History of Bipolar Disorders
Bipolar disorder has its roots back to the times of the ancient Greek, it was referred to as Mania and Melancholy. Mania referred to a state of being in an extremely mad and excited state. Melancholy was a state of extreme depression. A physician and philosopher, Aretaeus, was the first one to suggest these disorders (Burton, 68).
In the 19th century, the modern psychiatric concept of bipolar disorders emerged. Jules Baillarger and Jean-Pierre Falret in 1854 came up with the first independent explanation of bipolar disorders at Académie de Médicine in Paris. Falret observed that bipolar disorder is a disease inherited in families and pointed out its genetic influence on the human beings.
In 1650, Richard Burton, the scientist, wrote a book titled ‘The Anatomy of Melancholia’ that dealt with the subject of depression. Dubbed as the “Father of Depression,” his book has been significant in researching the reasons of mental illness and health.
On the other hand, Francois Baillarger, postulated that there is a marked distinction between the bipolar disorders and schizophrenia. He largely drew on the depressive phase of bipolar disorders and played a significant role in classifying and differentiating the bipolar disorder from other diseases prevalent at that time.
A renowned German psychiatrist, Emil Kraepelin, in the beginning of 1900s studied the natural course of the disorder and found that the disease was clocked by symptom-free-interval. Using his own findings, he differentiated the symptoms of bipolar disorder from that of schizophrenia. He coined the term of “manic-depressive psychosis” and concluded that the course of manic-depressive psychosis had been rather episodic with a benign outcome (Burton, 134).
The findings of Kraepelin, lack the distinction between the people who had both manic and depressive episodes and the people who only suffered depressive episodes but with psychotic symptoms. In 1960s, a distinction was made between these disorders with emphasis on bipolarity and mood elevation.
Despite all the advancement in recognizing the bipolar disorders, as a separate illness, many of the people with this illness were not institutionalized just because Congress refused to recognize it as a legitimate illness. At the start of the 1970s, laws were formed and enacted and standards were formulated to help the people with bipolar illness.
With the foundation of the National Association of Mental Health in 1979, the bipolar disorders attained a legitimate status and the term of bipolar disorders was replaced by manic-depressive disorder in the year of 1980. This is the term that the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) used to further study the problem. With the passage of time, the researchers were able to differentiate between the bipolar disorders of adults and children more clearly, but still it leaves room for more research and findings so as to find the most probable causes and treatment of the disorder (Burton, 245).
Signs and Symptoms of Bipolar disorders
Bipolar being a complex disorder has many different types of signs and symptoms. A serious and alarming shift in moods is caused by thought-process and behavior of an individual. A person suffering from this disorder displays abnormally elevated hypo manic or manic states of mood which interferes with the normal routine of working life. Often people also experience depressive episodes during bipolar disorders, but it is not a universal situation as such. Due to lack of simple physiological disorders for detection of disorders, the clear diagnosis of bipolar is often difficult. The main difficulty lies in distinguishing depressive episode of bipolar disorder from that of pure depression.
The first few depressive episodes are more likely in the case of younger onset age (Bowden). Given this, many of the patients are initially diagnosed and treated for suffering with major depression (Muzina,Kemp & McIntyre).
The symptoms of bipolar disorders differ largely in terms of their pattern, severity and frequency. Some patients display more of either mania or depression while others may experience alternate episodes with the same intensity. Some patients may have frequent mood disturbances while others would only experience them just a couple of times in their lives.
There are basically four types of bipolar disorders that depend on the intensity, frequency, and pattern of either depressive, manic or both episodes.
· Mixed episodes.
The signs and symptoms of bipolar disorder vary in frequency and intensity according to the degree of above-mentioned types.
Mania is the distinguishing feature of bipolar disorders. When an individual is going through a manic phase, one experiences heightened energy and develop feelings of euphoria which lasts for at least a week. People going through this phase of heightened energy, often talks a lot, has very little sleep and are extremely hyperactive. They develop feelings of being more powerful, greatness and invincibility. Along with this, they have very low attention span and have an impaired judgment.
People often tend to get reckless during this phase getting involved in substance abuse. They particularly take alcohol, cocaine or sleeping pills. They display a violent, aggressive, intrusive and delusional behavior having ideas of grandiose. If it moves towards extreme levels, an individual can experience a state of psychosis involving delusions and hallucinations (Bipolar Disorder).
Hypomania is a state of moderate elevation in mood. The characteristics of this state are optimism, emphasize on speech and activity and decreased need for sleep. But in general, it has been observed that hypomania does not interfere with routine functioning as mania does. The people having hypomania tend to become more productive, while in mania they are unable to complete the tasks due to shortened attention span (Hypomania and Mania in Bipolar Disorder). Some might exhibit increase in creativity and hyper sexuality.
People who are hypomanic often experience increased energy levels and activity but they do not display delusions or hallucinations. The hypomanic event is not considered as problematic unless accompanied by the frequent depressive episodes and uncontrollable mood swings. The untreated hypomania can span from a few days to many years. In the most common situations, symptoms exist from weeks till few months.
The depressive episode among patients is often characterized by intense feelings of hopelessness, sadness or emptiness. It more commonly involves irritability, inability to get involved in pleasurable activities, loss or gain of appetite, fatigue or lack of energy, problems in concentration and attention, sluggishness, both mentally and physically, having problems in sleep, extreme feelings of guilt of worthlessness and thoughts of committing suicide. In extreme cases, it might develop into psychotic depression, which involves losing contact with reality and impairment in work and social functioning (Smith & Segal).
