WHAT IS BIPOLAR DISORDER? | HOW COMMON IS BIPOLAR DISORDER? | WHAT CAUSES BIPOLAR DISORDER? | WHAT ARE THE SYMPTOMS OF BIPOLAR DISORDER? | DO SYMPTOMS CHANGE WITH DEVELOPMENT? | HOW IS BIPOLAR DISORDER DIAGNOSED? | WHAT ARE THE TREATMENTS FOR BIPOLAR DISORDER? | WHERE CAN I GET HELP FOR MY CLIENTS?
Bipolar disorder is psychiatric disorder characterized by wide variations in mood, from mania to depression. When individuals are manic, they have elated or irritable mood and may engage in dangerous and high-risk behaviors such as promiscuous sexual activity, increased spending, violence, and substance abuse. When individuals are depressed, they suffer from sad mood or lack or interest and may exhibit such symptoms as diminished energy, changes in sleep or appetite, lowered self esteem, and thoughts of suicide or death.
Bipolar disorder can cause major disruptions in family, social and occupational functioning. Individuals with the disorder have a 15 percent likelihood of committing suicide during their lifetimes.
In any give year, more than 2 million American adults, or about 1 percent of the population age 18 and older have bipolar disorder. Rates of the disorder are similar in adolescents. The frequency of bipolar disorder does not differ between men and women. Bipolar disorder is usually first diagnosed in persons between 18 and 24 years of age, although approximately 20% of all bipolar patients have their first episode during adolescence.
Most researchers agree that there is no single cause for bipolar disorder-rather, many factors act together to produce the illness. Bipolar disorder tends to run in families. Studies of identical twins, who share all the same genes, indicate that both genes play a role in bipolar disorder.
Biology also plays a role in the disorder. Brain-imaging techniques such as magnetic resonance imaging, positron emission tomography, and functional magnetic resonance imaging suggest that the brains of individuals with bipolar disorder may differ from the brains of healthy individuals.
Bipolar disorder involves dramatic mood swings-from overly "high" or irritable mood to sad mood, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. Some of the symptoms of mania include:
· Increased energy, activity, and restlessness
· Excessively "high," overly good, euphoric mood
· Extreme irritability
· Racing thoughts and talking very fast, jumping from one idea to another
· Little sleep needed
· Unrealistic beliefs in one's abilities and powers
· Poor judgment
· Increased sexual drive
· Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
· Provocative, intrusive, or aggressive behavior
Symptoms of depression include:
· Sad mood
· Feelings of hopelessness or pessimism
· Feelings of guilt, worthlessness, or helplessness
· Loss of interest or pleasure in activities once enjoyed, including sex
· Decreased energy, a feeling of fatigue or of being "slowed down"
· Difficulty concentrating, remembering, making decisions
· Restlessness or irritability
· Sleeping too much, or can't sleep
· Change in appetite and/or unintended weight loss or gain
· Thoughts of death or suicide, or suicide attempts
Sometimes individuals with bipolar disorder experience what are called mixed mood states, when symptoms of manic and depressed states occur at the same time.
Sometimes, severe episodes of mania or depression include symptoms of psychosis. Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.
Children with bipolar disorder often experience changes in mood and psychomotor agitation that are erratic, rather than persistent in nature. Hyperactivity is the most common behavioral manifestation of mania in young children. Manic children may also exhibit irritability or temper tantrums.
Adolescents are more likely than adults to present with irritability, belligerence, and mixed mania, rather than elated mood. Diagnosing bipolar disorder in adolescents is complicated by the fact that reckless behavior, a common symptom of the disorder, must be distinguished from normal childhood boasting, imaginary play, overactivity, and youthful indiscretions.
Assessment of bipolar disorder usually involves an initial evaluation by a psychiatrist, psychologist, or licensed clinical social worker. This evaluation involves a thorough clinical interview in which the clinician gathers information on the history and course of symptoms, family history of mental illness, and social, occupational, and academic functioning.
Once bipolar disorder is diagnosed, a physical examination needs to occur. Metabolic, endocrine, or infectious disorders, as well as acute intoxication or withdrawal can present with some of the same symptoms as bipolar disorder, so it is important to rule-out these conditions. In addition, routine laboratory tests such as blood counts, renal and liver functions, thyroid functions, a toxicology screen, and a pregnancy test are required before an individual can start psychotropic medications for bipolar disorder. A neurology consultation may also be warranted to rule-out traumatic brain injury.
