Atlas of Bipolar Disorders

Edward H. Taylor

• Publisher: CRC Press
• Year: 2006
• Print ISBN: 9781842142189
• eBook ISBN: 9781135401672
• Topic: Medicine
• Subtopic: Neurology

This is the first book to summarize research and clinical methods used for treating bipolar disorders across the life cycle. The author discusses all DSM-IV Bipolar Disorders and disorders similar to Bipolar Disorders. He includes easy-to-read summaries, numerous informative illustrations and an outline of "best practice methods" recommended by res

1: Introduction and Overview

HISTORY

Throughout recorded history there have been descriptions of people with symptoms resembling bipolar illness. This is particularly true for depressive episodes. Stories depicting manic and depressive episodes can be found in ancient Greek, Persian, and biblical writings. Areteus in the second century AD recounted observing people who, for no known reason, danced throughout the night, appeared euphoric, were overly talkative and self-confident, and just as unexpectedly became sorrowful¹. Hippocrates was well aware of depression, and insisted that what we call mental illness was caused by natural physical reasons rather than spiritual or other forces. The Greeks also identified the brain as the organ responsible for emotional disorders and intelligence. Unfortunately, by the peak of the Roman empire, scientific explanations for mental disorders gave way to mythology and religiously driven superstitions.

In the late 1600s more objective views of mental illness started gaining attention. Theophile Bonet is credited with describing patients who cycle between high and low moods. In the mid-1800s two French researchers, Falret and Baillarger, independently determined that a single form of illness could present both manic and depressive symptoms. Falret named the illness ‘circular insanity’, and included symptoms much as those listed in today’s diagnostic manuals. He considered the illness to be genetically caused, and hypothesized that research could find a medication for relieving symptoms¹. The work of Falret and Baillarger was built on by Emil Kraepelin. His careful systematic observations documented that mania and depression can occur in a single form of mental illness¹. Kraepelin’s 1896 textbook clinically described and named the illness manic-depressive insanity². The modified term manic depression has survived through the ages, and continues to be used^1,2.

The medical progress made in the late 1800s gave way to psychoanalytical philosophy as Europe and America entered into World War II. Major disorders such as manic depression, schizophrenia, and autism were largely framed as arising from unconscious conflicts caused by parents, environments, and personal choice. Manic-depressive or bipolar symptoms were hypothesized to resolve once a patient gained insight, and chose to confront their unconscious fears, anger, and incomplete parenting¹. The dominance of psychoanalytical talk therapy persisted in the United States for decades after World War II. This was also true throughout Europe. However, European doctors started using lithium shortly after its therapeutic properties were discovered by John F.J.Cade in the 1940s. The drug was not approved and widely available in the United States until the 1970s¹. Today there is little debate that bipolar disorders are neurobiological diseases that are highly associated with specific and general abnormalities in the brain’s structures and metabolism. A summary of brain abnormalities along with documenting single photon emission computed tomography (SPECT) scan images is presented in Chapter 4.

A COSTLY DISORDER

Bipolar disorders are a group of neurobiological disorders that historically have been associated with mild to severe shifts in mood, cognitive functions, and behaviors. Diagnostically the illness is classified throughout the industrialized world as a mood or affective disorder. A goal of this book, however, is to illustrate that bipolar disorders affect multiple neurological and body systems, creating disabilities, pain, and grief that cannot be explained in simple descriptive terms about a person’s moods and emotions. This illness has biological, social, and economic repercussions. Periods of frightening manic and depressive episodes can lead to divorce, loss of job, decreased opportunities, homelessness, alcohol and substance abuse, and hardships for family members. As an example, the divorce rate among people with bipolar disorders is estimated to be 3–6 times higher than that found in the general population³. People suffering from bipolar disorders can only find some relief through psychiatric help and lifelong medication therapy.

The burden that a disease causes is estimated by calculating the severity of pain, suffering, disability, and deaths attributed to the disorder. In Australia the burden due to bipolar disorders was found to be greater than that associated with ovarian cancer, rheumatoid arthritis, or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS), and similar to that associated with schizophrenia⁴. The United Nations’ World Health Organization (WHO) reports that bipolar illness is among the top ten causes of years lived with a disability⁵. In addition to disabilities, bipolar illness ends in suicide for many patients. Twelve percent of all suicides in Australia are committed by individuals with bipolar disorders⁴, and between 10 and 15% of patients suffering with bipolar illness in the United States will take their lives^2,6. Additional information on suicide and violence, including the dangers of postpartum depression and bipolar illness, is presented in Chapter 5.

