Bipolar disorder A SUMMARY Bipolar disorder is the modern name for what was previously called manic-depressive illness. The illness is characterised by fluctuations between, on the one hand, periods of hyper- activity and an intensified emotional life and, on the other hand, periods of low energy and depression. Without treatment, the illness is often serious and disabling, but effective forms of treatment are now available which make it possible for the great majority of those who are afflicted to live a normal life without any serious symptoms of illness. Modern treatment combines medication with educational and psychological methods of treatment.
All persons are subject to variations in their level of activity and emotional state. We are happy andactivated in situations where we see the prospect of reaching a positive goal. In other situations, wehave negative feelings and our level of activity is reduced. This is necessary for our social life andthis is the way in which we to a great extent control our behaviour. Our level of activity and ouremotional state are controlled very delicately by certain systems in the brain. In persons who sufferfrom bipolar disorder, these systems are out of balance and the regulatory system does notfunction in the normal way. The brain and the person's emotional life can be over-activated in anunhealthy manner – and this is what we call mania. Alternatively, the level of activity and emotionalstate can be reduced – and this is called depression. Common symptoms in mania: hyperactivity, reduced need for sleep, racing thoughts, difficulty in following the thread, irritability, elation, irresponsible behaviour. In serious cases, aggressiveness and delusions of grandeur. Manic periods can vary from a couple of days to several months. Common symptoms in depression: state of depression, inability to feel happiness, reduced energy, difficulty in concentrating, reduced zest for life, feelings of hopelessness, disturbed sleep, poor appetite. In serious cases, suicidal thoughts, delusions and an inability to function in a normal everyday life. Periods of depression usually last from a few weeks to many months, but a period lasting for several years is not uncommon. Mania and depression are the two typical expressions of the disorder. The fluctuations between these two poles have given the name "bipolar", but the illness can express itself in many other ways. The manic symptoms can be mild – so-called “hypomania”. Sometimes manic and depressive symptoms are mixed in what is called a “mixed state”. In other cases, changes between depression and mania can take place frequently – this is called a “rapid cycling”. The symptoms are often difficult to interpret. A bipolar disorder usually makes its debut some time between puberty and the age of about 25 years, but it is not uncommon for a debut to occur before puberty or at some time later in life. It may take a long time before it is understood that the emotional problems which a
person is suffering are symptoms of a bipolar disorder. The classical bipolar disorder with typicalalternating manic and depressive episodes affects about 1 % of the population. If other forms ofbipolar disorder are included, about 5% are affected. On what does bipolar disorder depend?
Mental illnesses depend on an interaction between inherited and environmental factors, where"vulnerability" is a central concept. From our parents we inherit genes which make us more or lessdisposed to develop a bipolar disorder. Illness and stress during gestation and birth, and alsopsychological and social conditions during our upbringing can increase this vulnerability. Thedevelopment of a "stress factor" during life can trigger a depression or mania. Such a psychologicalstress factor can be a conflict with closely related persons, overwork, or bodily stress factors such asmedication and abuse. This can be illustrated by a "stress-vulnerability model":
Environmental Stress factors factors Inheritance ➔ Vulnerability ➔ Bipolar Disorder Medicines for a bipolar disorder
The basis for all treatment of a bipolar disorder is medication with an mood-stabilizing medicine. These medicines act by making the brain cells grow so that they become more resistant and stable. In this way, the risk of fluctuations between mania and depression decreases. Without such amedicine, the risk of falling ill again in a bipolar disorder is very high. For many people, an emotion-stabilizing medicine is sufficient, but a combination of several medicines is often required. Thetreatment with an emotion-stabilizing medicine is usually life-long. A few examples of pharma-ceuticals which are often used against bipolar disorders are the following:
Lithium (Lithionite®) is the most tested emotion-stabilizing medicine which is active against both mania and depression. Side-effects occur in the form of e.g. tremors, an increased amount of urine, diarrhoea and an increase in weight, but most people have no or only slight side effects. The lithium dosage is adjusted with the help of regular measurements of the lithium content in the blood 3-4 times/year. Thyroid, parathyroid and kidney functions, which can sometimes be affected by lithium, are also checked regularly. Valproate (Ergenyl®, Orfiril®, Absenor®) is used primarily as a complement or alternative to lithium for the treatment and prevention of mania. Side-effects, which occur sometimes, are primarily tiredness, stomach troubles and an increase in weight. Blood test checks at the beginning of the treatment are necessary. Lamotrigin (Lamictal®) is an emotion-stabilizer which is used primarily as a complement to lithium for the treatment and prevention of depression in a bipolar disorder. It may in some cases lead to a rash, and the dosage must therefore be increased slowly over a period of at least 4 weeks. Neuroleptics (Zyprexa®, Haldol®, Risperdal®, Zeldox®, Trilafon®, Cisordinol®, Abilify®, Seroquel®) are used in the treatment of acute manic symptoms. They are sometimes required as a preventive medicine on a long-term basis. Seroquel is also used for depression in bipolar disorder. Serotonin absorption inhibitors (Cipramil®, Seroxat®, Zoloft®, Fontex®, Cipralex®, Paroxetin®, Fluoxetin, Citalopram, Cymbalta® etc) are not emotion-stabilizing, but rather emotion-raising (antidepressive). They can also be used in the treatment of depression in a bipolar disorder, but they must be used with caution since they can sometimes trigger mania, hypomania, a mixed state or a rapidly fluctuating state. In the case of a bipolar disorder, they should, therefore, be given together with an emotion-stabilizing medicine. Educational and psychological treatment
Each patient's need for educational and psychological treatment is different and the treatmentprogramme must be designed individually. Several different features may be included, such asconsultation with a doctor, contact with a nurse, group therapy and individual psychotherapy. Important elements of the educational and psychological treatment are:■ A basic understanding of what a bipolar disorder is. ■ An understanding of the importance of maintaining a good and regular daily rhythm. ■ An understanding of the negative influence of alcohol and other drugs on the disorder. ■ An understanding of medication, especially about one's own medicines. ■ An understanding of the stress factors to which you are sensitive. ■ An understanding of how best to handle different stress factors. ■ A recognition of early signs of falling ill again. ■ A plan of action for what to do if you show signs of falling ill again. ■ Information to relatives about the disorder and how they can participate in the treatment. FURTHER INFORMATION CAN BE OBTAINED FROM:The Affective Reception M59, Psychiatric clinic, the Karolinska University Hospital Huddinge,141 86 Stockholm. Tel: 08-585 866 34, 08-585 866 26.
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