorder, psychoeducation, cognitive therapy for bipolar disorder, and prodrome detection. All except psychoeducation and prodrome detection are available as books.
Abnormalities in brain function have been related to feelings of anxiety and lower stress resilience. When faced with a very stressful, negative major life event, such as a failure in an important area, an individual may have his first major depression. Conversely, when an individual accomplishes a major achievement he may experience his first hypomanic or manic episode. Individuals with bipolar disorder tend to experience episode triggers involving either interpersonal or achievement-related life events. An example of interpersonal-life events include falling in love or, conversely, the death of a close friend. Achievement-related life events include acceptance into an elite graduate school or by contrast, being fired from work (Miklowitz & Goldstein, 1997). Childbirth can also trigger a postpartum psychosis for bipolar women, which can lead in the worst cases to infanticide.
The "kindling" theory asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events,Link and reference involving kindling theory each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and becomes recurrent) by itself. Not all individuals experience subsequent mood episodes in the absence of positive or negative life events, however.
Individuals with late-adolescent/early adult onset of the disorder will very likely have experienced childhood anxiety and depression. Some argue that childhood-onset bipolar disorder should be treated early.
A family history of bipolar spectrum disorders can impart a genetic predisposition towards developing a bipolar spectrum disorder.Genetics and Risk PsychEducation.org Since bipolar disorders are polygenic (involving many genes), there are apt to be many unipolar and bipolar disordered individuals in the same family pedigree. This is very often the case (Barondes, 1998). Anxiety disorders, clinical depression, eating disorders, premenstrual dysphoric disorder, postpartum depression, postpartum psychosis and/or schizophrenia may be part of the patient\'s family history and reflects a term called "genetic loading".
Bipolar disorder is not either environmental or physiological, it is multifactorial; that is, many genes and environmental factors conspire to create the disorder (Johnson & Leahy, 2004).
Since bipolar disorder is so heterogeneous, it is likely that people experience different pathways towards the illness (Miklowitz & Goldstein, 1997).
Recent research done in Japan indicates a hypothesis of dysfunctional mitochondria in the brain (Stork & Renshaw, 2005).
The disorder runs in families. McGuffin, P; Rijsdijk, F & Andrew, M et al. (2003), "The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression", Archives of General Psychiatry 60 (5): 497-502, <http://archpsyc.ama-assn.org/cgi/content/abstract/60/5/497> More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression.
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.
There is increasing evidence for a genetic component in the causation of bipolar disorder, provided by a number of twin studies and gene linkage studies.
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. Dizygotic twins have a 23% concordance rate. These concordance rates are not universally replicated in the literature; recent studies have shown rates of around 40% for monozygotic and <10% for dizygotic twins (see Kieseppa, 2004 and Cardno, 1999).[1] Kieseppa T, Partonen T, Haukka J, Kaprio J, Lonnqvist J. (2004) High concordance of bipolar I disorder in a nationwide sample of twins.[2] Cardno AG, Marshall EJ, Coid B, Macdonald AM, Ribchester TR, Davies NJ, Venturi P, Jones LA, Lewis SW, Sham PC, Gottesman II, Farmer AE, McGuffin P, Reveley AM, Murray RM. (1999) Heritability estimates for psychotic disorders: the Maudsley twin psychosis series.
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.Barrett TB, Hauger RL, Kennedy JL, Sadovnick AD, Remick RA, Keck PE, McElroy SL, Alexander M, Shaw SH, Kelsoe JR. (May 2003). "Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder". Molecular Psychiatry 8 (5): 546-57. doi:10.1038/sj.mp.4001268.
A 2007 gene-linkage study by an international team coordinated by the NIMH has identified a number of genes as likely to be involved in the etiology of bipolar disorder, suggesting that bipolar disorder may be a polygenic disease. The researchers at NIMH have found a correlation between DGKH (diacylglycerol kinase eta) and bipolar disorder. The portion of the genome that encodes DGKH, a key protein in the lithium-sensitive phosphatidyl inositol pathway. Baum, A E & McMahon, F J (8 May 2007), "A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and several other genes in the etiology of bipolar disorder.", Molecular Psychiatry, <http://www.nature.com/mp/journal/vaop/ncurrent/abs/4002012a.html>
Bipolar disorder cannot be cured, instead the emphasis of treatment is on effective management of acute episodes and prevention of further episodes by use of pharmacological and psychotherapeutic techniques.
