Bipolar
Disorder (Manic Depression) Introduction: This
mood disorder is characterized by alternating cycles of extreme high to the point
of a manic episode and cycles of depression. However, there is a lot of variation
from person to person where some show and some do not show fairly regular cycling
of these two conditions. Others are not showing much manic behavior and they
may just pass as being depressed from time to time. When a group of depressed
persons is followed for 5 years by psychiatrists there is usually about a 20%
rate who suffer from unipolar disorder (=depression) to bipolar disorder (=manic
depression). The bipolar mood disorders are particularly vulnerable to sudden
changes and should be under close supervision of a psychiatrist well versed in
these conditions. It is only after assessment and treament with such therapy as
lithium or some of the newer atypical antipsychotic medications, that the patient's
mood and behavior will stabilize. These patients should not be followed
by the general practitioner alone in the beginning until the psychiatrist has
properly assessed the exact condition of the patient and the potential for violence.
Untreated bipolar disorder is one of the conditions in man capable of the most
bizarre behaviors such as throwing furniture out of a window or running wild on
a killing spree. It is tragic that often these cases could have been treated weeks
and months before, if the family members had known what symptoms to look out for.
Bipolar I disorder: In this disorder there is an alternating
course of major depressive episode with a full manic episode.
| Manic episode: A
manic episode is a distinct period where the mood is abnormally high,
where the patient has a decreased need for sleep, a pressured speech, grandiose
thinking, risk oriented behavior, agitation and possible irritability. |
One of the important symptoms is the lack of a need for sleep.
The patient may either get up hours before others do, but have seemingly limitless
energies. In fact some patients can go several days in a row without sleep. There
is an increased need for social interaction, calling on old friends, including
calling on strangers at all hours of the day. Such a manic episode will last at
least 7 days or more. In 50% to 60% of cases a manic episode is followed or preceded
by a major depressive episode( Ref. 2). Bipolar I disorder is a recurring disorder
according to Ref. 2 in that more than 90% of patients with a single manic episode
have such episodes in the future. Another interesting fact is that according to
the DMS-IV "60% to 70% of manic episodes occur immediately before or after
a major depressive episode"(Ref.2). First degree relatives of bipolar I disorder
have about a 15% probability of developing also bipolar I disorder, a 15% probability
of developing a major depressive disorder and a 3% probability of developing bipolar
II disorder. In some cases the manic or depressive episodes can follow each other
with several months or years between them. In cases not treated with Lithium maintenance
therapy, on average 4 such episodes would occur in a 10 year period.Bipolar
II disorder In this disorder a major depressive
episode alternates with a hypomanic episode.
| Hypomanic
episode: A hypomanic episodeis
defined as a period of 4 days or more, where the patient's mood is persistently
elevated, irritable and where the patient exhibits some grandiose thinking , pressured
speech, flight of ideas and risk oriented activities. Such activities could be
unrestrained shopping sprees, foolish business decisions or inappropriate sexual
indiscretions. There is a decreased need for sleep, where the patient feels rested
after only 3 hours of sleep. | Patients
with this bipolar II disorder may not call a hypomanic episode abnormal, but relatives
and friends are the best judges in knowing what is normal for the patient and
what is hypomanic and the physician or psychiatrist will depend on these informants.
As the patient ages, the intervals between episodes tend to decrease. Also, about
10% of patients with this disorder have 4 or more hypomanic or depressive episodes
in the course of a year. 85% of patients have a normal mood between episodes,
but 15% will show a labile mood, have relationship and employer problems between
episodes. Over a period of 5 years about 10% will develop a manic episode. Treatment
of bipolar disorder: Treatment of any form of bipolar illness
should be in the hands of a psychiatrist, at least initially as care must be taken
to properly classify and treat this condition. Lithium carbonate is the drug of
choice for more than 30 years. It is safe, provided blood levels are taken from
time to time and the kidney function and thyroid function is checked as well from
time to time. Many patients stabilize on lithium salt alone. Young patients
with mania need higher doses of lithium salt to achieve a therapeutic blood level
than older patients whose kidney function is slower. There is a lag period of
up to 10 days before the lithium effect sets in. This means that during the initial
phase antipsychotic medication such as haloperidol (brand names: Haldol or Peridol)
or other antipsychotic medication has to be taken to control the acute manic phase.
Lithium stabilizes mood swings, reduces aggressiveness in bipolar patients, stabilizes
biological sleep/wake rhythms, but leaves normal mood untouched. About
67% of patients with bipolar disorder will respond to lithium. Ask your doctor
about other side effects and your particular situation. Acute manic psychosis
is often treated with risperidone (brand name: Risperdal Tablets) or olanzapine
(brand name: Zyprexa), which have less extrapyramidal side effects than Haldol.
Psychiatrists use a few other medications for acute manic states and at times
the optimal medication has to be found for a patient by trial and error. Depression
is being treated with antidepressants as mentioned under unipolar disease above.
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