A brief overview of bipolar disorders for addictions counsellors
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“Compared to bipolar's magic, reality seems a
raw deal. It's not just the boredom that makes recovery so difficult, it's the slow
dawning pain that comes with sanity - the realization of illnesss, the
humiliating scenes, the blown money and friendships and confidence. Depression
seems almost inevitable. The pendulum swings back from transcendence in shards,
a bloody, dangerous mess. Crazy high is better than crazy low. So we gamble,
dump the pills, and stick it to the control freaks and doctors. They don't
understand, we say. They just don't get it. They'll never be artists.”
-David Lovelace, Scattershot: My Bipolar Family
As the name would
suggest, bipolar is disorder of extremes. It is also a disorder surrounded by
controversy and prejudice. In past times those suffering from bipolar have been
labelled demon possessed or witches and have been burnt at the stake or
institutionalised, and yet some of our most formidable talents have been
bipolar: Kurt Cobain, Winston Churchill, Robert Downey Jnr, Stephen Fry, Graham
Green, Ernest Hemingway, Jimmy Hendrix, Spike Milligan, Nietzsche, Jackson
Pollock, Van Gogh and Amy Winehouse, to name a few. What is also easily
recognised is the large number of these individuals who have also suffered
substance use disorders and how many have died by literal or metaphorical
suicide.
Even though this is
one of the oldest psychiatric conditions to be described, but in spite of the
fact that so many early physicians provided descriptions and hypothesis that
are still useful today, bipolar remains difficult to diagnose and treat, and in
some quarters still remains unacknowledged and sufferers labelled as crazy, bad
people.
Various studies have
varied greatly in the reported prevalence of bipolar disorder:
Type
|
Number of studies
|
Lifetime Prevalence
|
Bipolar Type I
|
13
|
0.0 - 1.7%
|
Bipolar Type II
|
9
|
0.2 - 3%
|
Bipolar Spectrum
Disorders
|
7
|
2.6 – 6.5%
|
Source: (Keller, 2004)
|
||
It is equally
prevalent amongst males and females and across all racial and ethnic groups.
The peak age of onset
is 15-19 years, closely followed by the 20-24 year old range. More than 50% of
cases start before the age of 25.
As early as the 1870s
Fairet recognised a genetic link to the disease. The incidence is around 11%
for patients with first-degree relatives who have a history of bipolar
disorder.
Thyroid problems have been
linked with bipolar disorders and there is thought to be a link between bipolar
disorders and schizophrenia, which is emerging from brain imaging studies.
Signs and Symptoms
Bipolar may present
initially with either a manic, depressive or mixed episode. I will discuss each
of these before describing the criteria for the various sub-types of bipolar
disorder.
Manic Episode
Manic episodes are
classified in the DSM-IV according to degrees of severity: Mild, moderate,
severe and severe with psychotic features. Carlson and Goodwin describe stage
1: hypomania; stage 2: acute mania; stage 3: delirious mania (Carlson & Goodwin, 1973) while Kraeplin (1921)
divides manic states into 4 forms: Hypomania, acute mania, delusional mania and
delirious mania
The main symptoms of
mania are: heightened mood (either euphoric or irritable); flight of ideas and
pressure of speech; and increased energy, decreased need for sleep,
and hyperactivity.
Hypersexuality is often also reported. As the episode worsens
delusions and fragmentation of behaviour become noticeable.
Box 1:
DSM-IV Criteria for Manic Episode
|
A) A distinct period
of abnormally and persistently elevated, expansive or irritable mood, lasting
at least 1 week (or any duration if hospitalization is necessary)
B) During the period
of mood disturbance, three (or more) of the following symptoms have persisted
(four if the mood is only irritable) and have been present to a significant
degree:
1) inflated
self-esteem or grandiosity
2) decreased need
for sleep (e.g., feels rested after only 3 hours of sleep)
3) more talkative
than usual or pressure to keep talking
4) flight of ideas
or subjective experience that thoughts are racing
5) distractibility
(i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)
6) increase in
goal-directed activity (at work, at school, or sexually) or psychomotor
agitation
7) excessive
involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
C) The symptoms do
not meet criteria for a Mixed Episode
D) The mood
disturbance is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or others, or there are
psychotic features.
E) The symptoms are
not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication or other treatment) or a general medical condition (e.g.,
hyperthyroidism)
|
Box 2:
DSM-IV Criteria for Hypomanic Episode
|
A) A distinct period
of persistently elevated, expansive or irritable mood, lasting throughout at
least 4 days, that is clearly different from the usual nondepressed mood.
