Abstract Bipolar Disorder is a mental illness in which a person's mood alternates between extreme mania and depression. Bipolar disorder is also called manic-depressive illness. In a related disorder called cyclothymia disorder (sometimes called Bipolar III), a person's mood alternates between mild depression and mild mania. Some people with cyclothymia disorder later develop full-blown bipolar disorder. Rates of bipolar disorder are similar throughout the world. At least fifteen percent of people with bipolar disorder commit suicide.

Bipolar disorder is much less common than depression. Many people with bipolar disorder function normally between episodes. Medications known as "mood stabilizers" are usually prescribed by psychiatrists to help control bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time. One of the most important thing family and friends can do for a person with bipolar disorder is learn about the illness. Never ignore remarks about suicide.

It is important to note that most people with bipolar disorder-even those with the most severe forms can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Bipolar Disorder is a mental illness in which a person's mood alternates between extreme mania and depression. Bipolar disorder is also called manic-depressive illness. When manic, individuals with bipolar disorder feel intensely elated, self-important, energetic, and irritable. When depressed, these individuals experience painful sadness, negative thinking, and indifference to things that used to bring them happiness Bipolar disorder is much less common than depression. In North America and Europe, about one percent of people experience bipolar disorder during their lives (J).

Rates of bipolar disorder are similar throughout the world. In comparison, at least eight percent of people experience serious depression during their lives. Bipolar disorder affects men and women about equally and is somewhat more common in higher socioeconomic classes. At least fifteen percent of people with bipolar disorder commit suicide. This rate roughly equals the rate for people with major depression, the most severe form of depression (E). Some research suggests that highly creative people-such as artists, composers, writers, and poets-show unusually high rates of bipolar disorder, and that periods of mania fuel their creativity.

Famous artists and writers who probably suffered from bipolar disorder include poets Lord Byron and Anne Sexton, novelists Virginia Woolf and Ernest Hemingway, composers Peter Ilynich Tchaikovsky and Sergey Rachmaninoff, and painters Amedeo Modigliani and Jackson Pollock. Critics of this research note that many creative people do not suffer from bipolar disorder, and that most people with bipolar disorder are not especially creative (E). SYMPTOMS Bipolar disorder usually begins in a person's late teens or twenties. Men usually experience mania as the first mood episode, whereas women typically experience depression first (E).

Episodes of mania and depression usually last from several weeks to several months. On average, people with untreated bipolar disorder experience four episodes of mania or depression over any ten-year period. Many people with bipolar disorder function normally between episodes. In rapid-cycling bipolar disorder, however, which represents five to fifteen percent of all cases, a person experiences four or more mood episodes within a year and may have little or no normal functioning in between episodes (H). In rare cases, swings between mania and depression can occur over a period of days or hours. The term ultra-rapid cycling may be applied to those who cycle through episodes within a month or less.

If this pattern is demonstrated within a twenty-four hour period, the person's diagnosis could possibly be phrased ultra-ultra-rapid cycling or ultra dian. Ultra dian cycling is often difficult to differentiate from a mixed state, when a person experiences aspects of both depression and mania or hypomania at the same time. Sometimes mania is prominent, sometimes depression (A). Bipolar I can have some very frightening characteristics of psychosis (loss of contact with reality).

These may include: hallucinations (hearing or seeing things that are not there), delusions (persistent beliefs in things that are not true), and paranoia (believing that a person or group is actively working to harm you, without any basis in fact). These psychotic features are also characteristic of schizophrenia, a mental illness where the patient is out of touch with reality, but without mood swings. Bridging the space between bipolar disorder and schizophrenia is schizo affective disorder. What distinguishes schizo affective disorder from Bipolar I with psychotic features is that sometimes (for at least two weeks) the patient has only psychotic symptoms, without mania or depression (A). In another type of bipolar disorder (Bipolar II), a person experiences major depression and hypo manic episodes, or episodes of milder mania. In a related disorder called cyclothymia disorder (sometimes called Bipolar III), a person's mood alternates between mild depression and mild mania.