Financially, this neurobiological disorder is estimated to cost £2 billion ($US3.8 billion) in the United Kingdom⁷, $1.59 billion in Australia⁴, and $45 billion in the United States annually³. Indirect costs account for a large proportion of the total expenditure for bipolar disorders within each of these countries. For example, in the United States, approximately $7 billion annually is spent on inpatient care and other direct costs, and $38 billion is thought to result from indirect costs such as loss of productivity³. Much of these costs occur because of hospitalization. However, they also represent the price of misdiagnosis, lack of community treatment, and comorbid substance abuse. The Australian study found that, on average, a correct diagnosis required 10 years from time of onset, and that patients have a 66% chance of initially receiving a wrong diagnosis⁴.

Emily Dickinson

People from every walk of life have bipolar disorders. For some, mild symptom severity, or longer periods between episodes allow reflection and creative use of their experiences

Many think that Emily Dickinson (Figure 1.1) was one of these individuals. She may have been trying to reflect on the pain of depression, and the frightening disorientation of mania, in her poems. The following verses are from Poems of Emily Dickinson.

I Can Wade Grief
I CAN wade grief,
Whole pools of it,
I’m used to that.

I Felt a Cleavage in My Mind
I FELT a cleavage in my mind
As if my brain had split;
I tried to match it, seam by seam,
But could not make them fit.

The thought behind I strove to join
Unto the thought before,
But sequence ravelled out of reach
Like balls upon a floor.

Figure 1.1 Emily Dickinson (1830–86)

A United States study found that approximately 45% of patients with bipolar illness were either untreated or improperly treated⁸.

The WHO’s Project Atlas examined worldwide mental-health resources. Using information from 185 countries, the researchers found that 41% of these countries have no mental health policy, 28% no designated mental health treatment budget, and 37% no community-care facilities. Furthermore, within countries that have a mental health policy, 57% of the plans were not initiated until the 1990s. Seventy percent of the world’s population has access to less than one psychiatrist per 100000 people. No attempt was made to estimate the accessibility for child psychiatrists⁹. The shortage of trained psychiatrists and community-care facilities predictably increases the international costs and suffering related to this disorder. Chapter 2 provides suggestions for improving diagnostic assessments. However, increasing the availability and quality of worldwide care for patients with bipolar illness and other disorders requires coordinated action by mental health professional organizations, graduate university programs, and government policy makers. Sadly, there is little motivation, or concern, within and across industrialized nations for resolving these treatment issues.

EPIDEMIOLOGY

Bipolar disorders occur worldwide. The WHO ranks bipolar disorder as the 14th highest cause of disease burden within high-income countries, and the 19th within low- and middle-income countries¹⁰. Prevalence estimates vary greatly within the literature. Goodwin and Jamison, reporting on epidemiology studies, found that the lifetime risk for bipolar disorder in England was 0.88%, and 1.2% for the United States⁶. The estimate for the United States, however, included both bipolar I and II. Within industrialized nations there appear to be between 9 and 15 new cases of bipolar illness per 100 000 people per year⁶. A more recent review of epidemiology studies found the lifetime prevalence rate for bipolar illness to range from a low of 0.15 per 100 persons in Hong Kong to 1.6 per 100 for both Taiwan and the United States. After controlling for numerous problems found in the epidemiological studies, the authors estimated that the worldwide prevalence for bipolar illness is approximately 0.82 per 100 people¹¹. These rates, because of the strict diagnostic criteria applied, are lower than what is often seen in research and clinical publications. Unlike unipolar depression and dysthymia, bipolar I disorder is equally distributed across genders. However, rapid cycling occurs more in women than in men, and women tend to have more depressive episodes. Additionally, the onset episode in women is most often depression, while the first episode for men tends to be mania^11,12. Men and women also differ in that, for men, manic episodes appear as much as or more often than depressive episodes¹². Schizoaffective illness is not officially part of the bipolar disorders, but triggers mood cycles along with symptoms of schizophrenia. A person with schizoaffective disorder meets all of the diagnostic criteria for schizophrenia and a major mood disorder. There is almost no epidemiological information about this disorder. Researchers believe that it occurs in less than 1% of the general population, but may be higher in patient populations. The illness is observed more often in women than in men^12,13.