B) During the period
of mood disturbance, three (or more) of the following symptoms have persisted
(four if the mood is only irritable) and have been present to a significant
degree:
1) inflated
self-esteem or grandiosity
2) decreased need
for sleep (e.g., feels rested after only 3 hours of sleep)
3) more talkative
than usual or pressure to keep talking
4) flight of ideas
or subjective experience that thoughts are racing
5) distractibility
(i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)
6) increase in
goal-directed activity (at work, at school, or sexually) or psychomotor
agitation
7) excessive
involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
C) The episode is
associated with an unequivocal change in functioning that is uncharacteristic
of the person when not symptomatic.
D) The disturbance
in mood and the change in functioning are observable by others.
E) The mood
disturbance not severe enough to cause marked impairment in social or
occupational functioning, or to necessitate hospitalization, and there are no
psychotic features.
F) The symptoms are
not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication or other treatment) or a general medical condition (e.g.,
hyperthyroidism)
|
Depressive Episodes
In bipolar the
depressive episodes tend to appear acutely (over a few weeks) and without any
apparent activating event. The depressions can last for about 6 months if
untreated and typical symptoms include psychomotor retardation, hyperphagia
(excessive hunger) and hypersomnolence. Due to the irritability, constant fault
finding, discontentment, apathy and silence the patient often becomes isolated
and this amplifies the situation.
Another common symptom
is the occurrence of visual and auditory hallucinations. These are usually dark
and “evil” in nature, as this quote from a bipolar forum describes:
I've had hallucinations during depression which
involve seeing dead, decaying flesh on people's faces. I've also had auditory
hallucinations (i.e., hearing "voices") during a mixed episode. The
voices have a buzzing sound, and it seems like there are thousands of them.
They are talking about me, but I can't make out what they say. And sometimes,
while extremely agitated, I think I hear a voice whispering my name.
There are also
frequent thoughts of suicide and spontaneous suicide attempts are not uncommon.
Bipolar patients, in general, are 30 times more likely to commit suicide than
the general population.
Box 3:
DSM-IV Criteria for Major Depressive Episode
|
A) Five (or more) of
the following symptoms have been present during the same 2-week period and
represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure
Note: Do not include
symptoms that are clearly due to a general medical condition, or
mood-incongruent delusions or hallucinations
1) depressed mood
most of the day, nearly every day, as indicated by either subjective report
(e.g., feels sad or empty) or observation made by others (e.g., appears
tearful). Note: In children and adolescents, can be irritable mood.
2) markedly
diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day (as indicated by either subjective account or observation
made by others)
3) significant
weight loss when not dieting or weight gain (e.g., a change of more than 5%
of body weight in a month), or decrease or increase in appetite nearly every
day. Note: In children, consider failure to make expected weight gains.
4) insomnia or
hypersomnia nearly every day
5) psychomotor
agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down)
6) fatigue or loss
of energy nearly every day
7) feelings of
worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick)
8) diminished
ability to think or concentrate, or indecisiveness, nearly every day (either
by subjective account or as observed by others)
9) recurrent
thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for
committing suicide
B) The symptoms do
not meet criteria for a Mixed Episode
C) The symptoms
cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D) The symptoms are
not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hypothyroidism)
E) The symptoms are
not better accounted for by Bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months or are characterized by marked
functional impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation.
|
Mixed Episodes
Although not as common
as manic or depressive episodes, mixed episodes tend to last longer. As the
name would suggest these episodes display both sets of symptoms, either cycling
rapidly or even simultaneously. There may be no congruence between outward
emotional state and reported emotional state.
Box 3:
DSM-IV Criteria for Mixed Episode
|
A. The criteria are
met both for a Manic Episode and for a Major Depressive Episode (except for
duration) nearly every day during at least a 1-week period.
B. The mood
disturbance is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or others, or there are
psychotic features.
C. The symptoms are
not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication, or other treatment), or a general medical condition
(e.g., hyperthyroidism)
|
Types and Diagnosis
Bipolar comes in three
main types:
Bipolar I
Bipolar I is
defined by manic or mixed episodes that endure for at least 7 days and often
also involves periods of depression lasting at least 2 weeks at a time. Bipolar
I is typified by a chronic and recurrent nature and tends to have a younger age
index episode (Keller, 2004).
Sufferers have a
greater degree of social problems (one study found that 57% of marriages end in
divorce) and a high degree of substance use.
