Kathy Belous Abstract: Bipolar disorder (BPD) is a multifaceted genetic disorder in which a person experiences drastic mood swing, from intense mania to profound depression. Also known as Manic-depressive illness, about five million Americans suffer from this disorder as it affects more women than men. Individuals are usually diagnosed with BPD anywhere form adolescence to early adulthood. The complication, however, include more than just individual suffering, a common misconception. The families and caretakers of these patients experience psychological as well as emotional burdens, as the country experiences financial complications. The treatment of bipolar disorder is not a simple task, Lithium, anticonvulsants, and forms of therapy have been used for many years, only to suppress the problem. As research advances and experts obtain a clearer meaning of this disorder, further innovations of treatment will be discovered. As for the time being, these BPD patients need to feel support from their surrounding peers so as not to make their situation worse.
Introduction: Bipolar disorder (also known as manic depressive illness) is a complex genetic disorder in which the core feature is disturbance in mood. The affects range from extreme mania to severe depression usually accompanied by disturbances in thinking and behavior, which may include psychotic symptoms, such as delusions and hallucinations. Typically it is an episodic illness, meaning that full recovery takes place between episodes. In all modern classifications, such as DSM-IV, the diagnosis of bipolar disorder
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Kathy Belous requires that a person has suffered one or more episodes of mania with or without episodes of depression at other times during the life history. In DSM-IV, bipolar disorder is sub-classified into bipolar I disorder, in which episodes of clear cut mania occur, and bipolar II disorder, in which only milder forms of mania (so-called "hypomania") occur. (Danielyan and Kowatch, 2005) Now from an evolutionary perspective, since humans are affected by evolutionary selection, why does this disease still exist at all? According to this theory only highly „fit‟ individuals survive and spread their genes to future generations. If these individuals prospered, they were able to aid their children in survival, so they, too, can reproduce. Genes that created increased „fitness‟ would be preserved, so more people can acquire them, while genes that decreased „fitness‟, in theory, should eventually die out. This process avoids the struggle of survival by those „unfit‟ individuals, who would not prosper enough to help their children live on. It is clear that Bipolar disorder (BD) reduces „fitness‟, yet even after thousands of years, it still affects about five million people in the United States (Rif S. El-Mallakh, 2001). So why wasn‟t this „gene‟, or genes, for bipolar disorder eliminated by evolution? Oddly enough, there are numerous genes which appear to decrease a person‟s fitness, yet still have not disappeared. The most common explanation for this states that: these genes may, in some way, benefit some individuals, if in small doses. Only a large dosage of these genes will actually account for a person to function below average. For example, a bipolar person experiencing high energy levels, during manic phases, may find it hard to settle down and focus, whereas a person with a small amount of the same gene can use that energy for productivity.
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Kathy Belous As the fact remains that bipolar disorder is still evident amongst certain individuals and evolution has not eliminated it, a better understanding of this disease will help in further research for treatment. This paper will discuss the genetics of bipolar disorder and how it affects the individuals who have it, as well as their caretakers. In addition, the causes of this disorder and, both clinical and non-pharmacologic, treatments will be addressed. The Nature of Bipolar Disorder: Genetics: Experts have conducted many studies over the last couple decades trying to pinpoint the exact cause of bipolar disorder (BPD), yet none have reached a solid conclusion. There is, however, evidence demonstrating a strong connection between BPD, genes, and the environment. Nimgaonkar and Alda (2001) found that the initial step in classifying disease genes is to define a phenotype, which is typically the result of an interaction between genes and the environment. Secondly, they stated that the genetic influence must be evident in the phenotype for the „gene-mapping‟ effort to continue. Luckily, the genetic connection to bipolar disorder is very clear. It is verified by the propensity of BPD to cultivate in families, as cited by Guroff JJ et al. (1982). Studies showed that there is a 5.7-7.8% chance of first degree relatives receiving bipolar disorder from members of the family who already have it (McGuffin P, Katz R., 1989). Using the Risch notation, the risk ratio of a sibling receiving it, divided by the population frequency of BPD equals about eight (Risch 1990). Lastly, studies among adopted offspring proposed an increased risk of obtaining BPD (Mendlewicz J, Rainer JD, 1977). As all these studies set a clear
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Kathy Belous relationship between bipolar disorder and genetics, Nimgaonkar and Alda continue to note that an influence by the environment is just as important. Bipolar disorder has the greatest societal impact in comparison with other disorders, a topic which will later be discussed in more detail. Since the mode of inheritance of BPD is unknown, locating the precise gene of this uncommon disorder has not been done. Although, both autosomal and sex-linked modes of inheritance have been mentioned, further research has shown that more than one gene contributes to this disorder. In addition, most experts agree that bipolar disorder is a heterogeneous condition with individual genetic mechanisms. And while it is possible, in some families, for this illness to focus on one gene, there are cases where no genetic factors took play at all.
