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Bipolar Disorder Information - Causes, Symptoms And Treatment

Marked by severe mood swings from hyperactivity and euphoria to sadness and depression, bipolar disorder (also known as manic depression) involves various symptom combinations. type 1 bipolar disorder is characterized by alternating episodes of mania and depression, whereas type 2 is characterized by recurrent depressive episodes and occasional manic episodes.

Women are more commonly diagnosed with type 2 bipolar disorder. In addition, women are more affected by rapid cycling bipolar disorder, a complex variant of the disorder, than men. In some patients, bipolar disorder assumes a seasonal pattern, marked by a cyclic relation between the onset of the mood episode and a particular 60-day period each year.

The American Psychiatric Association estimates that over 2 million American adults suffer from bipolar disorder. Although this disorder affects men and women equally, recent studies suggest that gender differences exist in the prevalence, risks, symptoms, and clinical course of illness. For example, men tend to begin with a manic episode, while women tend to begin with a depressive episode. In addition, women with bipolar disorder have a higher risk of alcoholism than men with bipolar disorder. Alcoholism is associated with a history of poly substance use in women with bipolar disorder, while alcoholism is associated with a family history of alcoholism in men with bipolar disorder.

Bipolar disorder affects all ages, races, ethnic groups, and social classes. It usually manifests itself during late adolescence, but onset may start as early as childhood or much later in life. According to the American Academy of Child and Adolescent Psychiatry, up to one-third of the 3.4 million children and adolescents with depression in the United States actually may be experiencing the early onset of bipolar disorder.

Bipolar disorder recurs in 80% of patients; as they grow older, the episodes recur more frequently and last longer. This illness is associated with a significant mortality; 20% of patients commit suicide, many just as the depression lifts.

Causes of bipolar disorder

The cause of bipolar disorder is unclear but hereditary, biological. and psychological factors may playa part. For example, the incidence of bipolar disorder among relatives of affected patients is higher than in the general population, and highest among maternal relatives. The closer the familial relationship, the greater the susceptibility. A child with one affected parent has a 25% chance of developing bipolar disorder; a child with two affected parents, a 50% chance. The incidence of this illness in siblings is 20% to 25%; in identical twins, the incidence is 66% to 96%. Recent studies have shown that postpartum women are also at particular risk for bipolar disorder through postpartum psychosis.

Although certain biochemical changes accompany mood swings, it isn't clear whether these changes cause the mood swings or result from them. In both mania and depression,intracellular sodium concentration increases during illness and returns to normal with recovery.

Patients with mood disorders have a defect in the way the brain handles certain neurotransmitters - chemical messengers that shuttle nerve impulses between neurons. Low levels of the chemicals dopamine and norepinephrine. for example, have been linked to depression, whereas excessively high levels of these chemicals are associated with mania. Changes in the concentration of acetylcholine and serotonin may also playa role. Although neurobiologists have yet to prove that these chemical shifts cause bipolar disorder, it's widely assumed that most antidepressant medications work by modifying these neurotransmitter systems. In addition, new data suggest that changes in the circadian rhythms that control hormone secretion, body temperature, and appetite may contribute to the development of bipolar disorder.

Emotional or physical trauma, such as bereavement, disruption of an important relationship, or a serious acddental injury, may precede the onset of bipolar disorder. However, bipolar disorder commonly appears without identifiable predisposing factors. Manic episodes may follow a stressful event, but they're also associated with antidepressant therapy and childbirth. Chronic physical illness, psychoactive drug dependence, psychosocial stressors, and childbirth may predpitate major depressive episodes. Other familial influences - especially the early loss of a parent, parental depression, incest, or abuse - may predispose a person to depressive illness.

Signs and symptoms of bipolar disorder

Signs and symptoms vary widely, depending on whether the patient is experiencing a manic or depressive episode. Before the onset of overt symptoms, however, many patients with bipolar disorder have an energetic and outgoing personality with a history of wide mood swings. Bipolar disorder may be associated with high levels of creativity or high levels of destruction.

