Causes

Doctors don't completely understand the causes of bipolar disorder. But they've gained a greater understanding in the past 10 years of the bipolar spectrum, which includes the elated highs of mania to the lows of major depression, along with various mood states between these two extremes.

Experts do believe that bipolar disorder often runs in families, and there is a genetic component to this mood disorder. There is also growing evidence that environment and lifestyle issues have an effect on the disorder's severity. Stressful life events -- or alcohol or drug abuse -- can make bipolar disorder more difficult to treat.

A multitude of controlled studies of bipolar patients and their relatives have shown that bipolar disorder does run in families. Perhaps the most convincing data comes from twin studies. In the studies of identical twins with the same genes, scientists report that if one identical twin has bipolar disorder, the other twin has a greater chance of developing bipolar disorder than another sibling in the family. Using statistical data, researchers conclude that the lifetime chance of an identical twin (of a bipolar twin) to also develop bipolar disorder is about 40% to 70%. 

Along with a genetic link to bipolar disorder, research reveals that children of bipolar parents are often surrounded by significant environmental stressors, such as living with a parent who has a tendency toward wide and unpredictable mood swings, alcohol or substance abuse, financial and sexual indiscretions, and hospitalizations. Although not all bipolar offspring will develop bipolar disorder, many children of bipolar parents do progress to an entirely different psychiatric disorder such as ADHD, major depression, or substance abuse.

Some findings show that people with bipolar disorder have a genetic predisposition to sleep-wake cycle abnormalities that may be responsible for triggering the symptoms of depression and mania.

The problem for those with bipolar disorder, however, is that sleep loss may precipitate a mood episode such as mania (elation) in some patients. Worrying about losing sleep can add to cognitive arousal and increase anxiety, thus worsening the bipolar mood disorder altogether. Once a sleep-deprived person with bipolar disorder goes into the manic state of elation, the need for sleep decreases even more.

Treatment

There are mainly two options medication or therapy. 

Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:

• Lithium (sometimes known as Eskalith or Lithobid) was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
• Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for treating mania, is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder.^{23, 24} Also see the section in this booklet, "Should young women take valproic acid?"
• More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for maintenance treatment of bipolar disorder.
• Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.

2. Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional" or "first-generation" antipsychotics.

• Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.²⁸Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.
• Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.
• Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.
• Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.
• 3. Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking
•  only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.²⁹To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.Psychotherapy

  In addition to medication, psychotherapy, or "talk" therapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

  1. Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
  2. Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication and problem-solving.
  3. Interpersonal and social rhythm therapy helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
  4. Psychoeducation teaches people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

Symptoms

Bipolar Disorder is a brain disorder that causes unusual shifts in moon, shifts, energy, activity levels, and the ability to carry day to day tasks. 

Symptoms of bipolar disorder are severe. They are different from the ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job, or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives. 

Symptoms of mania or a manic episode include:

Symptoms of depression or a depressive episode include:

Mood Changes A long period of feeling "high," or an overly happy or outgoing mood Extremely irritable mood, agitation, feeling "jumpy" or "wired." Behavioral Changes Talking very fast, jumping from one idea to another, having racing thoughts Being easily distracted Increasing goal-directed activities, such as taking on new projects Being restless Sleeping little Having an unrealistic belief in one's abilities Behaving impulsively and taking part in a lot of pleasurable, high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.

Mood Changes A long period of feeling worried or empty Loss of interest in activities once enjoyed, including sex. Behavioral Changes Feeling tired or "slowed down" Having problems concentrating, remembering, and making decisions Being restless or irritable Changing eating, sleeping, or other habits Thinking of death or suicide, or attempting suicide.

Bipolar Disorder

CHILD AND ADOLESCENT PSYCHIATRY 

Offspring of Parents With Bipolar Disorder

By Karen Dineen Wagner, MD, PhD | February 8, 2010

Dr Wagner is the Marie B. Gale Centennial Professor and vice chair of the department of psychiatry and behavioral sciences and director of child and adolescent psychiatry at the University of Texas Medical Branch at Galveston.

It is generally held that the offspring of parents with bipolar disorder (BD) are at risk for BD. The degree of risk is an important question for both clinicians and parents. A recent study of bipolar offspring by Birmaher and colleagues¹ sheds light on this issue.

