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Bipolar Disorder

Bipolar disorder (BD) is a problem that attracts the attention of experts around the world. This pathology is one of the most serious diseases, and is a complex diagnostic and therapeutic challenge even for experienced physicians. Bipolar disorder (BD), or the so-called manic-depressive illness (psychosis,) is a periodic emotional disturbance phase of different polarity. The sequence of manic and depressive phases with periods intermissions may be different, but it has prognostic significance. The complexity of the problem is partly due to the fact that often recurrent depressive disorder may be undiagnosed bipolar disorder. Thus, the initial depressive episode does not necessarily mean the presence of unipolar depression, and in turn, the diagnosis of bipolar disorder in the manic phase, particularly in the presence of psychotic symptoms (delusions, hallucinations), requires a complex differential diagnosis with other mental illnesses such as schizophrenia and schizoaffective disorder. (Keller et al., 1991).

The history of study of mood disorders has more than two thousand years. The concepts of “melancholy” and “mania” as the medical terms can be find in Hippocrates (5th century BC. E..) For the first time as an independent disease bipolar disorder was described in 1854 by two French researchers, J.P. Falre called and J. Baillarger. However, the existence of this disorder was not recognized by psychiatry of that time, and only E. Kraepelin in1896 managed to point it as a separate disease. In 1896 Kraepelin proposed the concept of manic-depressive psychosis (MDP). He described the polar syndromes of mood – mania and depression as disorders with alternating exacerbations and remissions. (Angst & Sellaro, 2000)

The diagnosis of “bipolar disorder” replaced the manic-depressive illness in the American classification DSM-III in 1980. According to it, bipolar disorder is a severe chronic disease of mood, which is characterized by episodes of mania or hypomania that alternate or combined with episodes of depression. The DSM IV identifies four basic types of bipolar disorder, each with specific criteria for diagnosis:

  1. Bipolar I Disorder, which is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. (DSM-IV, p. 350)
  2. Bipolar II Disorder, which is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode. (DSM-IV, p. 359)

In the same classification there are the following episodes of BD: episodes of mania, hypomania, major depressive disorder, mixed episodes, cyclothymia. Thus bipolar disorder is a “cyclic” or “periodic” illness, when patients have a manic or mixed-manic episode, then returning to normal, and later may have depressive episode. That is why Bipolar disorder in the past was referred to as “manic depressive illness, circular type.” (Angst & Sellaro, 2000)

The depressive episodes seen in bipolar disorder, in contrast to those typically seen in a major depression, are characterized by psychomotor retardation, hyperphagia, and hypersomnolence and are not uncommonly accompanied by delusions or hallucinations. On the average, untreated, these bipolar depressions tend to last about a half year. Some of the criteria for major depressive episode include:

  • depressed mood most of the day, and nearly every day;
  • significant weight loss;
  • insomnia or hypersomnia nearly every day;
  • diminished ability to think or concentrate;
  • psychomotor agitation or retardation;
  • fatique or loss of energy nearly everyday;
  • recurrent thoughts of death, suicide attempt or specific plan for commiting suicide. (DSM IV, p.327)

Manic episodes are often preceded by a prodrome, lasting from a few days to a few months, of mild and often transitory and indistinct manic symptoms. The symptoms of mania are the following:

  • heightened mood (either euphoric or irritable);
  • flight of ideas and pressure of speech;
  • increased energy, decreased need for sleep, and hyperactivity;
  • delusions and some fragmentation of behavior. (DSM IV, p.332)

Mixed-manic episodes are not as common as manic episodes or depressive episodes, but tend to last longer. They are characterized with admixtures of manic and depressive symptoms, sometimes in sequence, sometimes simultaneously, so these mixed-manic episodes must be distinguished from the transitional periods that may appear in patients who “cycle” directly from a manic into a depressive episode, or vice versa. (Werder, 1995, p.1129)

The overall treatment of bipolar disorder includes treatment of the manic or mixed-manic episode first, and then the treatment of the depressive episode, with special emphasis on the phases of treatment: acute, continuation, and preventive.

