Abnormal Psychology - Bipolar Disorder

Charlotte Walton WALCHA07 17-01-05

Level 3 Psychology

Abnormal Psychology

Bipolar Disorder

Bipolar Disorder is the medical name for manic depression, and means an illness with ‘directly opposite’ states of mind. Sufferers of Bipolar illness have mood swings, sometimes feeling ‘high’ or manic, and at other times feeling ‘low’ or depressed. Although the ‘highs’ can occasionally be enjoyable, these extreme emotions are often distressing and can be very disruptive to people’s lives.

Few Disorders in history have been described with such consistency as Bipolar Disorder has been. Symptoms that characterise the illness can be found in medical literature throughout the centuries from the ancient Greeks to present day.

A sufferer of Bipolar will experience mood swings of two extremes, mania and depression, the extent to which these moods will affect the sufferer is determined by the severity of the illness. The distinction between Bipolar Disorder and Unipolar Disorder sufferers is the absence of mania in an individual who suffers from Unipolar Disorder or clinical depression. Common symptoms for both illnesses include:

Feeling sad or unhappy with no identifiable causes, or known as Endogenous Depression.
Lack of interest in activities usually enjoyed.
Insomnia or excessive periods of sleep.
Little energy.
Experience of medical problems or difficulty concentrating.
Loss of libido.
Social withdrawal.
Loss of self confidence.
Suicidal thoughts.
Changes of attitude.

The symptoms which determine an individual suffering from Bipolar Disorder during manic episodes can also include:

Having lots of energy.
Poor Judgement.
Self centeredness.
Be extremely active and talkative.(rapid pressurised speech)
Feel extremely happy or sometimes extremely angry.
Feel restless and irritable.
Have racing thoughts. (If these thoughts are strange or unfounded they are called delusional)
Insomnia.
Sometimes hear voices or see things that aren’t there. (called hallucinations)
Increased interest in sex or sexual behaviour which is unusual for an individual.

Bipolar Disorder has been divided into two sub types (Dunner et al 1976). Bipolar I sufferers are diagnosed with mania which is severe enough to require treatment, psychosis in these instances are frequently evident in manic episodes as are periods of rapid cycling from one emotional extreme to the other. Bipolar II sufferers experience episodes of hypomania but not acute enough to require hospitalisation, This classification for the milder forms of Bipolar have however been inconsistent and so to eliminate such ambiguity a system to distinguish the milder forms of mania were proposed (Angst 1978). Bipolar patients were divided into Md and mD, with M (Mania) and D (Depression) indicating an episode which required hospitalisation and m and d describing behaviour that could clearly differentiated from normal behaviour but not severe enough to merit hospitalisation.

Suggestions into the causes for Bipolar vary throughout the different psychological approaches. One of the strongest theories lie in the suggestion that the disease is strongly associated with the biological make up of the brain and the role neurochemicals play.

Brain-imaging studies are helping scientists learn what happens in the brain to produce Bipolar Disorder and other mental illnesses. Certain brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine Its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with Bipolar Disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.

The neurotransmitter system has received a great deal of attention as a possible cause of Bipolar Disorder. Researchers have known for decades that a link exists between neurotransmitters and mood Disorders, because drugs which alter these transmitters also relieve mood Disorders. Some studies hypothesize that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the cause. Others indicate that an imbalance of these substances is the problem - i.e., that a specific level of a neurotransmitter is not as important as its amount in relation to the other neurotransmitters. Still other studies have found evidence that a change in the sensitivity of the receptors on nerve cells may be the issue. In short, researchers are quite certain that the neurotransmitter system is at least part of the cause of Bipolar Disorder, but further research is still needed to define its exact role.

Our genes hold all of our hereditary information and provide the “genetic code” that allows our bodies to function, but our environment can affect how our genes function. Half of our genes are inherited from our mothers and half from our fathers. When looking at genes in the context of Bipolar Disorder, genes may confer predisposition to certain symptoms rather than the Disorder itself. For example, with Bipolar Disorder they look at susceptibility to mania or depression rather than mood Disorders as a whole.

Population studies, twin studies, and adoption studies were all reviewed for their findings regarding the role of genetics in Bipolar Disorder. The higher rates of Bipolar Disorder among relatives, identical twins, and biological parents relative to adoptive parents were all cited as evidence of the role of genetics. These higher risks compare to Bipolar Disorder occurring in roughly one percent of the population as a whole.

In population studies they found that there is a 10 percent risk that others in the nuclear family (father, mother, siblings) will have the Disorder once one family member is diagnosed. Second degree ...

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Twin studies looked at the question of when one twin has Bipolar Disorder, how often does the other twin also have the Disorder? With identical (monozygotic) twins, this was found to be true 60 percent of the time. With fraternal (dizygotic) twins, the frequency was found to be 10 percent, the same as that for traditional siblings.

Adoption studies compared the rate of Bipolar Disorder in biological and adoptive parents of adoptees with Bipolar Disorder. Biological parents share the genes of the afflicted person, while the adoptive parents share the same environment. The incidence of Bipolar in the biological parents of adoptees with Bipolar Disorder was 18 percent, while the rate of concurring Bipolar Disorder in adoptive parents was roughly 7 percent.

After presenting the compelling genetic evidence, it was concluded that genetic factors alone do not determine susceptibility to Bipolar Disorder. The risk for Bipolar Disorder stems from a complex mix of both genetic and environmental factors, and their current theory is that most individuals who develop these conditions must have several risk genes and significant environmental influences. It has also been illustrated that the current line of thought is that Bipolar Disorder represents not a single gene Disorder, but a complex issue involving multiple genes.

