Introduction
Bipolar disorder is an episodic or chronic mental disorder that causes unusual, extreme, and rapid-cycling changes in energy, mood, concentration, and activity (Grande, Berk, Birmaher & Vieta, 2016). It is also referred to as manic depression or manic-depressive disorder. Normal people undergo changes in mood and activity depending on various situations that they find themselves in. However, in individuals with bipolar disorder, these changes in mood and activity are extreme. During manic episodes, they feel extremely elated, irritable and there is a significant increase in activity, while during depressive episodes the person feels hopeless, sad, and indifferent and there is very little activity. Some of them may experience hypomanic episodes that are similar to manic episodes but are less troublesome and less severe.
Characteristics of bipolar disorder
Bipolar disorder is a mood disorder that is characterized by disturbances in mood, behavior, cognition, sleep, and physical well-being. The characteristics observed as a result of these disturbances are:
- Mood. Bipolar disorder is characterized by manic or hypomanic and depressive episodes. The disturbances observed in mood during the manic and hypomanic episodes are elevated mood and euphoria while those observed during the depressive episodes are sadness, apathy, anger, guilt, anxiety, hopelessness, generalized discontent, and loss of pleasure and interest in activities. Due to the continuous cycling between mania and depression, the person will display mood swings.
- Behavior. During the manic episodes, they will display risk-taking behavior, aggression, increased sexual desire, restlessness, pressured speech, irritability, hyperactivity, and impulsivity while during the depressive episodes, individuals display, disorganized behavior, agitation, self-harm, and crying.
- Cognition. In the manic phase, they will experience unwanted thoughts, racing thoughts, delusions, and lack of concentration while in the depressive episodes they will experience delusions and slowness in thinking.
- Sleep. During the manic phase, they find it difficult to fall asleep while in the depressive state they experience excessive sleepiness.
- Physical well-being. Some of them may have weight loss or weight gain and fatigue.
Etiology
The exact cause of the bipolar disorder is unknown as there has been no biological or physiological agent linked to its occurrence. However, several factors are found to increase the risk of developing bipolar disorder. The condition has high incidences of heredity but because not all individuals are genetically inclined to develop the disorder, there is an element of environmental influence and psychological factors that can lead to the development of the condition (Aldinger & Schulze, 2016). The following are the etiological factors for bipolar disorder:
1. Life events. A significant excess of emotions resulting from a life event is usually evident before relapse of the condition (Aldinger & Schulze, 2016). This can be in the form of the attainment of a goal of losing a loved one. In these situations, normal feelings of happiness or sadness can deteriorate into manic or depressive episodes respectively.
2. Neurochemistry.
- Dopamine neurotransmission. During manic episodes, there is increased dopamine neurotransmission from the substantia nigra to the neostriatum causing increased movement and sensory stimuli (Sigitova, Fišar, Hroudová, Cikánková & Raboch, 2017).
- Noradrenaline neurotransmission is increased in the locus ceruleus and the caudate nucleus in mania (Sigitova et al., 2017).
- GABA neurotransmission is decreased in manic and depressive episodes (Sigitova et al., 2017).
3. Genetics and family history. Individuals that have a first-degree relative with the disorder are at higher risk of developing the disorder (Hafeman et al., 2017). Symptoms are first evident during the teenage years and in some instances in early adulthood, the average age of onset being at 25 years.
4. Traumatic stress. Men/ women that have gone through traumatic events are more predisposed to developing the disorder (Aldinger & Schulze, 2016). Childhood events such as physical abuse, sexual abuse, the death of a parent, and neglect are significant triggers. In adulthood, traumatic events such as experiencing a death, changing physical locations, and losing a job are triggers.
5. Substance abuse. Alcohol and other drugs have the potential of triggering exacerbations of existing mood disorders or hastening the onset of symptoms.
6. Gender. The disorder affects both males and females equally. However, females are three times more predisposed to experiencing the rapid cycling observed in mood disorders. Females are also more predisposed to mixed and depressive episodes of bipolar disorder than males.
Diagnostic criteria
The fifth edition of the Diagnostic and Statistical Manual classifies bipolar disorder into bipolar I disorder, bipolar II disorder, medication or substance-induced bipolar disorder, bipolar due to a medical condition, other specified bipolar, and unspecified bipolar disorder.
Bipolar I
Bipolar I is characterized by a manic episode that is preceded by or followed by major depressive or hypomanic episodes. The manic episode is characterized by a period of abnormal, persistently elevated irritable or expansive mood and increased goal-oriented energy or activity lasting a week and consistently present for most of the day. During this period, there are occurrences of three or more of the following symptoms: increased grandiosity or esteem, less need for sleep, the pressure of speech, racing thoughts, flight of ideas, increased goal-oriented activity, risk-taking, and distractibility. The hypomanic episode has a similar description with the difference being that it lasts a minimum of four consecutive days.