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These authors compared the lifetime prevalence of bipolar and other psychiatric disorders in children whose parents had–or did not have–BD. The study involved 233 parents with BD and their 388 offspring and a control group of 143 parents without BD and their 251 offspring.

Parents with BD were recruited from outpatient clinics and advertisements for participation in the study. On the basis of diagnostic interviews, 158 parents had bipolar I disorder and 75 had bipolar II disorder. The majority (80%) of the parents interviewed were female. The mean age of parents with BD was 40 years. Sixty-four percent of parents reported that the onset of their mood disorder occurred before they were 20 years old. Parents with BD were less likely to be married at the time of intake and had a slightly lower socioeconomic status than parents without BD.

The offspring of parents with BD did not have to be symptomatic to participate in the study. The mean age of these children was 12 years; 49% were female; and 88% were white. Fewer than half (42%) were living with both biological parents.

The rate of bipolar spectrum disorder in the offspring of parents with BD was 10.6% versus 0.8% in the offspring of control parents. The rate of bipolar I disorder was 2.1%; bipolar II disorder, 1.3%; and bipolar not otherwise specified (NOS), 7.2%. The rate of BD increased substantially–to 29%–when both parents had BD.

Overall, the offspring of parents with BD were at significantly greater risk (52%) for any Axis I disorder than those in the control group (29%).

The majority (76%) of these offspring experienced childhood-onset bipolar disorder before age 12 years. Bipolar NOS was the most common first episode of illness. Rates of comorbidity in these youths were high: 51% had anxiety disorder, 53% had disruptive behavior disorder, and 39% had attention-deficit/hyperactivity disorder (ADHD).

The authors concluded that there is a 14-fold increase in the rate of bipolar spectrum disorder in youths who have a biological parent with BD. If both parents have BD, then the offspring are 3 times more likely to have BD.

The mean age of youths in this study was 12 years. Prevalence rates may therefore be an underestimate because some children with depression may become bipolar in adolescence. It is recommended that clinicians who treat adults with BD inquire about the functioning of their children to provide appropriate early intervention.

Posttraumatic stress disorder and substance abuse

In a family study of BD in youths, Steinbuchel and colleagues2 investigated the relationships among adolescent BD, posttraumatic stress disorder (PTSD), and substance use disorder (SUD). Because adults with BD who were severely abused as children are at high risk for SUD, these investigators sought to determine whether there is a similar association in adolescents.

A total of 105 adolescent offspring of parents with BD and a control group of 98 youths without mood disorders participated in this study. The diagnosis of BD was based on structured psychiatric interviews. SUDs included any alcohol or drug abuse or dependence.

Rates of PTSD were significantly higher in adolescents with BD than in the control group. Sixteen percent of youths with BD had full or subthreshold PTSD compared with 3% in the control group. These youths had experienced trauma in the form of physical abuse, sexual abuse, witnessing of death, or family violence. Rates of SUDs were higher among youths with BD than in those in the control group (32% vs 4%, respectively). Alcohol was the most frequently used substance (86%) followed by marijuana (71%) and tobacco (29%).

What was the temporal order of these disorders? In half of the cases, BD preceded PTSD. In the other half of cases, PTSD was diagnosed before BD. For those youths in whom SUD developed, the majority had BD followed by PTSD and then SUD.

This study confirms an association between PTSD in adolescents with BD and subsequent development of SUD. Rates of SUD were higher in those youths who met full criteria for PTSD than for those with subthreshold symptoms. The findings reveal that BD increases the risk for PTSD, which in turn increases the risk for SUDs. The investigators suggest that treatment of adolescents with BD may prevent trauma related to the development of PTSD and subsequent SUD. It is recommended that clinicians who treat adolescents with BD evaluate for the presence of PTSD and SUD.

http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1490412

The Role of Antidepressants in the Treatment of Bipolar Depression

February 17, 2010

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Although rapid-cycling bipolar disorder has been linked to the use of antidepressants, these treatments may still have a role in the management of patients with bipolar depression, said Stephen V. Sobel, MD, clinical instructor at the University of California, San Diego School of Medicine, in a presentation at the US Psychiatric and Mental Health Congress in Las Vegas.¹ Patients with bipolar disorder spend most of their time in depression, and antidepressants can alleviate the symptoms, he said.

The use of antidepressants may increase a patient’s risk of rapid-cycling bipolar disorder. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) included 1742 patients treated with a variety of approved medications for bipolar I and bipolar II disorder, and 32% reported having rapid-cycling at baseline. After 2 years of treatment, 5% still had rapid-cycling bipolar disorder. Those who were treated with an antidepressant were 3.8 times more likely to have rapid-cycling bipolar disorder.¹

In his clinical experience, Sobel has seen positive results when treating patients who have bipolar depression with antidepressants as adjunctive therapy. But he said that antidepressants have been shown in studies to be ineffective as adjunctive therapy. In another STEP-BD study, patients with bipolar depression were treated for up to 26 weeks with a mood stabilizer and adjunctive antidepressant therapy or a mood stabilizer and placebo. Results showed that in patients with bipolar depression who were treated with a mood stabilizer, the addition of an antidepressant was no more effective than the addition of placebo.²

Adjunctive antidepressant therapy has also been shown to cause an increase in the incidence of symptoms of hypomania or mania. In a study with a 10-week acute phase and a 1-year continuation phase, 150 patients with bipolar I or bipolar II disorder were treated with an antidepressant (bupropion, sertraline, or venlafaxine) in addition to a mood stabilizer. In the acute phase, 11.4% of the patients switched to hypomania and 7.9% switched to mania. In the continuation phase, 21.8% switched to hypomania and 14.9% switched to mania. Only 23% of all patients experienced a sustained response to the antidepressants.³

Guidelines state that patients with bipolar depression who are treated with an antidepressant should discontinue therapy within 3 to 6 months after achieving remission. However, discontinuation of antidepressants has been shown to cause depressive relapse in these patients.⁴ Sobel suggests that physicians should use their discretion to determine how best to treat their patients while also keeping the results of these studies in mind.

http://www.psychiatrictimes.com/bipolar-disorder/content/article/1145628/1524717

Bipolar Disorder Stories

I'm a 17 year old female and am amongst the still short-term strugglers of bipolar disorder.  But despite only having had problems for a little over two years, my symptoms have been quite severe - almost to the point where I cannot imagine myself struggling with the disorder for much longer.

 

I have only reached out for professional help two times, and neither times have I continued to receive their support. BP itself has made it impossible for me to continue therapy for longer than a month at a time. I have also never been properly diagnosed with BP, because I have not given the doctors enough time or proof of symptoms to be diagnosed with anything besides depression. Therefore the only kind of medication I have taken is an overthecounter anti-depressant called 'Lexapro', which did not prove helpful in the least.

 

One of the reasons my case has been so difficult for me and my family to deal with properly is because apart from the BP-like symptoms, I have been both anorexic and bulimic for three years. The EDs have been cycling in and out alongside my hypomanic and depressive states and most of the time, it's hard to know whether my ED has caused my ups and downs (BP swings), or whether my ups and downs has caused my ED to resurface.

 

My ups and downs cycle in average two-three month patterns, where for the first couple of months I'm in a hypomanic state, going outside everyday, shopping and spending excessive amounts of money, wearing makeup, and losing a large amount of weight caused by anorexia, feeling invincible, and then the next couple of months I'm back to locking myself up inside the house, binge eating, gaining lots of weight, crying, and completely cutting off all my connections with the outside world. Due to this unstable cycle I have dropped regular school and had to take up homeschooling, lost all friends, have been unable to work for an allowance, and feel worthless and hateful toward myself most of the time. I have never actually seriously attempted to hurt myself, but have thought of death many times.

I don't want to keep struggling with this into my adulthood, because I want to be normal, and I want to pursue fading dreams and become a successful adult with a successful job and a successful life. I've never had a relationship and wish to be loved and to love as someone who has confidence being themselves. But even though I wish for all this I know that mental and psychotic disorders cannot be cured as easily with meds or other physical procedures. It's much more complicated than that.

http://www.mental-health-today.com/bp/story.htm