Bipolar

Bipolar disorder, still often referred to colloquially as manic depression, is a mood disorder marked by episodes of clinically significant impairment due to mania or depression.

Emil Kraepelin(1856-1926), a German psychiatrist who first described the illness and coined the term "manic depression", noted in his original delineation of the disease that intervals of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals in which a patient was able to function normally.

To that point, there are currently three types of bipolar disorder outlined by the DSM-IV-TR and generally accepted within the medical community: Bipolar I, Bipolar II, and Cyclothymia. Like many disorders involving brain chemistry, bipolar disorder is still under investigation, and symptoms may differ significantly from person to person. Typically, symptoms include periods of euphoria, which alternate with periods of profound depression. In most cases, periods of mood stability complement these periods of instability.

Diagnostic criteria
The DSM-IV-TR details two general profiles of bipolar disorder, Bipolar I and Bipolar II. Bipolar I is characterized by alternating episodes of full-blown mania and depression, while Bipolar II, the less severe and more common type of the disorder, is characterized by episodes of hypomania and depression.

Criteria for a manic episode (DSM-IV-TR)
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
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)
The symptoms do not meet criteria for a Mixed Episode.
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.
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).

Criteria for a major depressive period (DSM-IV-TR)
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) or (2).
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.
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)
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.
Insomnia or Hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
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
The symptoms do not meet criteria for a Mixed Episode.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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).
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.

Criteria for a mixed episode
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.
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.
The symptoms are not due to the direct physiological effects of a substance (e.g., a illicit drugs, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Criteria for a hypomanic episode
A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
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:
inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
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).

According to the DSM-IV-TR, a diagnosis of bipolar I disorder requires at least one manic or mixed episode, but may also include hypomanic or depressive episodes. A depressive episode is not required for a diagnosis of bipolar I disorder.

A diagnosis of bipolar II disorder requires neither a manic nor mixed episode, but requires at least one hypomanic episode and one major depressive episode.

A diagnosis of cyclothymic disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet the criteria for major depressive episodes.

If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the conditions laid out above, he or she receives a diagnosis of Bipolar, Not Otherwise Specified (NOS).

Treatment of bipolar disorder
There is no cure for bipolar disorder; the emphasis is on management of the symptoms. A variety of medications are used to treat bipolar disorder; many people with bipolar disorder require multiple medications. Some people with bipolar disorder add to or replace their Western medication with herbal or holistic options. Still, even with optimal medication treatment, many people with the illness have some residual symptoms or relapses of depression or mania. Cognitive therapy may work to lessen the severity of mood swings by recognizing and managing triggering symptoms or events. Interpersonal and Social Rhythm Therapy (ISPRT) emphasizes the regulation of sleep, diet and exercise to prevent episodes, along with teaching coping skills; it is well-documented that sleep disruptions can trigger manic episodes.

Principles
Medications called mood stabilizers are used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are sometimes also treated with antidepressants. However, as stated above, antidepressants carry the risk of inducing mania, especially in bipolar patients who are not taking a mood stabilizer.

In severe cases where the mania or the depression is severe enough to cause psychosis (and recently sometimes in less severe cases as well, although this remains controversial), The antipsychotic drugs may also be used. A new class of "atypical" antipsychotics has also become more widely used for bipolar episodes. The FDA has only approved them for acute episodes, if at all (with the exception of olanzapine, which is approved as a mood stabilizer). Like most doctors, psychiatrists use medication for "off-label" uses, even when such uses are not supported by available research. It is becoming accepted practice to use atypical antipsychotics as mood stabilizers at this point, and there is support in the literature for their effectiveness in mood stabilization.

Some people have reported that antipsychotics cause mania, panic attacks, or psychosis[citation needed]. Any agitation should be reported to the doctor immediately. Antipsychotics also carry a risk of causing tardive dyskinesia, a potentially disfiguring and sometimes irreversible movement disorder that may case the arms, legs, face or head to jerk or twitch. The risk is thought to be proportionate to the length of duration of neuroleptic/antipsychotic use (roughly 5% per year in non-elderly patients) and has recently been linked to an equally high occurence in both typical and atypical antipsychotics[citation needed], in contrast to claims of lower risks when the atypicals were introduced. Patients and physicians need to be careful to watch for symptoms of this side effect carefully so that an antipsychotic can be reduced in dosage, or changed to another medication, before the condition progresses. The doctor should, of course, be consulted about any change in dosage. The only antipsychotic with no apparent association with tardive dyskinesia is clozapine.