The major depressive episode is characterized by a two-week history of loss of pleasure or interest or depressed mood coupled with five or more of the following symptoms: depressed mood for most of the day, decreased pleasure or interest in activities, weight loss or weight gain, hypersomnia or insomnia, psychomotor retardation or agitation, loss of energy or fatigue, feeling of guilt or worthlessness, decreased capacity to think and recurrent thoughts of death.
Bipolar II
Bipolar II is characterized by the presence of a hypomanic episode and a major depressive episode. The criteria for the hypomanic and major depressive episodes is similar to that in bipolar I.
Medication or substance-induced bipolar. This disorder is characterized by irritable, elevated, or expansive mood with or without depressed mood or decreased pleasure and interest in activities that develop following exposure to medications or substance consumption or withdrawal. The medication or substance consumed must be capable of producing the symptoms of bipolar disorder. Such substances include cocaine, stimulants such as amphetamine, anxiolytics, sedatives, and hypnotic drugs.
Bipolar due to another medical condition. This condition is characterized by disturbances in the mood with evidence from history, laboratory findings, and physical examination that this is caused by the pathological process of another medical condition. The disturbance is usually not well attributable to another mental condition.
Implications for treatment
The treatment of bipolar disorder involves taking history and acquiring additional information followed by laboratory investigations and the establishment of a diagnosis. Definitive treatment involves addressing specific psychosocial stressors and the administration of medication.
Information is collected from the client and close contacts for purposes of corroboration. It can also be gathered from previous records of primary physicians and therapists. As the information is gathered, the diagnosis and other comorbidities are established. These include substance use disorders, psychosis, catatonia, risk of violence, and suicide risk. The therapist also needs to establish a drug history to rule out drugs that may precipitate mania such as antidepressants, corticosteroids, and anti-parkinsonism medication.
Specific treatment for bipolar disorder involves the use of mood stabilizers, antidepressants, antipsychotic medication, and somatic treatments. The mood stabilizers include lithium, lamotrigine, and topiramate. Lithium is the most effective mode of long-term treatment of the bipolar disorder. It is however too toxic, and the other compounds such as valproate are preferred. The antidepressants used for the treatment of bipolar include tricyclic antidepressants and SSRIs. The antipsychotics used are the first generation and second-generation antipsychotics while somatic treatments include electroconvulsive therapy and transcranial direct current stimulation.
There are several concerns with the treatment options. Lithium has an extensive toxicity profile. The blood levels of lithium must also be monitored because it has a narrow therapeutic index (Alda, 2015). Common adverse effects include polydipsia and polyuria, nausea, vomiting, and diarrhea, goiter, renal toxicity, and gait disturbance (Alda, 2015). The antidepressants have the risk of precipitating manic episodes hence must be used carefully. The first-generation antipsychotics are of concern because they precipitate extrapyramidal side effects such as dyskinesia, dystonia, neuroleptic malignant syndrome, akathisia, Parkinsonism, akinesia, and tardive dyskinesia (Sykes et al., 2017). These side effects are unpleasant to clients and lead to poor adherence to treatment. The second-generation antipsychotics have lower tendencies to produce extrapyramidal effects, but they have antiadrenergic and antimuscarinic side effects such as hypotension and constipation respectively.
References
- Alda, M. (2015). Lithium in the treatment of bipolar disorder: Pharmacology and pharmacogenetics. Molecular Psychiatry, 20(6), 661-670. doi: 10.1038/mp.2015.4
- Aldinger, F., & Schulze, T. (2016). Environmental factors, life events, and trauma in the course of bipolar disorder. Psychiatry and Clinical Neurosciences, 71(1), 6-17. doi: 10.1111/pcn.12433
- Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572. doi: 10.1016/s0140-6736(15)00241-x
- Hafeman, D., Merranko, J., Goldstein, T., Axelson, D., Goldstein, B., & Monk, K., … Birmaher, B. (2017). Assessment of a person-level risk calculator to predict new-onset bipolar spectrum disorder in youth at familial risk. JAMA Psychiatry, 74(8), 841. doi: 10.1001/jamapsychiatry.2017.1763
- Sigitova, E., Fišar, Z., Hroudová, J., Cikánková, T., & Raboch, J. (2017). Biological hypotheses and biomarkers of bipolar disorder. Psychiatry and Clinical Neurosciences, 71(2), 77-103. doi: 10.1111/pcn.12476
- Sykes, D., Moore, H., Stott, L., Holliday, N., Javitch, J., Lane, J., & Charlton, S. (2017). Extrapyramidal side effects of antipsychotics are linked to their association kinetics at dopamine D2 receptors. Nature Communications, 8(1). doi: 10.1038/s41467-017-00716-z