The phenomenon of bipolar affective disorder has been a mystery since the 16th
century. History has shown that this affliction can appear in almost anyone.
Even the great painter Vincent Van Gogh is believed to have had bipolar
disorder. It is clear that in our society many people live with bipolar
disorder; however, despite the abundance of people suffering from the it, we are
still waiting for definite explanations for the causes and cure. The one fact of
which we are painfully aware is that bipolar disorder severely undermines its`
victims ability to obtain and maintain social and occupational success. Because
bipolar disorder has such debilitating symptoms, it is imperative that we remain
vigilant in the quest for explanations of its causes and treatment. Affective
disorders are characterized by a smorgasbord of symptoms that can be broken into
manic and depressive episodes. The depressive episodes are characterized by
intense feelings of sadness and despair that can become feelings of hopelessness
and helplessness. Some of the symptoms of a depressive episode include anhedonia,
disturbances in sleep and appetite, psycomoter retardation, loss of energy,
feelings of worthlessness, guilt, difficulty thinking, indecision, and recurrent
thoughts of death and suicide (Hollandsworth, Jr. 1990 ). The manic episodes are
characterized by elevated or irritable mood, increased energy, decreased need
for sleep, poor judgment and insight, and often reckless or irresponsible
behavior (Hollandsworth, Jr. 1990 ). Bipolar affective disorder affects
approximately one percent of the population (approximately three million people)
in the United States. It is presented by both males and females. Bipolar
disorder involves episodes of mania and depression. These episodes may alternate
with profound depressions characterized by a pervasive sadness, almost inability
to move, hopelessness, and disturbances in appetite, sleep, in concentrations
and driving. Bipolar disorder is diagnosed if an episode of mania occurs whether
depression has been diagnosed or not (Goodwin, Guze, 1989, p 11). Most commonly,
individuals with manic episodes experience a period of depression. Symptoms
include elated, expansive, or irritable mood, hyperactivity, pressure of speech,
flight of ideas, inflated self esteem, decreased need for sleep,
distractibility, and excessive involvement in reckless activities (Hollandsworth,
Jr. 1990 ). Rarest symptoms were periods of loss of all interest and retardation
or agitation (Weisman, 1991). As the National Depressive and Manic Depressive
Association (MDMDA) has demonstrated, bipolar disorder can create substantial
developmental delays, marital and family disruptions, occupational setbacks, and
financial disasters. This devastating disease causes disruptions of families,
loss of jobs and millions of dollars in cost to society. Many times bipolar
patients report that the depressions are longer and increase in frequency as the
individual ages. Many times bipolar states and psychotic states are misdiagnosed
as schizophrenia. Speech patterns help distinguish between the two disorders (Lish,
1994). The onset of Bipolar disorder usually occurs between the ages of 20 and
30 years of age, with a second peak in the mid-forties for women. A typical
bipolar patient may experience eight to ten episodes in their lifetime. However,
those who have rapid cycling may experience more episodes of mania and
depression that succeed each other without a period of remission (DSM III-R).
The three stages of mania begin with hypomania, in which patients report that
they are energetic, extroverted and assertive (Hirschfeld, 1995). The hypomania
state has led observers to feel that bipolar patients are "addicted"
to their mania. Hypomania progresses into mania and the transition is marked by
loss of judgment (Hirschfeld, 1995). Often, euphoric grandiose characteristics
are displayed, and paranoid or irritable characteristics begin to manifest. The
third stage of mania is evident when the patient experiences delusions with
often paranoid themes. Speech is generally rapid and hyperactive behavior
manifests sometimes associated with violence (Hirschfeld, 1995). When both manic
and depressive symptoms occur at the same time it is called a mixed episode.
Those afflicted are a special risk because there is a combination of
hopelessness, agitation, and anxiety that makes them feel like they "could
jump out of their skin"(Hirschfeld, 1995). Up to 50% of all patients with
mania have a mixture of depressed moods. Patients report feeling dysphoric,
depressed, and unhappy; yet, they exhibit the energy associated with mania.
Rapid cycling mania is another presentation of bipolar disorder. Mania may be
present with four or more distinct episodes within a 12 month period. There is
now evidence to suggest that sometimes rapid cycling may be a transient
manifestation of the bipolar disorder. This form of the disease exhibits more
episodes of mania and depression than bipolar. Lithium has been the primary
treatment of bipolar disorder since its introduction in the 1960's. It is main
function is to stabilize the cycling characteristic of bipolar disorder. In four
controlled studies by F. K. Goodwin and K. R. Jamison, the overall response rate
for bipolar subjects treated with Lithium was 78% (1990). Lithium is also the
primary drug used for long- term maintenance of bipolar disorder. In a majority
of bipolar patients, it lessens the duration, frequency, and severity of the
episodes of both mania and depression. Unfortunately, as many as 40% of bipolar
patients are either unresponsive to lithium or can not tolerate the side
effects. Some of the side effects include thirst, weight gain, nausea, diarrhea,
and edema. Patients who are unresponsive to lithium treatment are often those
who experience dysphoric mania, mixed states, or rapid cycling bipolar disorder.