Some people with cyclothymia disorder later develop full-blown bipolar disorder. Bipolar disorder may also follow a seasonal pattern (Seasonal Affective Disorder), with a person typically experiencing depression in the fall and winter and mania in the spring or summer (A). People in the depressive phase of bipolar disorder feel intensely sad or profoundly indifferent to work, activities, and people that once brought them pleasure. They think slowly, concentrate poorly, feel tired, and experience changes-usually an increase-in their appetite and sleep. They often feel a sense of worthlessness or helplessness. In addition, they may feel pessimistic or hopeless about the future and may think about or attempt suicide.

In the manic phase of bipolar disorder, people feel intensely and inappropriately happy, self-important, and irritable. In this highly energized state they sleep less, have racing thoughts, and talk in rapid-fire speech that goes off in many directions. They have inflated self-esteem and confidence and may even have delusions of grandeur. Mania may make people impatient and abrasive, and when frustrated, physically abusive.

They often behave in socially inappropriate ways, think irrationally, and show impaired judgment. For example, they may take airplane trips all over the country, make indecent sexual advances, and formulate grandiose plans involving indiscriminate investments of money. The self-destructive behavior of mania includes excessive gambling, buying outrageously expensive gifts, abusing alcohol or other drugs, and provoking confrontations with obnoxious or combative behavior. The most dangerous aspect of manic depression, however, is the danger of suicide. The suicide rate among people with bipolar disorder has been given as high as twenty percent, which means a staggering number of bipolar people make unsuccessful and / or repeated attempts on their own lives, and even more than that consider suicide without acting on the urge. Yet people with manic-depressive illness are often highly intelligent, extraordinarily gifted, marvelously talented people whose brilliance makes the world a better place while they themselves are struggling every day to cope, to function, and to stay alive (A).

CAUSES A newly published study in the American Journal of Psychiatry reports "in those with bipolar disorder, two major areas of the brain contain thirty percent more cells that send signals to other brain cells." This report theorizes that "the extra signal-sending cells may lead to a kind of over stimulation, which makes sense considering the symptoms of bipolar disorder" (P). According to Durand and Barlow, most scientists believe that "psychological disorders are always the products of multiple interacting causal factors" (D). As it relates to bipolar disorder, these causal factors are usually divided into biological and psychological explanations. Psychopathology is the study of significant causes and processes in the development of mental illness, which means there are physical and mental, and environmental and emotional causes for mental illnesses. In considering the biological explanations, the first issue is inheritability. This question has been researched via multiple family, adoption, and twin studies.

In families of persons with bipolar disorder, first-degree relatives (parents, children, siblings) are more likely to have a mood disorder than the relatives of those who do not have bipolar disorder (C). Twin studies indicate that "if one twin presents with a mood disorder, an identical twin is approximately three times more likely than a fraternal twin to have a mood disorder" (D/H). In considering bipolar disorder specifically, the concordance rate (when both twins have the disorder) is eighty percent for identical twins, as compared to only sixteen percent for fraternal twins (D). "Overwhelming evidence suggests that such disorders are familial and almost certainly reflect an underlying genetic vulnerability" (D). However, exactly what is inherited? The neurotransmitter system has received a great deal of attention as a possible cause of bipolar disorder.

Researchers have known for decades that a link exists between neurotransmitters and mood disorders, because drugs which alter these transmitters also relieve mood disorders (B). Some studies hypothesize that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine, or dopamine is the cause. Others indicate that an imbalance of these substances is the problem in other words, that a specific level of a neurotransmitter is not as important as its amount in relation to the other neurotransmitters (D). Still other studies have found evidence that a change in the sensitivity of the receptors on nerve cells may be the issue (B). In short, researchers are quite certain that the neurotransmitter system is at least part of the cause of bipolar disorder, but further research is still needed to define its exact role.

The primary psychological culprit implicated in the manifestation of bipolar disorder is stressful life changes (G p. 91). These can range from a death in the family to the loss of a job, from the birth of a child to a move. It can be anything, but it cannot be precisely defined, due to personality traits such as hardiness, since one person's stress may be another person's piece of cake.

