Bipolar I disorder: clinical features and treatment approaches

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.

History

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, & Goodwin (2002) also point out that the diagnosis, and subsequent treatment, of bipolar disorder has been "inconsistent and frequently misunderstood in recent years," due to the fact that presenting symptoms will not seem to fall in line with bipolar spectrum disorder (p. 125). This would be especially true for a patient with cyclothymia or bipolar 2 disorders, rather than bipolar 1 disorder, given that the latter's manic episodes are particularly severe and warranting attention. Still, a patient experiencing a manic episode might not seek treatment as readily as a patient with a depressive episode, leading the psychiatrist to conclude that depression is the prevailing problem. Underdiagnosis or misdiagnosis might also be related to "clinicians' inadequate understanding of manic symptoms, from patients' impaired insight into mania, and especially from failure to involve family members or third parties in the diagnostic process," (Ghaemi & Goodwin, 2002, p. 125). The concept of bipolar spectrum of illnesses, as opposed to a monolithic bipolar classification, has been helpful in increasing awareness of the problem and encouraging correct identification of the disease (Ghaemi & Goodwin, 2002).

Misdiagnosis can lead to severe problems, especially when antidepressant medications are given to a patient believed to have major depressive disorder instead of bipolar 1 disorder. In particular, Ghaemi & Goodwin (2002) found that antidepressants can, and often do, heighten or exacerbate the manic episodes in bipolar patients. Ghaemi & Goodwin (2002) therefore suggest that therapists give "greater weight to family history and antidepressant-induced manic symptoms," (Ghaemi & Goodwin, 2002, p. 125). If manic symptoms appear after a patient diagnosed with depression is given treatment with anti-depressants, then that patient might need to be reassessed and reevaluated for bipolar disorder. A Christian worldview embraces the idea that diagnosis should not be made too hastily, and should taken into account the patient's family history as well as the presenting symptoms.

Hirschfeld, et al. (2000) point out the need for better screening instruments to help psychiatrists and psychologists identify patients that might have bipolar spectrum disorders. In an experimental research design, Hirschfeld et al. (2000) administered the new Mood Disorder Questionnaire to a total of 198 patients, 109 of which were diagnosed with bipolar spectrum disorders. The Mood Disorder Questionnaire is a self-report instrument. Results confirmed the hypothesis that the Mood Disorder Questionnaire proved useful, suggesting that similar self-report surveys can be used prior to making a hasty diagnosis, or dismissing diagnosis altogether.

Symptoms: Clinical Diagnosis

When clinicians screen for and diagnose bipolar 1 disorder, they must follow the guidelines listed in the DSM-IV. These guidelines prevent false positives and negatives in diagnosis, but also raise the important question of whether the clinician is experienced or trained enough to recognize bipolar 1 and distinguish it from other clinical disorders. The primary symptoms of bipolar 1 disorder are the presence of both manic and depressive episodes. Manic episodes must last for a week or more. Borchard (2011) lists the signs and symptoms of mania (or a manic episode) as follows:

Excessive "high," overly good, euphoric mood

Extreme irritability

Increased energy, activity, and restlessness

Racing thoughts and talking very fast, jumping from one idea to another

Distractibility and inability to concentrate

Diminished need for sleep

Unrealistic, grandiose beliefs in one's ability and powers

Poor judgment

Spending sprees

A lasting period of behavior that is distinctly different from usual behavior

Increased sexual drive

Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

Provocative, intrusive, or aggressive behavior

Denial that anything is wrong

Clinicians must also be able to distinguish between mania and its milder cousin, hypomania. If mania is mild and lasts for four days only, then bipolar 2 might be the more accurate diagnosis.

Depression is the other pole of mania in bipolar 1 disorder. For the diagnosis of bipolar 1 disorder to be present, a major depressive episode must last for two weeks or more. Unlike other types of depression, the major depressive episodes associated with bipolar 1 disorder do not need to be associated with a precipitating incident such as a trauma ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89)" n.d.). The primary symptom of major depression is the inability to take pleasure in things, but other symptoms may also be present such as sleep disorder (either insomnia or excessive sleeping), sluggishness, and despair. Suicide is relatively common in patients with bipolar disorder, affecting between ten and twenty percent of the patient population ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89)" n.d.). Most suicides occur when the patient is in an acute major depressive episode ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89)" n.d.). Judd, et al. (2002) performed one of the only existing longitudinal studies on patients clinically diagnosed with bipolar 1 disorder and found that the majority of persons with bipolar 1 disorder exhibit more depressive episodes than manic episodes.

Rumination appears to be a unique feature to bipolar spectrum disorders, which can help clinicians differentiate a major depressive disorder from unipolar depressive disorder (without mania). Research has shown that the depression that is associated most closely with bipolar spectrum disorders can be classified as "ruminating" depression, meaning that the individual is engaged in "a form of self-focused repetitive cognitive activity," (Ghaznavi & Deckersbach, 2012, p. 1).

