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Bipolar affective disorder has been a mystery to scientists and
physicians since the sixteenth century. The artist Vincent Van Gogh is
the first documented case of the disorder, but since then, we have not
learned much more about what causes the disease or even a cure for
sufferers. The biggest hindrance to scientists is that there are so
many symptoms, and they aren’t sure what the source is. Right now,
approximately one percent of the population (three million people) in
the United States is victim of the Bipolar disorder. As of now,
scientists have learned almost all that they know just from watching
and interviewing their patients, and although a cure is needed for
sufferers to lead normal lives, no true cure has come along yet.

Bipolar disorder typically most often begins during adolescence or
early adulthood and continues throughout life. It is often not
recognized as an illness and people who have it may suffer needlessly
for years or even decades. This particular disorder is characterized
by a variety of symptoms that can be broken into manic (excessive
highs) and depressive (deep hopelessness) episodes with periods of
normal mood in between. The manic episodes are characterized by
discrete periods of: increased energy, activity, and restlessness,
racing thoughts; rapid talking; excessive “high” or euphoric feelings,
extreme irritability and distractibility, decreased need for sleep,
unrealistic beliefs in one’s abilities and powers,
uncharacteristically poor judgment, sustained period of behavior that
is different than usual, increased sexual drive, abuse of drugs
(particularly cocaine, alcohol, and sleeping medications),
provocative, intrusive, or aggressive behavior, and denial that
anything is wrong.

Bipolar disorder is diagnosed if an episode of mania occurs whether
depression has been diagnosed or not, but most commonly, individuals
with manic episodes experience a period of depression. The depressive
episodes are characterized by intense feelings of sadness and despair
that can eventually grow into feelings of hopelessness and
helplessness. Some of the symptoms of a depressive episode include:
discrete periods of persistent sad, anxious, or empty feelings, mood
swings, feelings of hopelessness or pessimism, feelings of guilt,
worthlessness, or helplessness loss of interest or pleasure in
ordinary activities, decreased energy, a feeling of fatigue,
difficulty concentrating, remembering, or making decisions,
restlessness or irritability, sleep disturbances, loss of appetite and
weight, or weight gain, chronic pain or other persistent bodily
symptoms that are not caused by physical disease, anhedonia,
psycomoter retardation, near inability to move, and thoughts of death
or suicide.

When both manic and depressive symptoms occur at the same time it is
called a mixed episode. Those afflicted are at a special risk because
there is a combination of hopelessness, agitation, and anxiety that
makes them feel as if they “could jump out of their skin. Up to 50% of
all patients with mania have a mixture of depressed mood’s. Patients
report feeling dysphoric, depressed, and unhappy; yet, they exhibit
the energy associated with mania. Rapid cycling mania is another
presentation of bipolar disorder. Mania may be present with four or
more distinct episodes within a 12-month period. There is now evidence
to suggest that occasionally, rapid cycling may be a transient
manifestation of the bipolar disorder.

It may be helpful to think of the various mood states in
manic-depressive illness as a spectrum or continuous range. At one end
is severe depression, which shades into moderate depression, then come
mild and brief mood disturbances that many people call “the blues,
then normal mood, then hypomania (a mild form of mania), and then
mania. Some people with untreated bipolar disorder have repeated
depressions. In the other extreme, mania may be the main problem and
depression may occur only infrequently. In fact, symptoms of mania and
depression may be mixed together in a single “mixed” bipolar state.

Many times bipolar patients report that the depressions are longer and
increase in frequency as the individual ages. The stages of the
bipolar disorder most often begin in patients between the ages of 18
and 24 years of age with a second peak in the mid-forties of women.
Most individuals with the disorder experience their first mood episode
in there 20’s. However, manic-depression quite often strikes teenagers
and has been diagnosed in children under 12. A typical bipolar patient
may experience eight to ten episodes in their lifetime. These episodes
are life altering, and prohibit those afflicted with the disorder from
leading normal lives. The National Depressive and Manic Depressive
Association (MDMDA) has reported that the bipolar disorder can create
substantial developmental delays, marital and family disruptions,
occupational setbacks, and financial disasters. Even more seriously,
the risk of suicide among persons afflicted with bipolar illness is
unrealistically high. In the past, as many as 1 in 5 people with the
bipolar disorder have committed suicide in the United States. This
devastating disease causes disruptions of families, loss of jobs and
millions of dollars in cost to society. Therefore, scientists are
desperately searching for ways to alleviate symptoms, or even find a
cure.