Speaking about the prevalence of the disease it is necessary to point that until the 1970s manic-depressive illness was perceived as a rare disorder (0.5% of the population) with a typical clinic and a favorable prognosis, which is easily diagnosed and treated (Angst & Marneros, 2001). But in recent years, taking into account the epidemiological data, mood disorders has become one of the global challenges of the XXI century. This is because the initial idea of a low prevalence of the MDP was rejected. Current epidemiological studies, which were published after 2000 showed that the prevalence of the MDP several times more than 0.5-1%. It should be mentioned that the disease is difficult to assess. Difficulties in accurately assessing the prevalence of bipolar disorder are associated not only with a variety of criteria, but with the inevitable subjectivity of diagnosis in of psychiatry. According to some studies, the prevalence ranges from 0.5 to 0.8% (5.8 per 1,000). (Hirschfeld et al., 2002) But according to the U.S. National study, which included assessments of 9282 respondents with a complete diagnostic WHO interview, found that the prevalence of dipolar disorder throughout life and in the last year for type I and II is 3,9 ± 0,2% and 2 6 ± 0,2% respectively. It was also found that patients diagnosed with BD were much more likely to have comorbid psychiatric (alcoholism, drug addiction, anxiety) and somatic disorders. (Kessler R. et al., 2005)

The causes and mechanism of bipolar disorder are not entirely clear, although in recent years in this area appeared new information, especially about the nature and inheritance of the disease and its neurochemistry. In addition, the study of antidepressants and other drugs at the level of the nerve cells enables a deeper understanding of the pathological processes underlying the BD. All these data allow to get new understanding of the role in the development of the disease of metabolism of biogenic amines, endocrine changes, changes in water-salt metabolism, pathology, circadian rhythms, the influence of gender and age, constitutional features. Based on these data, hypotheses describe not only the notion of biological essence of the disease, but also provide information on the role of individual factors on the clinical features of disease. Anyway BD is a disease with a strong genetic predisposition: the risk of bipolar disorder is about 13%, and the risk of unipolar depression – 15%, the risk of schizoaffective disorder – 1% (Werder S., 1995).

According to studies on identical twins, the role of hereditary factors in the development of BR is 79%, while the remaining 21% is the impact of environmental factors (stress, frustration Sexual abuse of psychotropic drugs). Epidemiological studies have shown the highest prevalence of BD in the age group from 18 to 24 years, with no sex differences. (Keller, 1991)

This disease is an important social problem, as patients are maladjusted in professional, social and family life, and have an increased risk of suicide. According to the calculations of modern researchers, manic-depressive psychosis takes the 6th place among causes of disability (WHO, 2001). Unemployment among these patients may reach 57% within the first 6 months and 75% after 2 years of disease. Significant problems for the bipolar patients are associated medical condition: for example, obesity occurs in 21-32% of patients, another 31% may be overweight. Hypertension affects up to 35% of patients, hyperlipidemia – 23%, diabetes – 11-17%, osteo-articular pathology of the system – about 15%. High frequency of concomitant somatic pathology also leads to a deterioration in the quality of life of patients with bipolar disorder and a significant reduction in its duration. Patients suffering from manic-depressive illness lost during the disease in average about 9 years in life expectancy, 14 years of disability and 12 years of normal health, primarily due to suicide and medical comorbidity, that makes this disease one of the most acute problems of modern society. (Kilbourne et al., 2005)

 

Works cited:

Angst J., Sellaro R. “Historical perspectives and natural history of bipolar disorder”. Biol Psychiatry 48. 6 (2000): 445–57.
Angst J., Marneros A. Affect. Disorders 67 (2001): 3 –19.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. 4th ed. Washington, DC: American Psychiatric Association, 2000.
Keller M.B., Baker L.A. “Bipolar disorder: epidemiology, course, diagnosis, and treatment”. Bull Menninger Clin. 55 (1991): 172–81.
Kessler R. et al. Arch. Gen. Psychiatry 62 (2005): 593—602, 617—627.
Kilbourne A., Cornelius J., Han X. et al. Bipolar Disorders 6 (2004): 368–373.
Mitchell P.B., Ball J.R., Best J.A. “The management of bipolar disorder in general practice”. MJA 184.11 (2006): 566–70.
Werder S.F. “An update on the diagnosis and treatment of mania in bipolar disorder”. American Family Physician 51 (1995): 1126–36.
World Health Organization. “The World Health Report 2001; Mental Health: New Understanding, New Hope”. Geneva, WHO, 2001.