Hospitalization may occur, especially with manic episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur.Becker T, Kilian R. (2006) Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? Acta Psychiatrica Scandinavica Supplement, 429, 9–16. PMID 16445476 Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups.McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. Am J Psychiatry. Mar;164(3):437–41. PMID 17329468
The mainstay of treatment is a mood stabilizer medication; these comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is lithium,Poolsup N, Li Wan Po A, de Oliveira IR. (2000) Systematic overview of lithium treatment in acute mania. J Clin Pharm Ther 25: 139-156 PMID: 10849192 while almost as widely used is sodium valproate,Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G. (2002). "(abstract) Valproate for acute mood episodes in bipolar disorder". The Cochrane Database of Systematic Reviews (2). John Wiley and Sons, Ltd.. doi:10.1002/14651858.CD004052. ISSN 1464-780X. originally used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder, and lamotrigine, which is the first one to be shown to be of benefit in bipolar depression.Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD.(1999) A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. J Clin Psychiatry 60: 79-88
Treatment of the agitation in acute manic episodes has often required the use of antipsychotic medications, such as Quetiapine, Olanzapine and Chlorpromazine. More recently, Olanzapine and Quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder. Now Approved: ZYPREXA for maintenance therapy for bipolar disorder. Official Zyprexa Website. A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.Tohen, Mauricio; Waldemar Greil, Joseph R. Calabrese, Gary S. Sachs, Lakshmi N. Yatham, Bruno Müller Oerlinghausen, Athanasios Koukopoulos, Giovanni B. Cassano, Heinz Grunze, Rasmus W. Licht, Liliana Dell’Osso, Angela R. Evans, Richard Risser, Robert W. Baker, Heidi Crane, Martin R. Dossenbach and Charles L. Bowden (July 2005). "Olanzapine Versus Lithium in the Maintenance Treatment of Bipolar Disorder: A 12-Month, Randomized, Double-Blind, Controlled Clinical Trial". American Journal of Psychiatry 162 (7): 1281-1290.
The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes, especially if no mood stabiliser is used. However, most mood stabilizers are of limited effectiveness in depressive episodes.
The following studies are ongoing, and are recruiting volunteers:
The Maudsley Bipolar Twin Study, based at the Institute of Psychiatry in London is conducting research about the genetic basis of bipolar disorder using twin methodology. Currently recruiting volunteers: identical and non-identical twins pairs, where either one or both twins has a diagnosis of bipolar I or II.
The Maudsley Bipolar eMonitoring Project, another research study based at the Institute of Psychiatry in London, 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. The study is currently recruiting volunteers from all over the world (see Remote eMonitoring)
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 amygdala,Strakowski, S.M., DelBello, M.P, Sax, K.W. et. al. (1999). "Brain magnetic resonance imaging of structural abnormalities in bipolar disorder," Archives of General Psychiatry, 56:254–60. prefrontal cortexPrefrontal Cortex in Bipolar Disorder Neurotransmitter.net. 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,Emma Young (2006). New gene linked to bipolar disorder. New Scientist. may influence the development of new and better treatments, and may ultimately aid in early diagnosis and even a cure.
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.LFMS: Low Field Magnetic Stimulation: Original EP-MRSI Study in Volunteers with Bipolar Disorder McLean Hospital Neuroimaging Center.Rohan, Michael; Aimee Parow, Andrew L. Stoll, Christina Demopulos, Seth Friedman, Stephen Dager, John Hennen, Bruce M. Cohen, and Perry F. Renshaw (January 2004). "Low-Field Magnetic Stimulation in Bipolar Depression Using an MRI-Based Stimulator". American Journal of Psychiatry 161 (1): 93-98. PubMed.
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.http://www.nimh.nih.gov/studies/studies_ct.cfm?id=4.
Transcranial magnetic stimulation is another fairly new technique being studied.
Pharmaceutical research is extensive and ongoing, as seen at clinicaltrials.gov.
A good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder continues to have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar disorder can be a severely disabling medical condition. However, with appropriate treatment, many individuals with bipolar disorder can live full and satisfying lives. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.
Ultimately one\'s prognosis depends on many factors, which are, in fact, under the individual\'s control: the right medicines; the right dose of each; a very informed patient; a good working relationship with a competent medical doctor; a competent, supportive and warm therapist; a supportive family or significant other; and a balanced lifestyle including a regulated stress level, regular exercise and regular sleep and wake times.
There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one\'s energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one\'s doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.Introduction. cs.umd.edu. Retrieved on 2008-02-16.
Even when on medication, some people may still experience weaker episodes, or have a complete manic or depressive episode. In fact, a recent study found bipolar disorder to be "characterized by a low rate of recovery, a high rate of recurrence, and poor interepisodic functioning." Worse, the study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately 2-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States."Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski "Bipolar Disorder: Defining Remission and Selecting Treatment" Vol. XXIII, No. 11 (October 2006)
The following behaviors can lead to depressive or manic recurrence:
