Bipolar disorder

Bipolar disorder is a form of mood disorder. The other principal division of mood disorder is depression. Together these form what is commonly known as manic depression. Manic depression with its two principal components, bipolar disorder and major depression, was first discovered by psychiatrist Emil Kraepelin near the end of the 19th century. As described below, there are several forms of bipolar disorder.

Bipolar disorder takes two principal forms, neither of which requires plural "cycles". According to the DSM-IV-TR (p. 345), these two principal forms of Bipolar disorder are:

Bipolar I disorder, the diagnosis of which requires over the entire course of the patient's life at least one manic (or mixed state) episode which is usually (though not always) accompanied by episodes of Major Depressive disorder.

Bipolar II disorder, which over the course of the patient's life must involve at least one Major Depressive episode and must be accompanied by at least one hypomanic episode; i.e. there need be no full manic episodes at all.

Therefore Bipolar disorder need not have both severe mania and depression and in certain cases has only episodes of the one type. It is therefore evident that there need be no "cycles" of mania and depression.

This is the actual reason why certain contemporary psychiatrists shy away from the original name, Manic Depression, i.e. because the latter name might suggest that all patients have both mania and depression. It has nothing to do with the notion of equal distribution of cycles of mania and depression, since there need not be any cycles at all--in fact, even when there is one (or more) bout of both mania and depression over the course of a patient's life, the two episodes may be so unrelated to each other temporally and otherwise that this need not constitute a cycle. However, a significant portion of bipolar patients does experience the classical alternating episodes (cycles) of mania and depression and therefore it is overstating the case to say that the classical alternation "rarely" occurs.

The DSM-IV treats these bipolar disorders as variants of mood or affective disorders. Others types include Major Depressive Disorder and Dysthymic Disorder. Bipolar and other mood disorders may have no identifiable medical, traumatic or other external cause (endogenous) or may be due to e.g. a medical condition (exogenous).

Furthermore, this disease does not consist of mere "ups and downs". Ups and downs are experienced by virtually everyone and do not constitute a disease.

What is generally known as Manic Depression, comprising both unipolar Major Depression and the several forms of Bipolar Disorder, was first discovered by Emil Kraepelin who published his account of the disease in his Textbook of Psychiatry.

Kraepelin included in his description of Manic Depression the phenomenon that episodes of acute illness, whether mania or depression, are usually punctuated by relatively symptom-free intervals during which the patient is able to function normally both at work and in social affairs.

The cycles of bipolar disorder may be long or short, and the ups and downs may be of different magnitudes: for instance, a person suffering from bipolar disorder may suffer a protracted mild depression followed by a shorter and intense mania. The manic periods typically include euphoria, tirelessness, and impulsiveness; the depressed periods may seem much worse following a manic period.

The name bipolar disorder is used to distinguish the condition from unipolar depression, and bipolar disorder is in turn divided into two forms, Bipolar I and the Bipolar II form, considered by some as a 'milder' version of the disorder. However, other doctors believe there is no sound basis for the blanket statement that Bipolar II is "milder" than Bipolar I.

Medications, called "mood stabilizers" can sometimes be used to prevent manic or depressive episodes. (See http://people.ne.mediaone.net/pmbrig/BP_pharm.html for a summary of the psychopharmacology of bipolar disorder.) Periods of depression can also be treated with antidepressants. In extreme cases where the mania or the depression is severe enough to cause psychosis, antipsychotic drugs may also be used.

These drugs do not work in all patients, work sometimes in others, and it is very difficult to determine in any particular case whether they are effective at all since bipolar disorder (as well as most other psychiatric disturbances and diseases are mostly transient or episodic, and patients experience remissions whether or not they receive treatment. It is not clear how it would even be possible to determine that medications prevent such episodes. Tens of millions of patients have severe mood disorders and if any medication could prevent episodes, such diseases as bipolar disorder would be rare indeed. There is some evidence that they may be effective for some patients, some of the time but the evidence for their efficacy is at best statistical and it is virtually impossible to say that any particular patient was benefitted by any particular treatment. In discussing these medications one must also take into account the fact that many patients experience severe side effects. Until recently, one might reasonably question whether the enormously harmful side effects and the tendency to abuse psychotropic drugs outweighed any possible benefits (real or imagined).

Compliance with medications can be a major problem because some people becoming manic lose insight, or an awareness of having an illness, and discontinue medications; then they often suffer a manic episode and may suddenly find themselves initiating multiple projects often being scattered and ineffective, or may go on a spending spree or take a poorly planned trip landing them in an unfamiliar location without cash. The manic periods, euphoric as they may be, are often disastrous because of the impulsiveness and irrationality that comes with them. Contrary to the patient's wishes, the depression does not respond instantaneously to resumed medication, typically taking 2-6 weeks to respond.

Bipolar disorder appears to run in families, that is, a vulnerablility for bipolar disorder may be inherited. The rate of suicide is higher in people who have bipolar disorder than in the general population. The rate of prevalence of bipolar disorder is roughly equal (around 1%) in men and women.

Whilst bipolar disorder can be one of the most severe and devastating medical conditions, many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Unlike patients with schizophrenia, persons with bipolar disorder have periods of normal functioning between the extremes of mood.

CORRECTION: The latter statement is incorrect. Schizophrenic patients frequently have remissions with relatively high levels of functioning. However, such intervals are less common and schizophrenic patients have a generally greater tendency to suffer impairments even during these intervals.

The classic work on this subject is "Manic-Depressive Illness" by Frederick K. Goodwin and Kay Redfield Jamison. ISBN 0195039343 (Amazon, Pricescan)

CORRECTION: The classic work on the subject of Manic Depression is by Kraepelin, who discovered the disease: "Manic-depressive insanity and paranoia" / by Emil Kraepelin., 1921. (English translation of the original German from the earlier Eighth Edition of Kraepelin's Textbook). The Goodwin and Jamison text is one of scores of texts on manic depression (which is much broader than "the subject"--which is Bipolar Disorder) and, with a publication date of 1990, can hardly be regarded as "the classic work". It is hard to imagine what might merit this designation in their work.

Many famous people have been affected by bipolar disorder, including Spike Milligan, Lord Byron and Winston Churchill. There appears to be an association between bipolar disorder and talent in many cases - this is documented in Jamison's book "Touched with Fire".

CAUTION: Psychohistory is a highly unreliable and dubious enterprise generally promoted by less than reputable psychologists and psychiatrists, patients who wish to be in good company, and organizations that stand to benefit from contributions made by those whose sympathies would be aroused by such "diagnoses at a distance". There is no scientific basis for classifying any of the above deceased persons as having had bipolar disorder, though they may very well have suffered from severe and even recurrent bouts of disordered mood. The fact is that until very recently there were no diagnostic systems with any degree of reliability. Even with the development of tools such as DSM-IV, there is a great deal of diagnostic uncertainty with living patients who have been intensively studied for decades, and there is no reason to think that it is any easier to diagnose individuals in their graves.

Resources:

(US) National Depressive and Manic-Depressive Association, http://www.ndmda.org/

A list of famous people believed to have bipolar disorder can be found at http://www.nami.org/helpline/peoplew.htm

A list of famous living people with unipolar or bipolar disorder can be found at: http://www.frii.com/~parrot/living.html

For detailed information concerning Emil Kraepelin who discovered Manic Depression: http://www.kraepelin.org/

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