With that in mind, research has found that stressful life changes can lead to the onset of symptoms in bipolar disorder. However, once the disorder is triggered and progresses, "it seems to develop a life of its own. Once the cycle begins, a psychological or process takes over and ensures that the disorder will continue" (D). When we look for the cause of bipolar disorder, the best explanation via the research available at this time is what is termed the "Diathesis-Stress Model." Diathesis means, in simplified terms, a bodily condition that make a person more than usually susceptible to certain diseases. Thus the Diathesis-Stress Model says that "each person inherits certain physical predispositions that leave him or her vulnerable to problems that may or may not appear, depending on what kinds of situations that person confronts" (B). Durand and Barlow define this model as a "hypothesis that both an inherited tendency and specific stressful conditions are required to produce a disorder" (D).

TREATMENT SIt is important to note that most people with bipolar disorder-even those with the most severe forms can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time. In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan.

Working closely with a doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness. In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively. Different therapies may shorten, delay, or even prevent the extreme moods caused by bipolar disorder.

Medications for bipolar disorder are generally prescribed by psychiatrists. While primary care physicians who do not specialize in psychiatry may also prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment. Medications known as "mood stabilizers" are usually prescribed to help control bipolar disorder (L). Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.

Lithium carbonate, a natural mineral salt, can help control both mania and depression in bipolar disorder. The drug generally takes two to three weeks to become effective. People with bipolar disorder may take lithium during periods of relatively normal mood to delay or prevent subsequent episodes of mania or depression. Common side effects of lithium include nausea, increased thirst and urination, vertigo, loss of appetite, and muscle weakness. In addition, long-term use can impair functioning of the kidneys. For this reason, doctors do not prescribe lithium to bipolar patients with kidney disease.

Many people find the side effects so unpleasant that they stop taking the medication, which often results in relapse. From twenty to forty percent of people do not respond to lithium therapy. For these people, two anti convulsant drugs may help dampen severe manic episodes: (Tegretol) and (Dep akene). Newer anti convulsant medications, including (Lamictal), (Neurontin), and (Topamax), are being studied to determine how well they work in stabilizing mood cycles.

Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication (N). Therefore, mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications. Atypical antipsychotic medications, including (Clozaril), (Zyprexa), (Risperdal), (Seroquel), and (Geod on), are being studied as possible treatments for bipolar disorder.

Evidence suggests may be helpful as a mood stabilizer for people who do not respond to lithium or (M). Other research has supported the efficacy of for acute mania, an indication that has recently received FDA approval (O). Olanzapine may also help relieve psychotic depression (K). If insomnia is a problem, a high-potency medication such as (Klonopin) or (Ativan) may be helpful to promote better sleep.

However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Other types of sedative medications, such as (Ambien), are sometimes used instead. People with bipolar disorder often have abnormal thyroid gland function (F). Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician. People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Also, lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

A FINAL NOTE One of the most important thing family and friends can do for a person with bipolar disorder is learn about the illness. Often people who are depressed or experiencing mania or mood swings do not recognize the symptoms in themselves. If you are concerned about a friend or family member, help him or her get an appropriate diagnosis and treatment. This may involve helping the person to find a doctor or therapist and make their first appointment.

You may also want to offer go with the person to their first appointment for support. Encourage the individual to stay with treatment. Keep reassuring the person that, with time and help, he or she will feel better. It is also important to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the person in conversation and listen carefully.

Resist the urge to function as a therapist or try to come up with answers to the person's concerns. Often times we just want someone to listen. Do not put down feelings expressed, but point out realities and offer hope. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your first invitation is refused. It is often a good idea for the person with bipolar disorder to develop a plan should he or she experience severe manic or depressive symptoms.

Such a plan might include contacting the person's doctor, taking control of credit cards and car keys or increasing contact with the person until the severe episode has passed. Your plan should be shared with a trusted family member and / or friend. Keep in mind, however, that people with bipolar disorder, like all people, have good and bad days. Being in a bad mood one day is not necessarily a sign of an upcoming severe episode. Never ignore remarks about suicide.

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