WHAT CAUSES BIPOLAR DISORDERS?

As in the case of most neurobiological illnesses, science does not have a definitive answer for this question. Perhaps more so than for any other disorder, there is mounting evidence that most individuals inherit bipolar illness. Studies of twins, family histories, and adoptions support a genetic causation hypothesis¹. Studying identical twins has been a cornerstone for identifying genetic relationships in mental disorders. Between 1967 and 1999 there were six studies of bipolar illness in twins. Concordance rates for identical twins were reported to range from 20 to 79%, and 0 to 19% for dizygotic twin samples¹⁴. The study reporting 20% monozygotic concordance was methodologically flawed, and consisted of only five identical and 15 fraternal sets of twins. A concordance rate predicts the probability or odds that if one twin has bipolar disorder (or any disorder) the the other will at some point become ill. However, some researchers believe that concordance rates in the past have been inflated because of the employment of retrospective designs and overly broad diagnostic criteria. Torrey and Knable, as an example, report two recent studies with concordance rates of 43% and 44%². Interpretation of the data is difficult in that one study included only seven pairs of twins. The second study with 44% concordance included 25 pairs, but has not been replicated. Nonetheless, like schizophrenia, genetics may explain causation in a large number of (but not all) cases. There may be multiple neurological pathways that lead to developing bipolar disorders. Torrey and Knable suggest that the illness, in addition to— or even in association with—genetics, may occur as a result of any of the following factors²:

Improving Diagnosis

Self-rating scales can greatly help clinicians identify hidden hypomania. However, most of the published scales have not been adequately studied for measurement reliability and validity with minority clients and age groups across the life span.

1. Neurological attacks from viruses, bacteria, protozoa, and fungi;
2. Immunological factors;
3. Neurotransmitter abnormalities;
4. Second-messenger systems, or what is sometimes referred to as the brain’s signal transduction system;
5. Neuropeptides (endorphins, somatostatin, vasopressin, oxytocin substance P, cholecystokinin, neurotensin, and calcitonin);
6. Body rhythm disturbances;
7. Endocrine dysfunction.

There is varying support among scientists for these alternative explanations. The important thing for patients and family members to know is that there is no scientifically accepted evidence that families or home environments cause bipolar disorders. A detailed discussion on the role of environments and bipolar illness is provided in Chapter 2.

STRESS

Professionals, patients, and families rightfully worry about the relationship between stress and bipolar symptoms. There are numerous assumptions and hypotheses relating stress and illness onset, severity, and cycling. The research supporting any of these concepts is scanty. Stress does not appear to be a major factor in explaining why people develop bipolar disorders, nor does it relate to the number of episodes and relapses that are experienced^1,2. There is some evidence that the first depressive or manic episode may be more influenced by stress than those that follow¹. Nonetheless, there is little empirical support that multiple episodes are triggered by a kindling process within the brain^1,2. Kindling refers to a dynamic interaction where the brain learns from repeated episodes to trigger future episodes automatically. This is believed to happen in seizures, but has not been documented in manic or depressive episodes. As in most physical illnesses, stress is most likely an additive interacting factor that plays a secondary role in symptom severity and quality-of-life issues.

Stress is created by perceptions, emotional responses, and int...

Table of contents

• Cover Page
• Atlas of Bipolar Disorders
• Dedication
• Title Page
• Copyright Page
• Note of Appreciation
• Preface
• 1: Introduction and Overview
• 2: Presentation and Classification of Bipolar: Disorders
• 3: Child and Adolescent Bipolar Illness
• 4: Bipolar Disorders and the Changing Brain
• 5: Suicide and Bipolar Disorders: A Case Study
• 6: Treating Bipolar Disorders
• Conclusion: Much to Do, Much to Make Us: Hopeful
• Appendix I: Postpartum Questionnaires
• Appendix 2: Patient Questionnaires