Diagnosis: The Diagnostic and Statistical Manual Disorders (4 th edition), DSM-IV, is a diagnostic system in order to characterize and identify mental disorders. Danielyan and Kowatch (2005) state that, for BPD it is important to identify the type of bipolar „episode‟ a person experienced in order to conduct an appropriate treatment. According to DSM-IV, the mood episodes consist of a) manic episodes, b) hypomania episodes, and c) a mixture of episodes. The authors describe a manic episode as a period lasting at least a week in which the person has abnormal, extreme, or irritable moods. During these phases, a complex socially or educationally must occur, if not some duration of hospitalization. They further explain that if a patient experienced a single manic episode that lasted for over a week, he or she is diagnosed with bipolar I disorder. If, however,
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Kathy Belous there is history of, at least one, major depressive and hypomanic episodes, manic and mixed episodes excluded, bipolar II disorder is diagnosed. To further narrow down the diagnostic system, clinical rating scales are used to measure the level of the illness and any changes which occur during treatment. The Mania rating Scale is one of the more commonly used scales due to its precise accuracy and consistency (Young RC, Biggs JT, Ziegler VE et al. 1978). Commencement Age: Montejano, Goetzel, and Ozminkowski state that bipolar disorder usually occurs anywhere from late teenage years to early adulthood, anything earlier may have to do with the family history of this disorder. Typically, bipolar I disorder has an earlier onset that bipolar II disorder, as cited by Suppes T, Leverich GS, Keck PE et al. (2001). And although it is unlikely, children may also be diagnosed with BPD. A study done by Peris RH, Marangell LB, et al. in 2004 demonstrated that almost a third of 1000 patients with bipolar, were children under the age of 13. With children, however, the course of illness may be slightly different. Mood swings occur more frequently while irritability dominates during manic phases. As a result, a younger a person diagnosed with BPD suffers a more severe course of illness with worse outcomes. Sex Differentiations: According to Montejano, Goetzel, and Ozminkowski the ratio of males to females with bipolar disorder are about the same, yet the median age of onset for women is higher (Arnold LM, 2003). Women are also more likely to undergo depressive episodes, rapid cycling, and mixed episodes leading to the fact that women are also more prone to bipolar II disorder than men (Arnold LM, 2003). Usually women are also more associated with
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Kathy Belous medical and psychological conditions, whereas men are more likely to have substance abuse-linked comorbidity (Arnold LM, 2003). Life Style: Although BPD is classified as an individual disorder, on a larger scope, evidence has proven this not completely true. A person with BPD has many complexities in his or her quality of life, ranging from family and social complications to inabilities in performing everyday life functions. Yet possible connection to creativity have been linked to BPD, on the positive note, as well as extreme cases in which patients may commit suicide from depression, the negative aspect. Furthermore, it is not only the individual who suffers from this chronic disorder. The family and or caretakers experience drastic constraints also, from economical and emotional standpoints to psychological ones as well. Complications for the patient: Montejano, Goetzel, and Ozminkowski reported that the severe and continuous nature of bipolar disorder causes many negative impacts on occupation and social life. In a study done by Lish JD, Dime-Meenam S, and Whybrow PC in 1994, 45% of the people with BPD said to have experienced regular symptoms affecting their social existence. Another study done by the authors found that patients had struggled more with psychosocial functioning, work-related tasks, and family relations. About 25% of the patients with BPD rated their social abilities and skills anywhere from poor to incredibly insufficient. In 2000, a study done by Kusznir A, Cooke RG, and Young LT provided information on patient‟s limitations in normal functioning, even when not experiencing episodes of depression or hypomania. Although, research by Arnold LM, Witzeman KA,
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Kathy Belous and Swank ML (2000) reported that bipolar patients, in comparison with the general population, did drastically worse on role limitations, bodily pain, general health, liveliness, social function, and mental health. Though it is a common misconception that when in states of euphoria, quality of life may be affected in a positive way, both manic and especially depression phases diminish quality of life (Vojta C, Kinosian B, and Glick H, 2001). Especially during depression episodes, patients have been known follow through with such extremes like suicide. As most bipolar patients are diagnosed when just about done with college and entering the work force, this disorder has provides negative impacts there as well. Montejano, Goetzel, and Ozminkowski found that bipolar employers experiencing irritability usually take action by sudden outbursts and overreactions due to the slightest