One of the problems associated with lithium is the fact the long-term lithium
treatment has been associated with decreased thyroid functioning in patients
with bipolar disorder. Preliminary evidence also suggest that hypothyroidism may
actually lead to rapid-cycling (Bauer et al., 1990). Another problem associated
with the use of lithium is experienced by pregnant women. Its use during
pregnancy has been associated with birth defects, particularly Ebstein's
anomaly. Based on current data, the risk of a child with Ebstein's anomaly being
born to a mother who took lithium during her first trimester of pregnancy is
approximately 1 in 8,000, or 2.5 times that of the general population (Jacobson
et al., 1992). There are other effective treatments for bipolar disorder that
are used in cases where the patients cannot tolerate lithium or have been
unresponsive to it in the past. The American Psychiatric Association's
guidelines suggest the next line of treatment to be Anticonvulsant drugs such as
valproate and carbamazepine. These drugs are useful as antimanic agents,
especially in those patients with mixed states. Both of these medications can be
used in combination with lithium or in combination with each other. Valproate is
especially helpful for patients who are lithium noncompliant, experience
rapid-cycling, or have comorbid alcohol or drug abuse. Neuroleptics such as
haloperidol or chlorpromazine have also been used to help stabilize manic
patients who are highly agitated or psychotic. Use of these drugs is often
necessary because the response to them are rapid, but there are risks involved
in their use. Because of the often severe side effects, Benzodiazepines are
often used in their place. Benzodiazepines can achieve the same results as
Neuroleptics for most patients in terms of rapid control of agitation and
excitement, without the severe side effects. Antidepressants such as the
selective serotonin reuptake inhibitors (SSRI`s) fluovamine and amitriptyline
have also been used by some doctors as treatment for bipolar disorder. A
double-blind study by M. Gasperini, F. Gatti, L. Bellini, R.Anniverno, and E.
Smeraldi showed that fluvoxamine and amitriptyline are highly effective
treatments for bipolar patients experiencing depressive episodes (1992). This
study is controversial however, because conflicting research shows that SSRI`s
and other antidepressants can actually precipitate manic episodes. Most doctors
can see the usefulness of antidepressants when used in conjunction with mood
stabilizing medications such as lithium. In addition to the mentioned medical
treatments of bipolar disorder, there are several other options available to
bipolar patients, most of which are used in conjunction with medicine. One such
treatment is light therapy. One study compared the response to light therapy of
bipolar patients with that of unipolar patients. Patients were free of
psychotropic and hypnotic medications for at least one month before treatment.
Bipolar patients in this study showed an average of 90.3% improvement in their
depressive symptoms, with no incidence of mania or hypomania. They all continued
to use light therapy, and all showed a sustained positive response at a three
month follow-up (Hopkins and Gelenberg, 1994). Another study involved a four
week treatment of bright morning light treatment for patients with seasonal
affective disorder and bipolar patients. This study found a statistically
significant decrement in depressive symptoms, with the maximum antidepressant
effect of light not being reached until week four (Baur, Kurtz, Rubin, and
Markus, 1994). Hypomanic symptoms were experienced by 36% of bipolar patients in
this study. Predominant hypomanic symptoms included racing thoughts, deceased
sleep and irritability. Surprisingly, one-third of controls also developed
symptoms such as those mentioned above. Regardless of the explanation of the
emergence of hypomanic symptoms in undiagnosed controls, it is evident from this
study that light treatment may be associated with the observed symptoms. Based
on the results, careful professional monitoring during light treatment is
necessary, even for those without a history of major mood disorders. Another
popular treatment for bipolar disorder is electro-convulsive shock therapy. ECT
is the preferred treatment for severely manic pregnant patients and patients who
are homicidal, psychotic, catatonic, medically compromised, or severely
suicidal. In one study, researchers found marked improvement in 78% of patients
treated with ECT, compared to 62% of patients treated only with lithium and 37%
of patients who received neither, ECT or lithium (Black et al., 1987). A final
type of therapy that I found is outpatient group psychotherapy. According to Dr.
John Graves, spokesperson for The National Depressive and Manic Depressive
Association has called attention to the value of support groups, and challenged
mental health professionals to take a more serious look at group therapy for the
bipolar population. Research shows that group participation may help increase
lithium compliance, decrease denial regarding the illness, and increase
awareness of both external and internal stress factors leading to manic and
depressive episodes. Group therapy for patients with bipolar disorders responds
to the need for support and reinforcement of medication management, and the need
for education and support for the interpersonal difficulties that arise during
the course of the disorder.

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