Moreover, the "subsyndromal," symptoms, which are defined as symptoms that fall just below the threshold for qualifying as a full-blown episode, were more common than the acute or more severe symptoms (Judd et al., 2002). This suggests that bipolar 1 is chronic, and that the effects will impair a person's ability to enjoy life not just because of acute manifestations of the illness, but because everyday functioning is impaired regularly and continuously. As Marangell (2004) found, poor patient outcomes in bipolar 1 disorder are largely due to the presence of subsyndromal symptoms. Those symptoms are strongly associated with social functioning and occupational functioning (Marangell, 2004). Marangell (2004) suggests that clinicians pay close attention to their clients, watching for subsyndromal symptoms even before a diagnosis has been made. When subsyndromal symptoms are tracked, the larger patterns of bipolar 1 disorder may be recognized so that the patient can receive aggressive treatment. Otherwise, patients with bipolar disorder might not be diagnosed or get the help they need. It may even be necessary to update the DSM-IV criteria for bipolar spectrum illnesses to include the range of sybsyndromal symptoms so clinicians know what to look for (Marangell, 2004).

The rate of "cycling" between mania and depression varies from case to case, and can also vary over time. The incidence of four or more episodes in one year is known as "rapid cycling," ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89)" n.d.). Rapid cycling occurs in about ten percent of the bipolar population ("Bipolar Disorder (DSM-IV-TR #296.0 -- 296.89)" n.d.). Cycling is a cornerstone of the disease, which is always chronic and "highly recurrent," (Angst & Sellaro, 2000, p. 445). Bipolar patients who have been hospitalized spend a full 20% of their lives in acute episodes of depression or mania (Angst & Sellaro, 2000). This is why a client who arrives to the clinician with early symptoms of depression should be monitored. In some cases, patients will exhibit a "mixed episode," in which both symptoms of mania and symptoms of depression last for a week. However, the clinician must take care to observe the patient, because unless the symptoms are serious enough to warrant hospitalization because they are interfering with the client's life, the diagnosis of bipolar 1 might be premature. Bipolar 1 is the most serious of the bipolar spectrum disorder; a client will not be diagnosed with bipolar 1 if manic episodes and depressive episodes are not severe enough to interfere with daily functioning.

DSM-IV clinical diagnoses are based on phenomenological rather than biological evidence, meaning the diagnoses are made only with the observation of the clinician and not with biological tests (Ivleva, Thaker & Tamminga, 2008). However, there is a strong genetic and biological component with biopolar 1 disorder. Much research has been done on the similarities and differences between bipolar 1 (which is often accompanied by psychotic mania) and schizophrenia. An MRI study looking at the amygdalas of patients diagnosed with schizophrenia and bipolar 1 disorder reveals that bipolar patients have larger amygdalas vs. patients with schizophrenia (Mahon, et al., 2012). An MRI may therefore be used as a diagnostic tool in some patients, when either schizophrenia or bipolar 1 disorder is suspected. To differentiate between the two diseases, the clinician can look at the size of the patient's amygdala. There are other structural neurophysiology issues associated with bipolar 1 disorder, making neuroimaging a key component of the diagnostic procedure. For example, Houenou, et al. (2012) found both that "dorsal brain structures are thought to decrease in volume and activity in bipolar disorder, reducing inhibition of the ventral-limbic network and enhancing emotional responses," and that patients with bipolar disorder have "abnormal prefrontal-subcortical limbic connectivity," (p. 593). Rumination also characterizes the manic state Ghaznavi & Deckersbach, 2012, p. 1). Therefore, studies on the specific nature of rumination are looking to neurobiology for why this is the case. Rumination points to a feature called "executive dysfunction," in which the part of the brain responsible for self-consciousness and self-awareness is impaired somehow (Ghaznavi & Deckersbach, 2012).

Treatment: Pharmaceuticals

Because there is a biological component to the disease, the use of medications in bipolar 1 disorder is practically unavoidable; however, pharmaceutical intervention should be taken seriously. Medications are complicated interventions in the treatment of bipolar 1 disorder, as with other bipolar spectrum disorders. This is primarily because many medications target symptoms and not root causes of the cyclical and bipolar nature of the problem. In other words, medications are easier to prescribe to patients with unipolar mood disorders. Medications for mania, and medications for depression, might need to be used together in the same patient.

The three basic types of medications that are indicted for bipolar 1 disorder include mood stabilizers, antipsychotics, and antidepressants (Hall-Flavin, 2012). Mood stabilizers most commonly prescribed for bipolar 1 disorder include the following, listed with brand name as well as generic: lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal) (Hall-Flavin, 2012). The antipsychotic class of drugs prescribed for patients diagnosed with bipolar 1 disorder include olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon) or asenapine (Saphris) (Hall-Flavin, 2012). Anti-depressants that may be prescribed to a patient with bipolar disorder include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and bupropion (Wellbutrin) (Hall-Flavin, 2012). These three types of pharmaceutical interventions can be, and often are, prescribed together due to the multifaceted and multi-symptomatic nature of bipolar 1 disorder.

Most researchers agree that there should be "less emphasis on using antidepressants" with bipolar spectrum illnesses in general, because of the way antidepressants may exacerbate underlying mania (Ghaemi & Goodwin, 2002, p. 125). Mall-Flavin (2012) agrees that antidepressants are probably only going to be effective for patients with bipolar 1 disorder when prescribed alongside anti-pscyhotics or mood stabilizers. Each patient must be treated and evaluated differently, and carefully monitored for both symptom control and side effects. Unfortunately, prognosis for bipolar disorder is notoriously poor as "full recovery without further episodes rare, recurrence of episodes with incomplete remission the rule, and the development of chronicity and suicide still frequent," (Angst & Sellaro, 2000, p. 445).