During the mixed episodes of bipolar disorders the state of mania and depression occurs simultaneously. The most common signs and symptoms include combinations of irritability, aggressiveness, anxiety, loss of sleep, distractibility along with racing thoughts. During this episode the energy is in a high state, but the mood is low. This can be considered the most dangerous episode, as it can lead towards an increasing risk of developing panic disorders, conducting suicide attempts, high levels of substance abuse along with risk of many other complications (Goldman).
Classification of Bipolar disorder according to DSM
The doctors use the Diagnostic and Statistical Manual to diagnose bipolar disorders. DSM divides the disorder into four basic types;
· Bipolar I disorder is a classic form of severe manic depressive illness which is characterized by at least one episode of manic or mixed episodes. In most of the cases, there is at least one episode of depression which lasts typically for at least two weeks.. The patient needs to be hospitalized in this case.
· Bipolar II disorder has the symptoms of hypomania and severe form of depression. These symptoms keep on shifting back and forth.
· Bipolar disorder not Otherwise specified ( BP-NOS) is diagnosed in a case when an individual displays symptoms that neither fit the criteria of Bipolar I nor of Bipolar II. Such symptoms, though out of the normal range, are not enough to meet the criteria of Bipolar I or Bipolar II.
· Cyclothymia or cyclothymic disorder involves hypomania which is accompanied by mild depression. It is characterized by cyclical mood swings which are low in intensity ( Smith & Segal). The episodes of hypomania and mild depression keep recurring for a period of at least two years.
Etiology of bipolar disorder
The exact causes of Bipolar disorders are not known. Probably, it involves an interplay of genetic, neurochemical and environmental factors at different levels in its onset and progression. Currently, it is thought that its predominant cause is biological. It is caused by the malfunction of a particular part of the brain and the neurotransmitters. Having a biological basis, it may remain dormant and emerge simultaneously or is triggered by some stressor in life (Bressert, 146).
Although the exact causes of the disorder are not known but researchers have come up with some important factors.
· Genetic factors: bipolar disorders have a familial pattern. Children who have parents or siblings with a medical history of bipolar disorder are likely to develop the illness 4 to 6 times more as compared to others who do not have any familial history of the disorder (Nurnberger & Foroud). An individual has 25 % more chance of developing the disorder who has a non-identical twin with a disorder or his both parents suffer from this disorder. In case of having an identical twin the risk increases eight fold as compared to non-identical twin. The advancement in technology will help more in genetic research related to bipolar disorders. But still it has not been found that whether genes are the only cause or not (Bipolar disorder).
· Neurochemical factors: the primary basis of bipolar disorder is biological, caused due to a malfunction of certain brain area and neurotransmitters.
· Environmental factors: certain trauma or some experience in life may trigger the manic depressive episode in a person having some genetic predisposition. Besides, unhealthy and altered habits related to health, substance abuse or hormonal problems can also act as triggers of the disorder. It has been noticed that the bipolar disorder is having an earlier onset in most of the cases that are vulnerable to illness. This early onset might be due to the environmental and social factors that need to be explored (Bressert).
· Medication triggered disorder: sometimes medication such as use of anti-depressants can also cause the disorder in individuals who are vulnerable to bipolar disorders.
All or any of these factors may interact with each other to produce the mental illness called bipolar disorder.
Treatment of bipolar disorder
Any detection of the symptoms of bipolar disorders in others or yourself requires immediate help and treatment. If a patient simply ignores the problem, the disorder will get worse with the passage of time. The untreated bipolar disorder can cause problems in all walks of life. There are a number of effective treatment options available, though they are long-term and often chronic. The treatment is provided after taking into consideration the episode cycle and its level of intensity.
Medication is the part of every type of recommended treatment due to the biological nature of the illness. A psychiatrist is the one who usually prescribes the medication after diagnosis of bipolar disorder. The types of medications that are generally used for the treatment includes mood stabilizers, atypical anti-psychotic drugs, and a combination of different types of medications for bipolar disorder.
Along with this, psychotherapy and self- help strategies are used to make the individual learn coping strategies and to alter the unhealthy thinking pattern. This involves the help of a psychologist, psychiatrist or the psychiatric social workers (Bressert). Psychotherapy involves the use of Cognitive-behavioural therapy; Family focused therapy, Interpersonal and social rhythm therapy and psychoeducation (Bipolar disorder).
Other treatments may involve electroconvulsive therapy and sleep medications. The use of the different treatment options depends upon the severity of the illness. In extreme cases, hospitalization is a standard approach.
Prognosis for Bipolar disorder
Though bipolar disorder has no permanent cure, but with proper treatment and medication, it can be treated effectively. Its best control is the continuous treatment rather than taking intervals during the treatment. People mostly respond to a combination of treatments including medications.
A study conducted by STEP-BD, found that half of the people who recovered from the disorder still had some lingering symptoms where recovery meant having two or even fewer symptoms for at least eight weeks. Due to this, the patients either experience relapse or recurrence of usually a depressive episode (Perlis, Ostacher,Patel, et.al).
A person having some other mental illness along with bipolar disorder is more vulnerable to relapse. (Perlis, Ostacher,Patel, et.al). A combination of psychotherapy and medication help in the prevention of relapse for some people (Milkowitz,Otto,Frank, et.al).
If a treatment is discontinued after recovery, a person may remain free of symptoms for approximately five years. But the interval may become shorter between episodes if the treatment is stopped early (Bressert). Working more closely with the doctors and talking openly about the problem can make treatment more effective and long term.
Bipolar disorder is not incurable. It can be prevented and controlled through proper care and treatment.
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