During the assessment interview,the manic patient typically appears grandiose, euphoric, expansive, or irritable with little control over her activities and responses. She may describe hyperactive or excessive behavior, including elaborate plans for numerous social events, efforts to renew old acquaintances by telephoning friends at all hours of the night, buying sprees, or promiscuous sexual activity. She seldom hesitates to start projects for which she has little aptitude.

The patient's activities may have a bizarre quality, such as dressing in colorful or strange garments, wearing excessive makeup, or giving advice to passing strangers. She commonly expresses an inflated sense of self esteem, ranging from uncritical self confidence to marked grandiosity, which may be delusional.

Note the patient's speech patterns and concentration level. Accelerated and pressured speech, frequent topic changes, and flights of ideas are common features during the manic phase. The patient is easily distracted and responds rapidly to external stimuli,such as background noise or a ringing telephone.

Physical examination of the manic patient may reveal signs of malnutrition and poor personal hygiene. She may report sleeping and eating less as well as being more physically active than usual.

Hypomania, which is more common than acute mania, is similar to mania, but is less severe and delusions, hallucinations, and other symptoms of psychotic intensity aren't present. Three classic symptoms of hypomania may be recognized during the assessment interview: euphoric but unstable mood, pressured speech, and increased motor activity. The hypomanic patient may appear elated, hyperactive, easily distracted, talkative, irritable, impatient, impulsive, and full of energy but seldom exhibits flight of ideas.

The patient who experiences a depressive episode may report a loss of self-esteem, overwhelming inertia, social withdrawal, and feelings of hopelessness, apathy, or self-reproach. She may believe that she's wicked and deserves to be punished. Her groWing sadness, guilt, negativity, and fatigue place extraordinary' burdens on her family.

During the assessment interview, the depressed patient may speak and respond slowly. She may complain of difficulty concentrating or thinking clearly but usually isn't obviously disoriented or intellectually impaired.

Physical examination may reveal reduced psychomotor activity, lethargy,low muscle tonus, weight loss, slowed gait, and constipation. The patient may also report sleep disturbances (falling asleep, staying asleep, or early morning awakening), sexual dysfunction, headaches, chest pains, and heaviness in the limbs. Typically, symptoms are worse in the morning and gradually subside as the day goes on.

Concerns about her health may be come hypochondriacal: She may worry excessively about having cancer or some other serious illness. In an elderly patient, physical symptoms may be the only clues to depression.

Suicide is an ever-present risk, no matter what age, especially as the depression begins to lift. At that point, a rising energy level may strengthen the patient's resolve to carry out suicidal plans. The suicidal patient may also harbor homicidal ideas - for example, thinking of killing her family either in anger or to spare them pain and disgrace.

Diagnosis information

Most people are diagnosed between ages 20 and 35; many times, diagnosis in the adolescent or child is mistaken for attention deficit hyperactivity disorder, "teenage rebellion," or other age-appropriate behaviors. Physical examination and laboratory tests, such as endocrine function studies, rule out medical causes of mood disturbances, including intra-abdomiual neoplasm, hypothyroidism, heart failure, cerebral arteriosclerosis, parkinsonism, psychoactive drug abuse, brain tumor, and uremia. Moreover, a review of the medications prescribed for other disorders may point to drug induced depression or mania. (For characteristic findings in patients with bipolar disorder, see Diagnosing bipolar disorders.)

Bipolar disorder treatment

Widely used to treat bipolar disorder, lithium (lithotabs, Eskalith) has proven highly effective in relieving and preventing manic episodes. It curbs accelerated thought processes and hyperactive behavior without producing the sedating effect of antipsychotic drugs or medications. In addition, it may prevent the recurrence of depressive episodes. Even so, it's ineffective in treating acute depression.

