Bipolar I disorder is an axis 1 clinical disorder in the DSM-IV and is a serious mental illness that can lead to suicidal ideation or action. The history of bipolar disorder research is a long one, and understanding of the disease has deepened considerably over the last several generations. Diagnosis of bipolar disorder 1 is complicated by its resemblance to other mood disorders, mainly major depression but also psychotic disorders like schizophrenia. Research is revealing new treatment interventions that are targeted to the biological needs of bipolar patients, as antidepressants are often or usually contraindicated. A Christian worldview suggests that individualized treatment plans take into account the family history and patient's lifestyle when recommending a treatment plan.
Bipolar I disorder is a serious mental illness that affects between 1 and 2.5% of the general population in the United States (Ghaznavi & Deckersbach, 2012). The more conservative estimate, 1%, is generally reserved for Bipolar 1 disorder, the most severe on the bipolar spectrum (Hirschfeld, et al., 2000). Bipolar disorder has been written about in psychiatric and medical literature for centuries, and yet there is little progress in terms of finding an absolute cure. According to Angst & Sellaro (2000), two centuries of literature on bipolar disorder has shown mainly that the disease is "highly recurrent and considered to have a poor prognosis," (p. 445). Early historical evidence of bipolar existing in the general population stems back to ancient Greece, when Aretaeus of Cappadocia "first recognized some symptoms of mania and depression, and felt they could be linked to each other," ("A Brief History of Bipolar Disorder," 2012). That was in the first century after Christ, showing how deeply rooted manic-depressive disorder is in the human experience.
The coexistence of mania and depression in the same individual, manifesting collective symptoms exhibited intermittently, was again posited as a specific mental illness in the modern era. In 1854, French scientist Jules Farlet again linked depression and episodes of heightened mood, as well as suicide, referring to the phenomenon as "folie circulaire," or circular insanity ("A Brief History of Bipolar Disorder," 2012). In 1875, Falret and his contemporaries Francois Baillarger and Emil Kraepelin classified folie circulaire as a psychiatric illness and named it officially Manic-Depressive Psychosis ("A Brief History of Bipolar Disorder," 2012; Angst & Sellaro 2000). It was in 1899 that Kraepelin unified "all types of affective disorders," beneath one umbrella term. Kraepelin's concept of "mixed states" of affective disorder was a view that persisted as late as the 1960s (Angst & Marneros, 2001, p. 3). This early research showed that there was great awareness that depression and mania often went hand in hand. Furthermore, Falret and Baillarger were the first researchers to hypothesize a genetic component to Manic-Depressive Psychosis, now called bipolar disorder ("A Brief History of Bipolar Disorder," 2012).
German researchers also contributed to the first psychiatric classifications of manic-depression. In particular, Ewald Hecker (1843-1909) and Karl Ludwig Kahlbaum (1828-1899) "laid the groundwork for modern descriptive psychiatry," (Baethge, Salvatore & Baldessarini, 2003, p 377). In 1882, Hecker and Kahlbaum proposed the existence of a relatively benign form of manic-depressive illness," which the researchers called cyclothymia (Baethge, Salvatore & Baldessarini, 2003). The basic cyclothymia framework included "depressive (dysthymia), hypomanic (hyperthymia), and mixed hypomanic-depressive phases," a classification system that continues to underwrite today's Diagnostic and Statistical Manual (DSM) on bipolar disorder. In fact, cyclothymia is the term used in the current, fourth edition of the DSM (DSM-IV) to describe "a milder form of the bipolar II subtype" of bipolar disorder (DNS Learning Center, 2012).
The twentieth century saw revitalization in research on manic-depressive illness. Whereas the Falret, Baillarger and Kraepelin research, and even the Hecker and Kahlbaum classification system, of the late nineteenth and early twentieth centuries, were mainly theoretical and exploratory, empirical research would help psychiatrists and psychologists classify the disease with greater certainty. In the 1960s, Jules Angst, Carlo Perris, and George Winokur conducted independent empirical studies validating the concept of manic-depression (Angst & Marneros, 2001). Research was used to distinguish between unipolar (one state, such as depression) and bipolar (two states, mania and depression) affective disorders, therefore challenging the assumption made by Kraepelin that all affective disorders shared common roots and manifestations in symptoms (Angst & Marneros, 2001).