A variety of medications are used to treat the bipolar
(manic-depressive) disorder, but even with optimal medication
treatment, many people with manic-depressive disorder do not achieve
full remission of symptoms. Lithium has been the primary treatment of
bipolar disorder since its introduction in the 1960’s. Its main
function is to stabilize the cycling characteristic of bipolar
disorder. In four controlled studies by F. K. Goodwin and K. R.
Jamison, the overall response rate for bipolar subjects treated with
Lithium was 78%. Lithium is also the primary drug used for long- term
maintenance of bipolar disorder. In a majority of bipolar patients, it
lessens the duration, frequency, and severity of the episodes of both
mania and depression. Unfortunately, as many as 40% of bipolar
patients are either unresponsive to lithium or cannot tolerate the
side effects of: thirst, weight gain, nausea, diarrhea, and edema.
Patients who are unresponsive to lithium treatment are often those who
experience dysphonic mania, mixed states, or rapid cycling bipolar
disorder.

One of the problems associated with lithium is the fact that long-term
lithium treatment has been associated with decreased thyroid
functioning in patients with bipolar disorder. Preliminary evidence
also suggest that hypothyroidism may actually lead to rapid cycling.
Pregnant women experience another problem associated with the use of
lithium. Its use during pregnancy has been associated with birth
defects, particularly Epstein’s anomaly. Based on current data, the
risk of a child with Epstein’s anomaly being born to a mother who took
lithium during her first trimester of pregnancy is approximately 1 in
8,000, or 2.5 times that of the general population.

There are other effective treatments for bipolar disorder that are
used in cases where the patients cannot tolerate lithium or have been
unresponsive to it in the past. The American Psychiatric Association’s
guidelines suggest the next line of treatment to be Anticonvulsant
drugs such as Valproate and Carbamazepine. These drugs are useful as
antimanic agents, especially in those patients with mixed states. Both
of these medications can be used in combination with lithium or in
combination with each other. Valproate is especially helpful for
patients who are lithium noncompliant, experience rapid cycling, or
have alcohol or drug abuse.

Neuroleptics such as haloperidol or chlorpromazine have also been used
to help stabilize manic patients who are highly agitated or psychotic.
Use of these drugs is often necessary because the response to them is
rapid, but there are risks involved in their use. Because of the
often-severe side effects, Benzodiazepines are often used in their
place. Benzodiazepines can achieve the same results as Neuroleptics
for most patients in terms of rapid control of agitation and
excitement, without the severe side effect.

Psychotherapy, in combination with medication, often can provide
additional benefit. One such treatment is outpatient group
psychotherapy. Dr. John Graves, spokesperson for The National
Depressive and Manic Depressive Association, has called attention to
the value of support groups, and challenged mental health
professionals to take a more serious look at group therapy for the
bipolar population. Research shows that group participation may help
increase lithium compliance, decrease denial regarding the illness,
and increase awareness of both external and internal stress factors
leading to manic and depressive episodes. Group therapy for patients
with bipolar disorders responds to the need for support and
reinforcement of medication management, and the need for education and
support for the interpersonal difficulties that arise during the
course of the disorder.

More than two-thirds of people with manic-depressive disorder have at
least one close relative with the illness or with unipolar major
depression, indicating that the disease has a heritable component.
Studies seeking to identify the genetic basis of manic-depressive
disorder indicate that susceptibility stems from multiple genes.
Despite tremendous research efforts, however, the specific genes
involved have not yet been conclusively identified. Scientists are
continuing their search for these genes using advanced genetic
analytic methods and large samples of families affected by the
illness. The researchers are hopeful that identification of
susceptibility genes for manic-depressive disorder, and the brain
proteins they code for, will make it possible to develop better
treatments and preventive interventions targeted at the underlying
illness process.

In addition to the mentioned medical treatments of bipolar disorder,
there are several other options available to bipolar patients, most of
which are used in conjunction with medicine. But there is no assurance
that these medical measures will cure the patient in time. The one
fact of which we are painfully aware is that bipolar disorder severely
undermines its’ victims ability to obtain and maintain social and
occupational success. Because bipolar disorder has such debilitating
symptoms, it is imperative that we remain attentive in the quest for
explanations of its causes and treatment.