Bipolar II
Bipolar II patients
exhibit mainly depressive episodes cycling with hypomanic but not manic
episodes.
Cyclothymic Disorder
This is a milder
form where the person shifts between hypomania and mild depression for at least
2 years.
There is also Bipolar
NOS which tends to cycle with the seasons- summer inducing manic episodes and
winter depressive, and also rapid cycling bipolar where there are 4 or more
mood disorders within a 12-month period.
Comorbidity is common,
with anxiety and substance use disorders being the principle Comorbidity at a
rate of up to 51%. (Simon & et
al, 2004)
(Bhagwagar, 2007). A large number of
patients with eating disorders also have bipolar disorder (Bhagwagar, 2007). Obesity is a major
issue as 31% of all bipolar related deaths were linked to cardiovascular
disease.
Standardized mortality
rates in bipolar disorder where 19% for suicide, but this dropped significantly
if the disorder was treated.
TREATMENT
Perhaps the ancient
Greeks had inadvertently hit on the correct treatment protocol long before
modern times; they suggested extended periods submerged in the communal
lithium-rich hot springs. Today Lithium and Psychotherapies form the backbone
of bipolar treatment.
Medication
Lithium is the most
popular and effective treatment because it is the only medication effective
across the acute, preventative and continuative phases for both mania and
depression (Brown University).
During acute phases of
mania a combination of mood stabilizers and anti psychotics are used. Depending
on the prior history these may be continued until the episode would have run
its’ course. The patient needs to be monitored and doses lowered as indicated.
During acute phases of
depression a mood stabilizer is used at doses sufficient to offset a manic
episode. If the symptoms are persistent than an anti-depressent may be added,
but one must be aware that this could potentially induce a manic episode. For
this reason lamotrigine is used as it has no risk of inducing a manic episode
and is stronger than topiramate.
Psychotherapies
The psychotherapies
most commonly adopted are CBT, Psychoeducation, Family Focused Therapy and
Interpersonal and Social Rhythm Therapy. These are considered vital due to the
psycho-social effect of bipolar disorders. These therapies are normally
long-term due to the chronic nature of the disorder.
Electroconvulsive Therapy
Electroconlvulsive
therapy has been shown to be very effective in the cases where medication have
not proven effective during manic or depressive phases. ECT should not be seen
as a treatment in itself as it only has long-term efficacy if combigned with
cognitive and/or medical interventions.
Adherence
The biggest issue with
the ongoing effective treatment of bipolar is adherence. So much so that the
clinician should assume that patients will stop or at best modify their
treatment regimen.
Conclusion
Bipolar disorder is
debilitating, socially disrupting: Incomprehensible to the outsider, both a
nemesis and ally for the sufferer, their strength and weakness. To ask a
bipolar person to modulate those perfect moments when the balance between mania
and function is just right is like asking a musician to amputate their right
hand.
As we develop a better
understanding of psychiatric disorders we will, perhaps, be able to better
manage the pendulum of bipolar. The big question is, once we are able to do
this, will the world be a better place or somehow lacking in the genius that
only madness can bring. To again quote Lovelace:
“I know the empathy borne of despair; I know
the fluidity of thought, the expansive, even beautiful, mind that hypomania
brings, and I know this is quicksilver and precious and often it's poison.
There has always existed a sort of psychic butcher who works the scales of
transcendence, who weighs out the bloody cost of true art.”
Bibliography
Bhagwagar, Z. (2007). Medscape.
Retrieved 2012, from www.medscape.org:
http:/www.medscape.org/viewarticle/558733
Brown
University. (n.d.). Bipolar Disorder. Retrieved from Brown University
Course Material: http://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/Bipolar%20Disorder.pdf
Carlson,
G., & Goodwin, F. (1973). The stages of mania. Arch Gen Psychiatry
, 28:221-228.
Jacobi,
F., Rosi, S., & et al. (2005). Chapter 1: Mood Disorders: Clinical
Management and Research Issues. John Wiley and Sons Ltd.
Keller, M.
(2004). Improving the course of illness and promoting continuation of
treatment of bipolar disorder. Journal of Clinical Psychiatry ,
65(15):10-14.
National
Institute of Mental Health. (2008). Bipolar Disorder. 09-3679: US
department of Health and Human Services.
Simon, N.,
& et al. (2004). Anxiety Disorder comorbidity in bipolar disorder
patients. American Journal of Psychiatry , 161(12): 2222-2229.
Two-Year
Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With
Bipolar I Disorder. (2005). Arch Gen Psychiatry , 62(9):996-1004.