- April 25, 2020
BipolarDisorder (BD) is a chronic disease showcasing debilitating symptomsthat have highly negative effects on patients. BD also affects thecaregivers who are involved in taking care of the patients sufferingfrom this disease. Bipolar disorder is a brain disorder causingunprecedented changes in energy, moods, activity levels and theability to do the usual daily activities. There exist four basictypes of bipolar disorder. All these types involve the shifts inenergy mood and activity levels. These types include Bipolar IDisorder, Bipolar II Disorder, Cyclothymic Disorder (Cyclothymia) andother Specified and Unspecified Bipolar and Related Disorders that donot match the three categories listed but they are however defined bybipolar disorder symptoms ("NIMH» Symptoms Outdo Diagnoses in Predicting in At-RiskYouth", 2016). first appeared in medical published literature inthe 1850’s. For quite some time, the condition was referred to as“manic-depressive disorder, but in 1980, this changed and it wastermed as bipolar disorder. This paper aims at giving an insight onthe prevailing statistical rates of bipolar disorder the diagnosticcriteria used in diagnosis course age, gender and cultural issuesregarding BD possible causes and contributors possible treatmentand other things specific to this disorder
BipolarDisorder begins either in early adulthood or at adolescence andcauses adverse effects on the patient’s mental and physical healthand can last a lifetime (McCormick,Murray, & McNew, 2015).Although BD is not as prevalent as major depressive disorder (MDD),the lifelong occurrence in the US is approximately at 4%, withsimilar rates across races, gender, and ethnicity (McCormick, Ursulaet al. 2015). Bipolar disorder types I and II affect about 2.1 % ofthe total world population. In addition to type I and type II andCyclothymia, which in unison comprises the 3-4% of the world’spopulation. The bipolar spectrum contains the mentioned group ofbipolar disorder types, and together with the so-called soft end ofthe spectrum, they form an impressive 5-8% of the world populationand poses the greatest therapeutic and diagnostic challenge forcontemporary psychotherapy(Filaković, Petek & Požgain, 2011).Although BD is not as predominant as major depressive disorder (MDD),the lifelong prevalence in the US is approximately at 4%, withsimilar rates across races, gender, and ethnicity (McCormick, Ursulaet al. 2015).
Evenwith treatment, 37% of the patients relapse into depression within aspan of a year, and 60% within 2 years. Only 58% of patientssuffering from BD have fully recovered, but 49% have recurringoccurrences after intervals of 2 years (Geddes & Miklowitz,2013). Bipolar disorder usually onset at an early age and relapserisks persist for years until the age of 70 years, the identificationof long-term predictors of BD risk is extremely pertinent to thetreatment of patients and clinical management and also theimprovement of preventive strategies (Alberichet al., 2016).
Descriptionand diagnostic criteria of disorder and differential diagnosis
Afterthe primary onset of bipolar disorder, patients have lingeringdepressive symptoms for about 2-3 days. Patients also suffer impairedjudgment, psychotic symptoms, compromised quantity of life, andstigma. Patients with BD suffers recurring incidents of pathologicmood conditions that are characterized by depressive symptoms ormania, which are blended by the times of generally normal temperament(McCormick,Murray, & McNew, 2015).There are two main types of BD, they include the type I and type IIbipolar disorder. The bipolar I disorder (BD I) is characterized byan occurrence of one episode of mania, while bipolar II disorder isdefined by one occurrence of hypomania and depression. The severityof the manic symptoms is the main difference that distinguishes maniaand hypomania. Mania effects are severe and can lead tohospitalization where the patient suffers adverse functionalimpairment as it manifests as psychotic symptoms, whereas hypomaniadoes not have such strong effects. (McCormick,Murray, & McNew, 2015).
Successfulassessment and treatment by medical practitioners require theknow-how of the episodic nature that BD has. Diagnosis of the extrememanic episode may be significantly easy and straight forward. Whenpatients present to primary care, they may need to be referred tospecialist hospital care with immediate effect because of the riskthey pose of harming themselves as well as others who are surroundingthem. More common in the primary care set, however, is the showcasingof patients with this depressive symptom that need distinguishing BDand MDD and hence, all the patients showcasing depressive signsshould be assessed for a history of hypomanic or manic symptoms(Cerimele, Chwastiak, Chan, Harrison, & Unutzer, 2013).
Thefirst step in diagnosis is the use of bipolar screening tool whichturns out to be very time-efficient. This is followed by acomprehensive confirmatory clinical interview. The CompositeDiagnostic Interview (CIDI) and the Mood Disorder Questionnaire (MDQ)are the most common tools used for screening in which the resultscores above cut-off value may indicate the presence of BD. There isalso a development of electronic and web-based screening tools thataim for greater efficiency in time. (McCormick,Murray, & McNew, 2015).