Because lithium has a narrow therapeutic range, treatment must be initiated cautiously and the dosage adjusted slowly. Therapeutic blood levels during the active manic period are 0.4 to 1.4 mEq/L. For safety, the level should never exceed 1.5 mEq/L. Therapeutic blood levels must be maintained for 7 to 10 days before the drug's beneficial effects appear; for this reason, antipsychotic drugs are commonly used in the interim to provide sedation and symptomatic relief. Because the kidneys excrete lithium, any renal impairment necessitates withdrawal of the drug.

Anticonvulsants, such as carbamazepine (Tegretol. Carbatrol), valproic acid (Depakene), and clonazepam (Klonopin), are used either alone or with lithium to treat mood disorders. Carbamazepine, a potent antimanic drug, is effective in many lithium-resistant patients.

Antidepressants are used to treat depressive symptoms, but they may trigger a manic episode.



Symptoms of bipolar disorder may be especially difficult to discern in children because they may be mistaken for age-appropriate emotions and behaviors of children and adolescents. Also, their symptoms of bipolar disorder may vary somewhat from adults. For example, when manic, children and adolescents are more likely to be irritable and prone to destructive out­bursts than to be elated or euphoric. When depressed, they may complain about headaches, stomach aches, tiredness, poor performance in school, poor communication, and extreme sensitivity to rejection or failure.


Special considerations

For the manic patient

  • Remember the manic patient's physical needs. Encourage her to eat. Provide a diet high in calories, carbohydrates, and liquids.
  • As the patient's symptoms subside, encourage her to assume responsibility for personal care.
  • Provide emotional support, maintain a calm environment, and set realistic goals for behavior.
  • Provide diversionary activities suited to a short attention span; firmly discourage the patient if she tries to overextend herself. Provide structured activities involving large motor movements to expend surplus energy. Reduce or eliminate group activities durIng acute manic episodes.
  • When necessary, reorient the patient to reality. Tactfully divert conversations when they become intimately concerned with other patients of staff members.
  • Set limits in a calm, clear, and self confident manner for the manic patient's demanding, hyperactive, manipulative, and acting-out behaviors. Setting limits tells the patient that you'll provide security and protection by refusing inappropriate and possibly harmful requests. Avoid leaving fill opening for the patient to test you of argue with you.
  • Listen to requests attentively and with a neutral attitude. Avoid power struggles if a patient tries to put you Oil the spot for an immediate answer. Explain that you'll seriously consider I he request and will respond later.
  • Encourage solitary activities such as writing out one's thoughts.
  • Collaborate with other staff members to provide consistent responses to the patient's manipulative or acting out behaviors.
  • Watch for early signs of frustration (when the patient's anger escalates from verbal threats to hitting an object). Tell the patient firmly that threats and hitting are unacceptable. Explain that these behaviors show that she needs help to control her behavior. Inform her that the staff will help her move to a quiet area to help her control her behavior so she won't hurt herself or others. Staff members who have practiced as a team can work effectively to prevent acting-out behavior or to remove and confine a patient.
  • Alert the staff team promptly when acting-out behavior escalates. It's safer to have help available before you need it than to try controlling an anxious or frightened patient by yourself.
  • Once the incident is over and the patient is calm and in control, discuss her feelings with her and offer suggestions on how to prevent a recurrence.
  • If the patient is taking lithium, tell her and her family to temporarily discontinue the drug and notifY the physician if signs or symptoms of toxicity, such as diarrhea, abdominal cramps, vomiting, unsteadiness, drowsiness, muscle weakness, plural, and tremors, occur.

For the depressed patient

  • The depressed patient needs continual positive reinforcement to improve her self-esteem. Provide a structured routine, including activities to boost her self-confidence and promote inter. action With others (for instance, group therapy). Keep reassuring her that her depression Will lift.
  • Encourage the patient to talk or to write down her feelings if she's having trouble expressing them. Listen attentively and respectfully; allow her time to formulate her thoughts if she seems sluggish. Record your observations and conversations.
  • Don't forget the patient's physical needs. If she's too depressed to care for herself, help her With personal hygiene measures. Encourage her to eat, if necessary. If she's constipated, add high-fiber foods to her diet; offer small, frequent meals; and encourage physical activity.

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