Medications work differently in each person, and it takes considerable time to determine in any particular case whether a given drug is effective at all, since bipolar disorder is by nature episodic, and patients may experience remissions whether or not they receive treatment. For this reason, neither patients nor their doctors should expect immediate relief, although psychosis with mania can respond quickly to antipsychotics, and bipolar depression can be alleviated quickly with electroconvulsive therapy (ECT). Many doctors emphasize that patients should not expect full stabilization for at least 3-4 weeks (some antidepressants, for example, take 4-6 weeks to take effect), and should not “give up” on a medication prematurely Hope, nor should they discontinue medication with the disappearance of symptoms as the depression may return.

Compliance with medications can be a major problem, because some people as they become manic lose the awareness of having an illness, and they therefore discontinue medications. Patients also often quit taking medication when symptoms disappear, erroneously thinking themselves "cured", and some people enjoy the effects of unmedicated hypomania.

Depression does not respond instantaneously to resumed medication, typically taking 2–6 weeks to respond. Mania may disappear slowly, or it may become depression. Other reasons cited by individuals for discontinuing medication are side effects, expense, and the stigma of having a psychiatric disorder. In a relatively small number of cases stipulated by law (varying by locality but typically, according to the law, only when a patient poses a threat to himself or others), patients who do not agree with their psychiatric diagnosis and treatment can legally be required to have treatment without their consent. Throughout North America and the United Kingdom, involuntary treatment or detention laws exist for severe cases of bipolar disorder and other mental illnesses.

Prognosis
While bipolar disorder can be one of the most severe and devastating medical conditions, indeed the sixth highest cause of disability in the world according to the World Health Organization, fortunately many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Compared to patients with schizophrenia, persons with bipolar disorder are more likely to have periods of normal functioning in the absence of medication. Although schizophrenic patients may have remissions with relatively high levels of functioning, schizophrenic patients tend to suffer some impairment during these intervals in contrast to persons with bipolar disorder who often appear completely healthy when they are between mood swings.

Lithium salts
The use of lithium salts as a treatment of bipolar disorder was first discovered by Dr. John Cade, an Australian psychiatrist who published a paper on the use of lithium in 1949.

Lithium salts had long been used as a first-line treatment for bipolar disorder. In ancient times, doctors would send their mentally ill patients to drink from "alkali springs" as a treatment. They did not know it, but they were really prescribing lithium, which was present in high concentration in the waters. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li+. The two lithium salts used for bipolar therapy are lithium carbonate (mostly) and lithium citrate (sometimes). Approved for the treatment of acute mania in 1970 by the FDA, lithium has been an effective mood-stabilizing medication for many people with bipolar disorder. Lithium is also noted for reducing the risk of suicide[9]. Although lithium is among the most effective mood stabilizers, persons taking it may experience side effects similar to the effects of ingesting too much table salt, such as high blood pressure, water retention, and constipation. Regular blood testing is required when taking lithium to determine the correct lithium levels since the therapeutic dose is close to the toxic dose.

The mechanism of lithium salt treatment is believed to work as follows: some symptoms of bipolar disorder appear to be caused by the enzyme inositol monophosphatase (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. It is involved in signal transduction and is believed to create an imbalance in neurotransmitters in bipolar patients. The lithium ion is believed to produce a mood stabilizing effect by inhibiting IMPase by substituting for one of two magnesium ions in IMPase's active site, slowing down this enzyme.

Lithium orotate is used as an alternative treatment to lithium carbonate by some sufferers of bipolar disorder, mainly because it is available without a doctor's prescription. It is sometimes sold as "organic lithium" by nutritionists, as well as under a wide variety of brand names. There seems to be little evidence for its use in clinical treatment in preference to lithium carbonate. Self-treatment without medical monitoring is potentially dangerous.