The most effective treatments for bipolar disorder combine medication with psychotherapeutic interventions. Treatment attempts to reduce current symptoms, prevent relapse, and promote long-term growth and development. Although most research on bipolar disorder has been done with adults, this section will attempt to outline current best practice standards of care for children and adolescents with bipolar disorder.
Medication
Although considerable research exists of medication treatment for adults with bipolar disorder, the literature regarding medication treatment for children and adolescents is limited. Medication is usually used to address manic and depressive symptoms, or to prevent relapse of the disorder.
Lithium
Typically, the first line of treatment for bipolar disorder is a mood stabilizing medication such as lithium. Approximately 80% of patients with bipolar disorder respond to lithium.
Youth generally tolerate lithium well and may have fewer side effects than adults, although younger children may be more prone to side effects than older children. Commonly reported side effects include nausea, diarrhea, vomiting, tremor, weight gain, headache, enuresis, and fatigue. Lithium can have significant effects on cardiac conduction, and can induce or exacerbate dermatological problems, including acne, which may be a significant concern for adolescent patients.
Anticonvulsants
Some patients who cannot tolerate or do not respond to lithium may respond to anticonvulsants. Adult studies have supported the efficacy of the anticonvulsants carbamazepine and valproate for the acute treatment of bipolar disorder. Greater evidence supports the use of valproate, which was recently approved as a treatment for mania by the U.S. Food and Drug Administration. Anticonvulsants have been used by themselves, together, or in combination with lithium. Anticonvulsants are sometimes used for rapid cycling or mixed mania, both of which do not respond well lithium.
Neuroleptics (Antipsychotics)
In the adult literature, neuroleptics have been shown to be effective for the treatment of mania. Since their effects occur more rapidly than mood stabilizers, they may be useful during the initial phases when patients are highly agitated or psychotic. Little evidence indicates that neuroleptics, by themselves, should be used for maintenance treatment of bipolar disorder, although some patients whose symptoms do not respond adequately to antimanic agents alone may benefit from a combination of a mood stabilizer with a neuroleptic. Because of the possibility of serious side effects, neuroleptics require close monitoring and periodic reassessment of their ongoing use over the course of treatment.
Antidepressants
A major risk of antidepressant use in bipolar patients is that these medications can induce mania. Thus, these medications are generally used only as adjuncts to antimanic therapy in patients who have persistent depressive symptoms.
Psychosocial Treatments
Medications help with the core symptoms of bipolar disorder, but they do not address the associated functional impairments. Thus, a comprehensive treatment approach should combine medication with psychosocial therapies.
Patients with bipolar disorder suffer from the psychosocial consequences of past episodes, the ongoing vulnerability to future episodes, and the burdens of adhering to a long-term treatment plan that may involve unpleasant side effects. In addition, many patients have clinically significant mood instability between episodes. The goals of psychotherapeutic treatments are to reduce distress, improve the patient's functioning between episodes, and decrease the frequency of future episodes.
Significant issues for family members of patients with bipolar disorder include the stigma that is frequently associated with mental illness and the need for support and education. Because patients with bipolar disorder often loose judgment in the course of the illness and engage in high-risk behavior, family members may be interacting with the legal system and the health care system simultaneously.
Extrapolating from the adult literature and clinical experience with this population suggests that there are a range of psychotherapeutic approaches that may be helpful for some patients. These approaches include psychodynamic, interpersonal, behavioral, cognitive, and family. In addition, support groups may be helpful for some patients. While the approaches are discussed as separate entities, in clinical practice mental health practitioners commonly use a combination or synthesis of approaches depending on the patient's needs and preferences.
· Family therapy and psychoeducation have been used with patients who have bipolar disorder. In research studies, patients who had family therapy had lower rates of family separations, greater improvements in level of family functioning, higher rates of full recovery, and lower rates of re-hospitalization following family treatment.
· Cognitive behavioral therapy involves educating the patient regarding bipolar disorder and its treatment, teaching skills for coping with psychosocial stressors, facilitating compliance with treatment, and monitoring the occurrence and severity of symptoms.
· Support groups provide useful information about bipolar disorder and its treatment. Patients in these groups often benefit from hearing the experiences of others who are struggling with such issues as the need for medication, problems with side effects, and how to shoulder other burdens associated with the illness and its treatment. Advocacy groups such as the National Depressive and Manic-Depressive Association and the National Alliance for the Mentally Ill have many local chapters that provide both support and educational material to patients and their families.