Diagnosticcriteria for a manic episode is characterized by the followingphysical restlessness or heightened activity, whether at work orsocializing more talking than usual grandiosity or inflatedself-esteem, which may be delusional racing thoughts and ideasdecreased need for sleeping more attention to things which are notimportant high indulgence of activities that may lead to painful andregretful results such as sexual indiscretion, reckless driving,shopping extravagance (Mason, Brown, & Croarkin, 2016). At leastthree of these symptoms requires a duration of one week, for most ofthe time. Although, an episode might take place and be regarded as acondition regardless of the duration. Hospitalization may be requiredduring this time unless only irritable mood showcased and then foursymptoms were needed. Moreover, the criteria give in details thesymptoms that would preclude the diagnosis of a manic episode andgives direction to other more appropriate diagnoses, guiding theclinicians to appropriately diagnose where appropriate (Mason, Brown,& Croarkin, 2016).
Hypomaniadescribes a clinical syndrome that is not as severe as mania, but itis similar to. A patient who presents this type of episode is firstdescribed with the term Bipolar II, however, this does not become adiagnosis class and is referred to as an atypical diagnosis in thiscontext. Diagnosis of Cyclothymic Disorder requires the presence ofhypomania episodes in the absence of full manic periods for it to besuccessful, whereas the Diagnosis of needs the manicepisode. Hypomania, only requiring 4 days, can be diagnosedepisodically with the similar symptom criteria as those of manicepisodes. It also requires to be free from psychotic features andbeing clearly dissimilar from the non-depressed mood (Mason, Brown, &Croarkin, 2016). Mood episodes are highly variable when it comes toduration, both between an individual patient and between patients,but, in overall, a hypomanic episode can be experienced from days toweeks while a manic can last a fortnight to months and lastly, adepressive episode can last months to years (McCormick,Murray, & McNew, 2015).
TypeI and II of bipolar disorder, together with Cyclothymia are easy todiagnose, but they must be detected on the early onset of thedisorder where the patient experience unipolar depression, frequencyof illness and in case of any family history of bipolar as well asother comorbid disorders such as drug abuse, alcoholism and psychoticdepression, uncontrollable anger and violence tendencies as well assuicide attempts and postpartum depressions Thesestates are in most cases resistant to conventional therapy againstdepression, otherwise known as antidepressants. Recognition ofbipolar disorder as heterogenic in its comorbidity,ethiopathogenesis, and phenomenology has significantly heightened thepossibility of early diagnosis and has set the ball rolling towardsnew and advanced therapeutic strategies (Filaković, Petek &Požgain, 2011).Early detection and recognition of bipolar disorder can help toinitiate effective therapy early, with favorable outcomes on bothshort-term and long-term course of the disease. Most patients with BDmay showcase symptoms to the caregivers, but due to lack of properexpertise and enough resources, many of them do not get a sufficientassessment for conceivable bipolar diagnosis (McCormick,Murray, & McNew, 2015).
Bipolardisorder is in most cases, an episodic, lifetime disease with ahighly varying course. The initial episode may be manic, hypomanic ormissed, or depressive. During the first ten years after diagnosis hasbeen done, the average patient with BD will suffer around four majormood episodes. The episode’s duration and inter-episode remissions,in the traditional view, become shorter. They then stabilize afterthe fourth or fifth episode at around one episode per every yearconsequently from the disease onset. Experiencing four or moreepisodes yearly, 10-15% of patients will undergo full or partialremissions in between the episodes or switching to the oppositeextreme polarity of either Manic or Depressed. They may experiencesuch 10 periods in their lifetime if it goes untreated.
Age,gender, and cultural issues
Racialand ethnic minorities are underprivileged when it comes to access tomental health services. They are most likely to receive poor qualityhealthcare, if at all they get access. Culturecan also influence on the revealing of mania and depression symptoms.Misdiagnosis or underdiagnosis can be minimized by being more alertto some cultural or ethnic differences in relaying information orcomplaints about an episode. When administering medication, race orethnicity must be taken into great consideration, since this groupmay differ in metabolizing some medication.(Hirschfeldet al., 2010).
Childrenand adolescents with bipolar constitute up to 1% of their population,with an additional 5.7% suffering from mood swings that are howevernot categorized as bipolar. Children with BD in most cases have rapidcycling, mixed mania, and psychosis. Together with an adolescent,children have a recovery rate of 37.1% and have a relapse rate of38.3% (Hirschfeldet al., 2010). Bipolar disorder has a severe and chronic effect onchildren and adolescent. Effects may also have a devastating impacton social, academic and emotional development. Youths are at greaterrisk for substance use disorders when they have bipolar disorder.Patients who are 65 years and over have a prevalence rate of0.1%-0.4%. Patients, whose onset is that of old age, have a lesserfamily history of bipolar disorder. Although they also experiencelonger periods, their episodes are more frequent compared to youngerpatients.(Hirschfeldet al., 2010).
Gender-relatedissues must be considered when treating patients who have BD. Womencommonly suffer from hypothyroidism, and they may be more susceptibleto the lithium’s antithyroid effects. Moreover, women commonlyshowcase rapid cycling. Antipsychotic treatment and SSRIs mayheighten prolactin levels in serum, leading to sexual dysfunction,impaired fertility and menstrual disorder (Hirschfeldet al., 2010).