displeasures. On the other hand, they state that employees enduring depression will usually degrade themselves, making themselves accountable for all the cooperation‟s wrongdoings, or simply not being able to accept normal critique from their fellow employees. Depression is also closely linked to the lack of concern in work -related topics, low energy levels, and little concentration. Most jobs require intense energy and strong productivity, forms of action which bipolar patients, uncontrollably, may not always be able to do so therefore take little part in this factor of life. Enhanced Creativity: Richards, Kinney, Lunde, Benet, and Merzel (1988) studied the level of creativity in bipolar patients, their relatives, normal subjects (no relation), and psychiatric patients. The highest level of creativity was found in the relatives of bipolar patients, with BPD subjects scoring second best. Jamison (1989) found that bipolar patients, usually poets,
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Kathy Belous compared their psychological and physiological states during creative periods as similar to those during manic phases. She and her colleagues also found seasonal patterns reported by her subjects and clearly portrayed in their notebooks and portfolios. In 1995, Jamison studied a group of bipolar patients, finding that their speech usually involved more rhythm and alliteration, as well as an enhanced ability to perform word-associated tasks faster. Although all these factors go hand in hand with the linkage of bipolar to creativity and poets such as Edgar Allan Poe, William Blake, and Lord Byron demonstrate this, present analysis and research shows little support for the connection to be made a fact.
Burden of BPD on caretakers: “When my wife is depressed it obviously has an enormous effect on my life, my confidence is definitely reduced, because I feel so inadequate, I‟d go off the chart. When she feels good I feel very positive” –anonymous. This quote describes a husband‟s response to his bipolar wife‟s mood swings and it clearly portrays the psychological and emotional impact these patients have on their relatives and caretakers. As these patients experience difficulties in family, friend, and other social relationships a reciprocated response is evident in their family members. A study done among caretakers of people with bipolar disorder, in New Zealand, addressed several concerns which arose while taking care of their patients. Issues from marital and relationships complexities, increased stress, and fear of violence to employment problems, lower income, and less time for
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Kathy Belous leisure activities occurred (Dore G and Romans SE, 2001). Another study done in the United States showed that caretakers of BPD patients were more than 93% likely to have reported distress in at least one burden domain (Perlick D, Clarkin JF, and Sirey J, 1999). Families are expected to take care of BPD patients, that they obviously love, yet they have no prior training or knowledge of how to do so. And as these caretakers may, from time to time, get frustrated with their patients, a negative reaction may have a direct connection to future effects on the patient‟s mental state. Financial Difficulties: Bipolar disorder is not just a physiological burden, but an economical one as well. The Global Burden of Disease study found the BPD is the sixth leading cause of worldwide disability (Murray CJ and Lopez AD, 1996) and with that the annual cost of BPD in the United States was estimated to be around $45.2 billion (1991). About $ 7.6 billion is due too direct medical coverage and the remaining $37.6 billions accounts for the indirect costs (Wyatt RJ and Henter I, 1995). Inpatient hospitalization is one of the largest drivers of direct costs ($2.4 billion), along with outpatient treatment ($300 million), and drug prices ($130 million). Begley et al. estimated that the lifetime costs for 95,000 bipolar patients in the United States in 1998 should be somewhere around $24 billion. These figures, of course, depend on how many manic episodes and hospitalizations occurred through the course of that year. The estimated cost incorporated both direct and indirect costs, equal ratio, yet healthcare and medical care composed 49% of that estimate. In the United Kingdom an estimated £2 billion annually is necessary to support bipolar patients at 1999-2000 prices (Das Gupta R and Guest JF, 2002). 10% was for
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Kathy Belous healthcare costs, 4% for residential care, and the rest went to indirect costs. Overall, from the acquired data above, bipolar disorder turns out to be fairly expensive. This is due mainly to the intense hospital bills and many drugs prescribed to BPD patients. Treatments: Although the quality of life is impaired because of BPD, there are efficient treatments that lead to reduction of this disorder, yet no complete recovery has been noted yet. For treatment, it is not always necessary to turn to the pharmacologic approach because a psychosocial one exits as well, and in some cases it has proven to help. According to Anne D. Walling (2005), treatment of bipolar disorder is difficult to obtain because it requires the suppression of both manic and depressive phases, as well as the avoidance of relapse into either state.