Some of the following treatments, which have been shown effective with depressed patients, may also benefit some patients who have bipolar disorder:
· Psychodynamic psychotherapy aims to make conscious the internal processes that precipitate or perpetuate mood regulation problems. Once these forces are made conscious, mood regulation difficulties can be anticipated and overcome. Mastery and insight, experienced in the supportive or interpretive relationship with the therapist, permit the patient to overcome some of the negative effects of illness and to prevent future problems.
· Interpersonal therapy seeks to recognize and explore the ways in interpersonal conflicts or losses, social isolation, or deficits in social skills contribute to the development and maintenance of depression.
· Behavior therapy for depression is based on behavior analysis and social learning theory. Some of the techniques used include scheduling rewarding activities, social skills training, and problem solving.
· Cognitive therapy maintains that irrational beliefs and distorted attitudes toward the self, the environment, and the future perpetuate depression, and that these distorted beliefs may be reversed through learning new ways of thinking.
Flexible Models of Care
Many youth with bipolar disorder are chronically impaired, with complicated clinical and social needs. These youth may need an integrated continuum of service that includes clinical case management, intensive community and family support, in-home services, out-of-home care (including respite and specialized foster care), and specialized educational/vocational services. Some youth, either because of the severity of the symptoms or confounding environmental stressors, will need intensive community-based services to continue living in their homes. Consultation may be needed with other community, juvenile justice, and social welfare programs.
In some cases, the severity of the individual's illness or lack of effective response to treatment may necessitate day treatment, residential treatment, or hospitalization. These options should only be considered after less restrictive alternatives have been unsuccessful. Once in a long-term residential setting, the patient's status needs to be reassessed at regular intervals, with the goal of returning to a less restrictive setting when possible.
In seeking help, persons may be directed to physicians, mental health specialists, community mental health agencies, the psychiatric department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, private clinics, self-help groups, pastoral care providers, school counselors, or the local Mental Health Association.
The National Institute of Mental Health provides information on the treatment of children and adults with psychiatric disorders. This includes questions on the types of mental illnesses that affect adults and children, risk factors, detecting symptoms, where to obtain help, and the use of psychotropic medications. Information can be obtained by contacting the agency at:
National Institute of Mental Health (NIMH)
Office of Communications and Public Liaison
Information Resources and Inquiries Branch
6001 Executive Blvd., Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: (301) 443-4513; Fax: (301) 443-4279
Web site: http://www.nimh.nih.gov
The following agencies also provide useful information concerning bipolar disorder:
Child & Adolescent Bipolar Foundation
1187 Willmette Avenue, PMB #331
Willmette, IL 60091
Phone: (847) 256-8525
Web site: http://www.bpkids.org
Depression and Related Affective Disorders Association (DRADA)
Johns Hopkins Hospital, Meyer 3-181
600 North Wolfe Street
Baltimore, MD 21287-7381
Phone: (410) 955-4647 or (202) 955-5800
Web site: http://www.med.jhu.edu/drada
National Alliance for the Mentally Ill (NAMI)
Colonial Place Three
2107 Wilson Blvd., 3rd Floor
Arlington, VA 22201
Toll-Free: 1-800-950-NAMI (6264)
Phone: (703) 524-7600; Fax: (703) 524-9094
Web site: http://www.nami.org
National Depressive and Manic-Depressive Association (NDMDA)
730 North Franklin Street, Suite 501
Chicago, IL 60610
Toll-Free: 1-800-826-3632
Phone: (312) 642-0049; Fax: (312) 642-7243
Web site: http://www.ndmda.org
National Foundation for Depressive Illness, Inc. (NAFDI)
P.O. Box 2257
New York, NY 10116
Toll-Free: 1-800-239-1265
Web site: http://www.depression.org
National Mental Health Association (NMHA)
1021 Prince Street
Alexandria, VA 22314-2971
Toll-Free: 1-800-969-NMHA (6642)
Phone: (703) 684-7722; Fax: (703) 684-5968
Web site: http://www.nmha.org
1 Sections of this Clinical Information Guide are adapted from the National Institute of Mental Health publication Bipolar Disorder (Publication number 01-3679) and the American Psychiatric Association's Practice Guide for the Treatment of Bipolar Disorder (1994).
WHAT IS BIPOLAR DISORDER? | HOW COMMON IS BIPOLAR DISORDER? | WHAT CAUSES BIPOLAR DISORDER? | WHAT ARE THE SYMPTOMS OF BIPOLAR DISORDER? | DO SYMPTOMS CHANGE WITH DEVELOPMENT? | HOW IS BIPOLAR DISORDER DIAGNOSED? | WHAT ARE THE TREATMENTS FOR BIPOLAR DISORDER? | WHERE CAN I GET HELP FOR MY CLIENTS?