Potentialcauses/contributors to the disorder
Scientistsare taking steps in studying the possible causes of bipolar disorder.Most of them are in agreement that it is not a single factor thatcauses the illness, but rather a combination of many factors thatcontribute to increased risks ("NIMH » Symptoms Outdo Diagnosesin Predicting in At-Risk Youth", 2016). Studiesshow how the brains of patients suffering from BD may differ those ofpeople who are in good health or people with other mental disorders.Along with new data from studies of genetics and learning thesedifferences, we are in better positions to understand BD and makepredictions on which type of treatment will work best and effectivelywith patients. Some research makes suggestions that the geneticmakeup of a person can be a contributing factor to developing bipolardisorder. It suggests that people with some type of genes are morelikely to be a risk factor for BD. Some studies suggest that anindividual from a set of identical twin, might not necessarilydevelop bipolar disorder when the other one develops the disorder,given the fact that they have the same genes. Family History is alsoanother factor considered to be a cause of this disorder as it runsin the family. Children may develop bipolar disorder if their parentshad a similar disorder, however, it is vital to note that this is notalways the case. ("NIMH » Symptoms Outdo Diagnoses inPredicting in At-Risk Youth", 2016)
Possibletreatments and effectiveness of treatments (including empiricaldata)
Treatmentof Bipolar depression is a major challenge, only a few treatmentshave been successful. Bipolar disorder treatment conservatively putsfocus on acute stabilization, in which the aim is to bring a patientsuffering from depression and mania to a full symptomatic recoverywith stable mood and maintain the healthy condition in whichrelapses are prevented, subthreshold symptoms are reducedsignificantly, and the occupational and social functioning areenhanced (Geddes & Miklowitz, 2013). Treatment of both phases canbe quite challenging as the same medication used for alleviation ofdepression might offset mania or hypomania, and also the treatmentsthat suppress mania might cause depressive episodes.
Pharmacotherapytreatment is vital for managing patients with BD successfully. Withthe ultimate objective of full remission, the goal is symptomreduction in acute episodes. During maintenance treatment, the aim isto prevent any reappearance of mood episodes. Examples of medicationsused in the treatment of the bipolar disorder include moodstabilizers (e.g. Lithium, carbamazepine, and lamotrigine),conventional antidepressants and atypical antipsychotics (McCormick,Murray, & McNew, 2015).Lithium was the first mood stabilizer agent that was used in treatingBD. Lithium still has a role despite having so many limitations whichinclude narrow therapeutic window, inadequate efficacy in thetreatment of bipolar depression, and delayed initialization of actionin treating acute mania. Lithium is believed to possess antisuicidaland antiaggressive actions, therefore, it holds the latent beneficialactions in other domains of relevance in managing bipolar disorderbeyond its mood-stabilizing actions. Furthermore, an effect inneurodegenerative disorders has been suggested (Licht,R. W. (2012). Lithium reduces the probability of mood episodes inpatients for up to 2 years. The treatment effect is active for bothdepressive recurrence and manic relapse, with the statisticalimportance of the latest dependent findings (Severuset al., 2014).
Lithiumtogether with antipsychotic is used for the initiation of thetreatment of more severe mixed or manic episodes, this is referred toas the first line pharmacological treatment. Monotherapy with eitherlithium or antipsychotic is used on less ill patients as they aresolely efficient without mixing (Loebel et al., 2014). For patientswho experience mixed or manic episode even though they have receivedmedication for maintenance, should have their medication doseoptimized as the first line of intervention. Incases where the first line medication does not work to control thedisorder symptoms, alternative options such as the addition ofanother first line medication is recommended, this may include theaddition of carbamazepine on top of the additional first linemedication, or totally changing to a new medication(Hirschfeldet al., 2010).
Aftertreatment of an acute episode, a period 6 months, always calledcontinuation treatment phase, patients are at a high risk ofexperiencing a relapse. This period of treatment is referred to asthe maintenance phase. Regimes for maintenance are highly recommendedafter a manic episode. Consideration for this phase treatment ishighly warranted despite the few studies made concerning bipolar IIdisorder. Lithium and valproate represent medication with the bestempirical evidence to support their role in maintenance treatment.Patients with bipolar disorders are likely to gain from psychosocialintervention during maintenance treatment, this may includepsychotherapy addressing interpersonal difficulties and diseasemanagement (Hirschfeldet al., 2010).
BipolarDisorder is a chronic disease showcasing debilitating symptoms thathave highly negative effects both on patients and caregivers.Although the levels at which it has an effect on people of differentages, gender and ethnicity are different, it cuts across all,however, diagnosis may be affected by these factors. For bettertreatment, the diagnosis should be done during the early onset of theillness. After acute treatment is undergone, the patient must be putunder maintenance regime to prevent relapse episodes. Bipolardisorder is a manageable illness despite it being a lifetime illness
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