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.

EPIDEMIOLOGY

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

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.

An Overview of Bipolar Disorders