Bipolar affective disorder has been a mystery to scientists and physicians since the sixteenth century. The well-known artist Vincent Van Gogh is the first documented case of the disorder, but since then, we have not learned much more about what causes the disease or even a cure for sufferers. The biggest hindrance to scientists is that there are so many symptoms, and they aren't sure what the source is. Right now, approximately one percent of the population (three million people) in the United States is victim of the Bipolar disorder.

Bipolar disorder typically most often begins during adolescence or early adulthood and continues throughout life. It is often not recognized as an illness and people who have it may suffer needlessly for years or even decades. This particular disorder is characterized by a variety of symptoms that can be broken into manic, or excessive highs, and depressive, or deep hopelessness, episodes with periods of normal moods in between. Symptoms of manic episodes are characterized by discrete periods of increased energy, activity, and restlessness. Some display racing thoughts, rapid talking, and excessive "high" or euphoric feelings.

Most people that are diagnosed show extreme irritability and distractibility, decreased need for sleep, and unrealistic beliefs in one's abilities and powers. Every person that is diagnosed is in denial that anything is wrong usually because of embarrassment. Bipolar disorder is diagnosed if an episode of mania occurs whether depression has been diagnosed or not, but most commonly, individuals with manic episodes experience a period of depression. The depressive episodes are characterized by intense feelings of sadness and despair that can eventually Morris 2 grow into feelings of hopelessness and helplessness.

Some of the symptoms of a depressive episode include: discrete periods of persistent sad, anxious, or empty feelings. The majority experience mood swings, feelings of hopelessness, feelings of guilt, worthlessness, or helplessness. Depression episodes cause a dislike of normal daily activities, decreased energy; a feeling of fatigue; difficulty concentrating, remembering, or making decisions. It even causes people to loose their appetite and think about committing suicide. When both manic and depressive symptoms occur at the same time it is called a mixed episode. Those afflicted are at a special risk because there is a combination of hopelessness, agitation, and anxiety that makes them feel as if they could jump out of their skin.

Up to 50% of all patients with mania have a mixture of depressed moods. Patients report feeling depressed and unhappy, yet they exhibit the energy associated with mania. Rapid cycling mania is another presentation of bipolar disorder. Mania may be present with four or more distinct episodes within a 12-month period.

There is now evidence to suggest that occasionally, rapid cycling may be a transient manifestation of the bipolar disorder. It may be helpful to think of the various mood states in manic-depressive illness as a spectrum or continuous range. At one end is severe depression, which shades into moderate depression; then come mild and brief mood disturbances that many people call "the blues"; then normal mood; then hypomania (a mild form of mania); and then mania. Some people with untreated Morris 3 bipolar disorder have repeated depressions. In the other extreme, mania may be the main problem and depression may occur only every now and then. Many times bipolar patients report that the depressions are longer and increase in frequency as the individual ages.

The stages of the bipolar disorder most often begin in patients between the ages of 18 and 24 years of age with a second peak in the mid-forties of women. Most individuals with the disorder experience their first mood episode in their 20's. However, manic-depression quite often strikes teenagers and has been diagnosed in children under 12. A typical bipolar patient may experience eight to ten episodes in their lifetime. These episodes are life altering, and prohibit those afflicted with the disorder from leading normal lives. The National Depressive and Manic Depressive Association has reported that the bipolar disorder can create substantial developmental delays, marital and family disruptions, occupational setbacks, and financial disasters.

Even more seriously, the risk of suicide among persons afflicted with bipolar illness is unrealistically high. In the past, as many as 1 in 5 people with the bipolar disorder have committed suicide in the United States. Therefore, scientists are desperately searching for ways to alleviate symptoms, or even find a cure. A variety of medications are used to treat the bipolar disorder, but even with optimal medication treatment, many people with manic-depressive disorder do not achieve full remission of symptoms.

Lithium has been the primary treatment of bipolar disorder since its introduction in the 1960's. Its main function is to stabilize the cycling characteristic of bipolar disorder. "In four controlled Morris 4 studies by F. K. Goodwin and K. R.

Jamison, the overall response rate for bipolar subjects treated with Lithium was 78%. Lithium is also the primary drug used for long- term maintenance of bipolar disorder. In a majority of bipolar patients, it lessens the duration, frequency, and severity of the episodes of both mania and depression. Unfortunately, as many as 40% of bipolar patients are either unresponsive to lithium or cannot tolerate the side effects of: thirst, weight gain, nausea, diarrhea, and edema. Patients who are unresponsive to lithium treatment are often those who experience mixed states, or rapid cycling bipolar disorder. One of the problems associated with lithium is the fact that long-term lithium treatment has been associated with decreased thyroid functioning in patients with bipolar disorder.

Pregnant women experience another problem associated with the use of lithium. Its use during pregnancy has been associated with birth defects. There are other effective treatments for bipolar disorder that are used in cases where the patients cannot tolerate lithium or have been unresponsive to it in the past. The American Psychiatric Association's guidelines suggest the next line of treatment to be Anticonvulsant drugs such as Valproate and Carbamazepine. These drugs are useful as anti manic agents, especially in those patients with mixed states. Both of these medications can be used in combination with lithium or in combination with each other.

Valproate is especially helpful for patients who are lithium noncompliant, experience rapid cycling, or have alcohol or drug abuse. Neuroleptic's such as haloperidol or chlorpromazine have also Morris 5 been used to help stabilize manic patients who are highly agitated or psychotic. Use of these drugs is often necessary because the response to them is rapid, but there are risks involved in their use. Because of the often-severe side effects, Benzodiazepines are often used in their place.

Psychotherapy, in combination with medication, often can provide additional benefit. One such treatment is outpatient group psychotherapy. Dr. John Graves, spokesperson for The National Depressive and Manic Depressive Association, has praised the value of support groups, and challenged mental health professionals to take a more serious look at group therapy for the bipolar population.

Research shows that group participation may help increase lithium compliance, decrease denial regarding the illness, and increase awareness of both external and internal stress factors leading to manic and depressive episodes. More than two-thirds of people with manic-depressive disorder have at least one close relative with the illness or with unipolar major depression, indicating that the disease has a heritable component. Studies seeking to identify the genetic basis of manic-depressive disorder indicate that susceptibility comes from multiple genes. Despite tremendous research efforts, however, the specific genes involved have not yet been conclusively identified. Scientists are continuing their search for these genes using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for manic-depressive disorder, and the Morris 6 brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

In addition to the mentioned medical treatments of bipolar disorder, there are several other options available to bipolar patients, most of which are used in conjunction with medicine. But there is no assurance that these medical measures will cure the patient in time. The one fact of which we are painfully aware is that bipolar disorder severely undermines patient's ability to obtain and maintain social and occupational success. Because bipolar disorder has so many problematic symptoms, it is imperative that we push for explanations of its causes and treatment.