Lithium: Montejano, Goetzel, and Ozminkowski state that lithium is the earliest moodstabilizing medication and has the longest history of use for bipolar patients (Silverstone, 2000). It is well established in patients who experience manic phases, and it‟s known to reduce rates of suicide. This drug is most effective in patients who do not cycle rapidly, so unfortunately about 20-40% of the patients are not affected by this drug. Despite a few setbacks, lithium is clearly linked to about 56% reduction in mood episodes and an 82% reduction in the number of hospitalizations (Rivas-Vazquez RA and Johnson SL, 2002). Anticonvulsant drugs: These authors also address the second and third generation anticonvulsant drugs, such as divalproex and carbamazepine, and support their affect in patients with acute
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Kathy Belous mania, but exclude those suffering from depression. Newer anticonvulsant drugs, gabapentin and lamotrigine, have recently been prescribed to BPD patients, however there is no concrete evidence linking gabapentin to aiding mania (Ytham LN, Kusumkaer V, Calabresse JR 2002). Lamotrigine, however, has just been recently approved by the US FDA for bipolar maintenance therapy. These drugs are useful for those individuals who do not respond well to lithium, but their use is limited by side effects such as weight gain and sedation. Antidepressants: Antidepressant drugs are not recommended for BPD patients. Montejano, Goetzel, and Ozminkowski agree that they are sometime taken with lithium, yet they have been proven to induce mania. Research shows that about 20-40% of bipolar patients, who take antidepressants, are especially prone to „anti-depressant-induced mania.‟ Antipsychotic Drugs: Antipsychotic drugs have been used on bipolar patients to treat mania, either alone or combined with other medications. Ariprprazole, olanzapine, quetiapine, risperidone, and ziprasidone are the most common drugs prescribed, usually in small doses though. A study done by Shi, Namjoshi, and Zhang (2002) found that the use of olanzapine by bipolar patients improved their work activities. The biggest disadvantage of these drugs, however, is in the side effects; weight gain is the primary factor. Non-Medical Treatments: As medication is usually the first approach in curing/suppressing chronic disorders. Montejano, Goetzel, and Ozminkowski, as well as some research, identified
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Kathy Belous another way to go about this issue. Psychotherapy can very beneficial in the treatment of bipolar disorder, even if used in conjunction with other medication. Psychosocial involvements such as cognitive-behavioral, interpersonal, educational, or family therapy can all decrease medical reliance and increase social and normal functioning (RivasVazquez RA and Johnson SL, 2002). A study done by Cerbone and Mayo demonstrated that psychotherapy and medication, in treating bipolar subjects, resulted in fewer hospitalizations or at least a decreased duration at the hospital. In another study, conducted by Miklowitz, George, and Richards in 2003, that treatment of bipolar patients drastically improved with the combination of medical and educational therapy. In addition, patients who received family focused psycho-education and cognitive therapy were less likely to experience relapses in manic or depressive episodes. Electroconvulsive therapy (ECT) is another treatment option for bipolar patients. Especially when other treatments have not been affective or if the patient experienced many suicide attempts, this option can be helpful. Studies suggest that minor use of ECT as a stabilizer for manic or depressive mood swings is a good maintenance therapy (American Psychiatric Association, 2002). Conclusion: BPD is a chronic disorder which, to this day, has no defined treatment. Many suggestions have been put on the table, yet because experts are unclear of the direct cause or genes associated with it; it is difficult to find a cure. For a bipolar person, it is hard enough living life while experiencing drastic mood episodes, from extreme euphoria to the deepest depression, so the family or caretakers of these individuals should constantly be aware of that. Of course there are always extreme situations, in which bipolar patients
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Kathy Belous are so far from reality that suicide never leaves their mind or they are constantly bouncing off the walls, but that shouldn‟t be a reason to abandon them. As research has shown, when families take part in therapy with the patients, drastic improvement is evident. This goes to show that even if a person is abnormal, feeling love and support from surrounding people can only help their situation, it defiantly can‟t make it worse.
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