In fact, Kraepelin laid the groundwork for future research that showed that affective disorders do share certain features in common, but that there are several branches to the main trees of these disorders. Hecker and Kahlbaum's concept of cyclothymia has also made a resurgence in modern psychiatric diagnostic literature. The most important feature of the Hecker and Kahlbaum cyclothymia diagnosis is that it has contributed to an understanding of the continuum of symptoms that now comprises the bipolar spectrum.
Diagnosis: The Bipolar Spectrum of Disorders
Bipolar disorder is an Axis I diagnosis in the DSM-IV in the category of Mood Disorder. The Mood Disorder rubric encompasses not only bipolar disorders but also major depressive disorder, general depression, dysthymic disorder, substance-induced mood disorder, and mood disorders that are otherwise unspecified. Mood disorders are distinct from other Axis I mental disorders such as psychotic disorders. Moreover, mood disorders, like all Axis I clinical diagnoses are distinguished from any Axis II diagnosis related to personality disorders. Comorbidity with other clinical and personality disorders is not uncommon.
Several mental illnesses classified in the DSM-IV are listed as spectrum disorders; that is, there is an array of specific manifestations of the parent problem. For example, autism is a "spectrum" of disorders that includes Asperger's syndrome. With bipolar disorder, there are four sub-species of disease including bipolar disorder I, bipolar disorder II, cycloythymia, and bipolar not otherwise specified (NOS).
The bipolar spectrum is predicted on the Hecker and Kahlbaum cyclothymia concept being the "soft" side of the continuum (Marneros, 2001, p. 39). Now, cyclothymia has its own entry in the DSM-IV as a milder form of bipolar disorder -- meaning that the episodes of mania and depression are not as severe symptomatically as they would be for a person with full-fledged bipolar disorder. Bipolar disorder II is ranked next in terms of relative severity of symptoms, and bipolar I disorder is the more serious side of the continuum. Because bipolar 1 is qualitatively and measurably different from the other members of the bipolar family of illnesses, it has been given its own name: Cade's Disease (Ghaemi & Goodwin, 2002).
Whereas bipolar II disorder is classified by hypomania, bipolar I is characterized by full-blown mania. The difference is in degree. Manic episodes are also classified as being mild moderate, severe, and very severe ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89," n.d.). In keeping with the original Kraepelin classification, manic states in the DSM-IV include hypomania, acute mania, delusional mania, and delirious mania ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89," n.d.). Hypomania is the prerequisite for a bipolar II disorder diagnosis. Hypomania refers to elevated mood, coupled with a sense of high self-esteem. Mania, on the other hand, will be accompanied by hallucinations or delusions of grandeur. "Religious delusions are very common. The patients are prophets, elected by God for a magnificent, yet hidden, purpose. They are enthroned; indeed God has made way for them," ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89," n.d.).
The presence of a manic episode that includes or resembles psychosis is a prerequisite in bipolar 1 disorder, whereas it is not a prerequisite for bipolar II or any of the other bipolar spectrum disorders. This suggests a potential link between bipolar 1 disorder and schizophrenia. When Kraepelin developed his classification system, the researcher distinguished between two core types of what he called "insanity," and those types were basically bipolar and schizophrenia (Ivleva, Thaker & Tamminga, 2008). At the same time, the researcher did recognize that these were two different sides of the same coin of mental illness. Similarly, Francois Baillarger "believed there was a major distinction between bipolar disorder and schizophrenia," and this is what "allowed bipolar disorder to receive its own classification from other mental disorders of the time," ("A Brief Historyo f Bipolar Disorder," 2012).
In spite of the advances in diagnostic criteria, bipolar disorder often goes unrecognized or misdiagnosed (Hirschfeld et al., 2000). One of the reasons for lack of diagnosis or misdiagnosis is the fact that bipolar disorder 1 shares some features in common with schizophrenia including the presence of hallucinations, delusions, and psychosis. In fact, recent research reveals a possible biological connection between bipolar 1 disorder and schizophrenia, a connection that might revolutionize the way bipolar disorder is classified, viewed, and treated. For example, the International Schizophrenia Consortium (ISC) conducted genome research on schizophrenia and bipolar disorder. The data set revealed that common genetic variation underlies risk of schizophrenia," and "these alleles of small effect also contribute to risk of bipolar disorder," ("Common polygenic variation contributes to risk of schizophrenia and bipolar disorder," 2009, p. 748).
Another common reason for misdiagnosis or under diagnosis of bipolar disorder is that it is often mistaken for unipolar major depressive disorder (Ghaemi & Goodwin, 2002). Ghaemi, &…