Bipolar Also Known as Manic-Depressive Disorder, Bipolar

Bipolar Also known as manic-depressive disorder, bipolar disorder is a severe mental illness that can be treated with a combination of medication and regular therapy. Bipolar disorder is classified as a mood disorder, and is qualified by abnormal intensity of moods and mood swings, leading to dysfunctional, erratic, or self-destructive behaviors. When left untreated or unrecognized, bipolar disorder can disrupt daily functioning and human relationships. Therefore, chemical and non-chemical treatment interventions are critical for maintaining healthy functioning.

Bipolar disorder is referred to as having a cyclic pattern, because the symptoms are episodic. In other words, the person may be severely depressed, then normal, then fully manic, and then back to being depressed. Mania and depression are the two poles from which the person swings back and forth. Prevalence is equally common in men and women ("Bipolar Disorder," n.d.).

First signs of onset are usually in the teens or early twenties; more than 90% of patients have their first episode by the age of 50 ("Bipolar Disorder," n.d.).When left untreated, manic episodes of bipolar disorder usually last between three to six months, whereas depressive episodes can last between six and twelve months (National Health Services, 2014). Medications can reduce the intensity and duration of these episodes, even if they continue to occur.

The medications may vary from person to person, based on the subtype of bipolar disorder exhibited and the tendency toward mixed-mania. The causes of bipolar disorder are complex, and may include genetic factors as well as environmental triggers. Because bipolar disorder does tend to run in families, recent analysis of specific genes is showing that there is a definite biological marker (National Institute of Mental Health, 2014).

However, "most children with a family history of bipolar disorder will not develop the illness," and studies with identical twins show that it is possible for only one twin to develop the condition (National Institute of Mental Health, 2014). This points to the existence of causal factors other than genes, including environmental stressors or drug use causing a chemical imbalance. Genetics therefore have known but "subtle" effects on the development of bipolar disorder (McIntosh, 2005). Understanding the genetic etiology of the disease may lead to specific genome interventions.

Recent research shows that during "embryogenesis, the transcription factor Otx2 orchestrates the genetic networks directing the specification of dopaminergic and serotonergic neurons," (Jukic, et al., 2014). Thus, research into the genetic factors impacting the development of bipolar disorder reveals clues as to the specific neurochemical imbalances needing to be treated, leading to more effective treatments. The neurobiology of bipolar disorder also reveals clues as to the causes of the disease and also reveals potential treatment interventions.

Interventions can be long-term treatments, such as medications taken every day to prevent the onset of manic and depressive episodes. The need for additional medications for acute episodes, to target specific symptoms, may also be indicated. Likewise, psychological therapies may be long-term or targeted. Medical interventions for bipolar disorder are rooted in knowledge of the neurobiology of the disease. There are two distinct but related factors at play in the neurobiology of bipolar disorder: physical brain structure, and brain chemistry.

Empirical evidence shows a clear difference in the brains of people with bipolar and without. Using magnetic resonance imaging (MRI), researchers have shown, for example, enlarged amygdala in patients with bipolar disorder vs. controls without the illness (Strakowski, et al., 1999). Although several studies show little to no difference in grey matter content in persons with bipolar disorder, one study does demonstrate white matter abnormalities in bipolar patients (McDonald, 2005).

As bipolar disorder does have a psychotic component, as does schizophrenia, many studies have been conducted simultaneously on patient populations with one or the other disorder to reveal similarities and differences. It would appear that white matter, not gray matter, abnormalities impact both bipolar disorder and schizophrenia, but that only gray matter abnormalities are present in the brains of schizophrenics (McDonald, 2004). There may also be a link between patients with epilepsy and bipolar disorder, which may lead to more clues as to the neurological foundation of the disease.

One study shows that persons with epilepsy are over six times as likely to have bipolar symptoms than the standard population (Ettinger et al., 2005). Bipolar disorder occurs in about 12% of the population with epilepsy, versus 1% of the general population (Ettinger, et al., 2005; National Health Services, 2014). Chemical and hormonal imbalances may also be risk factors for developing or exacerbating bipolar disorder. The endocrinology of bipolar disorder has yielded "robust findings" ("Bipolar Disorder," n.d., p. 5).

Endocrinology research has focused on the efficacy of dexamethasone suppression tests in both major depression and in bipolar disorder because abnormal readings on the dexamethasone suppression test are associated with current depressive states or states that erupt within a week after the test was administered (Garden, et al., 1982). Immune system imbalances may also be linked with bipolar disorder.

However, more research is needed before determining the direction of the relationship: does bipolar disorder lead to biological responses that depress the immune system, like lymphocyte activation and increased pro-inflammatory cytokines, or does a depressed immune system lead to bipolar symptoms (Wieck, et al., 2013)? The chemical imbalances associated with bipolar disorder may also be present in other medical conditions including migraine, asthma, and diabetes mellitus (Ettinger, et al., 2005).

Based on what is known about the neurobiology and neurochemistry of the disease, interventions include mood stabilizers, which are generally not given to persons with major depression. Lithium carbonate is one of the most well-known and commonly prescribed medications for bipolar disorder, and is sometimes issued as a monotherapy. Likewise, valproate semisodium is a mood stabilizer sometimes prescribed in lieu of lithium carbonate as a monotherapy. However, Geddes et al. (2010) found that combination therapy using both of these drugs can potentially be more effective in reducing symptom intensity and duration.

