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Bipolar disorder is a Psychiatric condition defined as recurrent episodes of significant disturbance in Mood . These disturbances can occur on a Spectrum that ranges from debilitating Depression to unbridled Mania . Individuals suffering from bipolar disorder typically experience fluid states of Mania , Hypomania or what is referred to as a Mixed State in conjunction with Depressive episodes. These clinical states typically alternate with a normal range of mood. The disorder has been subdivided into Bipolar I , Bipolar II and Cyclothymia , with both Bipolar I and Bipolar II potentially presenting with Rapid Cycling . 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 19th century. {Link without Title} 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 .
Studies suggest that Genetics , early environment, Neurobiology , and psychological and social processes are important contributory factors. Current 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 Stabilizer s', in particular Lithium and Sodium Valproate ; these are a group of unrelated medications used to prevent relapses of further episodes. Antipsychotic medications, sometimes called Neuroleptic s, in particular Olanzapine , are used in the treatment of manic episodes and in maintenance. The benefits of using Antidepressant s 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 Nov 23; 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 obtaining, goals and achievements.Johnson SL. (2005) Mania and dysregulation in goal pursuit: a review. ''Clin Psychol Rev.'' Feb;25(2):241-62. SIGNS AND SYMPTOMS Bipolar disorder is 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 3-6 months.
Late adolescence and early adulthood are peak years for the onset of the illness.1Goodwin & Jamison. p121 These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset. Classification Bipolar disorder is commonly categorized 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.2 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. Depressive phase See Also: Clinical Depression 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 .3 Mania See Also: Mania 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. People may feel they have been 'chosen', or are 'on a special mission', which are considered grandiose or delusional ideas. 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. 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 two or more weeks. Hypomania See Also: Hypomania Hypomania is generally a less extreme state than mania, and people in the hypomanic phase generally experience fewer of the symptoms of mania than those in a full-blown manic episode. During an episode of Hypomania, 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. Mixed state See Also: Mixed state (psychiatry) In the context of bipolar disorder, a mixed state is a condition during which symptoms of , Insomnia , Irritability , morbid and/or Suicidal Ideation , Panic , Paranoia , persecutory delusions, pressured speech, racing thoughts, restlessness, and Rage ).4 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 Antidepressant s, unless there is adjunctive treatment with a mood stabilizer.5Sachs, 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.
There are references that describe very rapid (ultra-rapid) or extremely rapid
(ultra-ultra or ultraradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24-48 hour period. Cognition Recent studies have found that bipolar disorder involves certain Cognitive Deficit s 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), 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. Creativity See Also: 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. DIAGNOSIS 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 , 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 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,78 while others maintain the distinctness, though noting they often coexist.910 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. 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. Diagnostic criteria See Also: 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 hypomanic 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. Delay in diagnosis The behavioral manifestations of bipolar disorder are often not understood by patients nor recognized by mental health professionals, so people may suffer unnecessarily for over 10 years in some cases before receiving proper treatment.11 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 Special s, for example the BBC's ''The Secret Life of the Manic Depressive'',12 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.13 Children See Also: Bipolar disorder in children Children with bipolar disorder do not often meet the strict DSM-IV definition. In pediatric cases, the cycling can occur very quickly (see section above on rapid cycling).Kranowitz, C.S. & Post, R., (1996). Ultra-rapid and ultradian cycling in bipolar affective illness. British Journal of Psychiatry, 168, 314-323. Children with bipolar disorder tend to have rapid-cycling or mixed-cycling. Rapid cycling occurs when the cycles between depression and mania occur quickly, sometimes within the same day or the same hour. When the symptoms of both mania and depression occur simultaneously, mixed cycling occurs. 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. Misdiagnosis can lead to incorrect medication. On 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. However, the increase was due to the fact that Doctors more aggressively applied 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. [http://www.nytimes.com/2007/09/04/health/04psych.html?em&ex=1189051200&en=13c932cc4a338702&ei=5087%0A New York Times, Bipolar Illness Soars as a Diagnosis for the Young] EPIDEMIOLOGY Clinical depression and bipolar disorder are currently 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 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 Clinician s/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. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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