Anticonvulsants and antipsychotics may also be indicated, especially during manic episodes. The most commonly prescribed antipsychotics to address the symptoms of bipolar disorder include olanzapine, risperidone, aripiprazole, quetiapine, and ziprasidone ("Bipolar Disorder," n.d.). A combination of a mood stabilizer and an antipsychotic is a preferred method of intervention for most patients ("Bipolar Disorder," n.d.). Carbamazepine is also a mood stabilizer sometimes prescribed for bipolar disorder, as is divalproex.

Divalproex (Valproic acid) is an anticonvulsant, but because it increases testosterone levels, young women may be contraindicated and may be discouraged from using it, instead relying on other anticonvulsants like gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) (National Institute of Mental Health, 2014). One of the most severe side effects of anticonvulsants is suicidal ideation or even suicidal behaviors, which is why patients taking these drugs must be monitored closely (National Institute of Mental Health, 2014).

The choice of medication will depend on patient history and prior response to the drug, with lithium having the longest track record and therefore, greater sense of reliability and predictability for doctors ("Bipolar Disorder," n.d.). Side effects of lithium are generally outweighed by the benefits. In fact, research reveals that lithium has "no deleterious effects on cognition," (Lopez-Jamarillo, et al., 2010). However, other side effects of lithium include dermatological ones, such as lesions (Mehta, Raj, Singh & Sinha, 2014).

For patients with mixed-mania or predominant depression, divalproex may be indicated instead of lithium. In addition to the neurobiological and genetic precursors of bipolar disorder, there may also be psychological, cognitive, and personality markers for the disease. Having a "hypomanic personality," for example, is increases risk for developing the symptoms of bipolar disorder (Blechert & Meyer, 2010). Neuroticism, openness, low agreableness, conscientiousness, and extraversion are personality traits associated with bipolar disorder in the research (Barnett, et al., 2011).

Yet it is uncertain whether persons with specific personality traits are predisposed to developing bipolar disorder, or whether persons with bipolar disorder tend to exhibit these personality traits. Moreover, the exhibition of these traits depends on whether the person is in a manic or depressive stage (Barnett, et al., 2011).

Studies on the cognitive patterns of bipolar patients are relatively scarce, and the only conclusions that can be drawn have to do with the performance of persons with bipolar disorder on cognitive tests during seither manic or depressive episodes (Jabben, et al., 2012). The future of cognitive research on bipolar disorder may reveal methods of using cognitive therapies in a targeted manner.

Recent studies also show that the cognitive impairments associated with taking lithium carbonate as a monotherapy may be mitigated, but that most of the cognitive impairments are not due to the medication itself, but to the disease (Lopez-Jamarillo, et al., 2010). The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the bible of psychiatric diagnosis. According to the DSM, there are several subtypes of bipolar disorder, which is classified as a mood disorder along with major depression.

Classification of the patient into one of the subtypes depends on the specific symptoms of the disease, patterns of manifestation, and the frequency and duration of both manic and depressive episodes. With bipolar disorder, the person will exhibit not only persistent major depressive episodes, but also at least one manic episode. Manic episodes are defined as mild, moderate, severe, and severe plus psychosis. These divisions are sometimes framed in terms of hypomania, acute mania, delusional mania, or delirious mania ("Bipolar Disorder," n.d.).

Heightened mood, euphoria, increased energy, decreased need for or desire of sleep, hyperactivity, and "flight of ideas" are symptoms of hypomania ("Bipolar Disorder," n.d.). If the mania episode progresses to being acute, delusions may also be present. When delirium and psychosis manifest, the person is in an episode of severe mania. This would warrant the issue of antipsychotics such as olanzapine. As with lithium, restlessness is a common side effect of taking olanzapine.

Many of the side effects for olanzapine are more physical than cognitive, with changes in vision being especially common ("Olanzapine Side-Effects," 2014). Depressive episodes in bipolar disorder differ significantly from those present in persons with clinical depression. For one, bipolar episodes of depression are more acute, and therefore potentially intense as well as brief. There may be few precipitating factors or triggers in a bipolar depressive episode ("Bipolar Disorder," n.d.).

Irritability, apathy, lack of concentration, sluggish thoughts, pervasive feelings of guilt, and hypersomnolence (sleeping too much) are common symptoms, but hallucinations and delusions may also occur ("Bipolar Disorder," n.d.). Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are antidepressants that may be prescribed to patient s with bipolar disorder as well as major depression. Taking only an antidepressant is highly unusual and potentially even harmful to patients with bipolar disorder because doing that may cause recycling into a manic state more rapidly (National Institute of Mental Health, 2014).

Although it is more common to cycle between manic and depressive episodes, some patients will exhibit mixed-manic episodes in which depression and mania coexist at the same time. During a mixed-manic episode, the person may quickly flit between euphoria and despair, or go from sleeping too much to sleeping too little. Mixed-manic episodes tend to last longer than individual depressive or manic episodes ("Bipolar Disorder," n.d.). Taking medications preventatively is recommended in patients with frequent cycling, or even frequent episodes in.