Researchers concluded: "As defined by the DSM-IV, Bipolar affective Disorder is highly heritable. There are substantial genetic and non shared environmental correlations between mania and depression, but most of the genetic variance in liability to mania is specific to the manic syndrome."

The primary psychological culprit implicated in the manifestation of Bipolar Disorder is stressful life events. These can range from a death in the family to the loss of a job, from the birth of a child to a move. It can be pretty much anything, but it cannot be precisely defined, since an event which presents it’s self as stressful to one individual may not affect another. With that in mind, research has found that stressful life events can lead to the onset of symptoms in Bipolar Disorder. However, once the Disorder is triggered and progresses, "it seems to develop a life of its own. Once the cycle begins, a psychological or pathophysiological process takes over and ensures that the Disorder will continue”.

When we look for the cause of Bipolar Disorder, the best explanation via the research available at this time is what is termed the "Diathesis-Stress Model." The word diathesis means, in simplified terms, a bodily condition that make a person more than usually susceptible to certain diseases. Thus the Diathesis-Stress Model says that "each person inherits certain physical predispositions that leave him or her vulnerable to problems that may or may not appear, depending on what kinds of situations that person confronts." Durand and Barlow define this model as a "hypothesis that both an inherited tendency and specific stressful conditions are required to produce a Disorder."

The psychodynamic approach to the causes of depression look at the relationships sufferers had with their parents in early childhood. It has been suggested that unresolved conflicts or emotional pain associated with in these relationships can manifest n adulthood to cause self hatred, low self esteem and other negative emotions associated with depression. The psychodynamic approach associates itself only to the causes of unipolar and does not explain the manic symptoms displayed by those individuals suffering from Bipolar Disorder, It also fails to explain the many people who suffer from chronic depression who assure psychiatrists their childhoods were happy.

In conclusion to identifying the causes of Bipolar Disorder it seems apparent that no one cause can be identified. It is more probable that a number of the causes discussed above contribute to the condition however research continues.

Although Bipolar Disorder can become disabling, it is also among the most treatable of the mental illnesses. The combination of psychotherapy and medications returns the vast majority of manic-depressive patients to happy functioning lives. Bipolar treatments can be acute – intended to relieve symptoms in the short term, such as intense drug treatments and ECT (i.e. during a manic episode), or prophylactic – provided over the long term as maintenance therapy and intended to prevent symptoms from reoccurring e.g. Cognitive Behavioural Therapy.

The most common medication used in treating Bipolar Disorder are the mood stabilising drugs in particular Lithium Carbonate. Lithium which has been prescribed for over fifty years , successfully reduces the number and intensity of manic episodes for seventy percent of those who take medications. Twenty percent become free of symptoms. Those who respond best to Lithium are patients who have a family history of depressive illnesses and whom have periods of relatively normal mood between their manic depressive phases. Very effective in treating the manic phase, lithium also appears to prevent repeated episodes of depression. One theory for this is that in controlling the mania, lithium helps prevent the swing into depression.

Despite its long history, researchers are still unclear how lithium works. Studies have found that lithium has a range of effects in the brain; it raises (and lowers) levels of chemicals such as inositol phosphates.

Lithium also reduces levels of an enzyme called PKC that plays a vital role in the processing of nerve cell signalling, and other studies suggest that lithium increases the amount of grey matter in the brain. These findings may ultimately shed light on how lithium works in Bipolar illness.

Lithium has its drawbacks. It is not effective for 20-40% of people, especially those with dysphoric mania and mixed states. It has a narrow therapeutic range (a toxic dose is not much bigger than a therapeutic one). Lithium can cause lethal changes in electrolyte and fluid balance in the body. Lithium can take up to a week to effectively stabilise mood.

Lithium can also have severe side-effects, including:

Weight gain.
Tremors.
Acne.
Muscle weakness.
Cognitive defects, such as confused thought processes.
kidney problems (manifesting as polyuria - increased frequency/volume of urine, polydipsia - excessive thirst). Severe kidney problems are rare but serum creatinine levels are measured regularly during lithium treatment to give doctors an idea of whether the kidneys are still working as they should.

The unpleasant side-effects experienced can make some people stop taking the drug. But stopping lithium can cause withdrawal effects such as 'rebound mania'. Also, if people restart treatment after withdrawing from lithium, they may become resistant to its benefits. For these reasons, psychiatrists recommend that people stay on lithium for at least 2 years before they consider discontinuing treatment. For other drugs currently used to treat Bipolar Disorder please refer to appendix A.

In situations where medication, cognitive therapy or alternative forms of treatment for Bipolar have been found ineffective for a patient the use of ECT or electro convulsive therapy is an option. Used when the Disorder is at it’s most severe and particularly when suicidal thoughts have become increasingly prominent this form of treatment is considered appropriate and effective.

The procedure for administering ECT involves:

Procurement of a patient consent form.
Pre-treatment evaluation – a complete physical examination is given to ensure the patient has no medical conditions which might produce complications during the procedure.
Patient is given a general anaesthetic – so they do not feel any pain.
The patient is given a muscle relaxant – this prevents the patient injuring themselves during their convulsion.
An electric shock is applied to produce a convulsive seizure. The shock is typically between 140 – 170 volts and lasts between 0.5 and 1 second. The shock is applied in one of two ways. In bilateral ECT two electrodes are attached so that the shock is delivered to both brain hemispheres. In unilateral ECT (Goldman 1949) a single electrode is attached to the not dominant hemisphere, so that only one hemisphere is shocked. The later reduces the unwanted cognitive side effects of ECT (Squire & Slater 1978) but studies have shown it to be less successful in actually treating the depressive Disorder.
A typical course of treatment consists of between 6 and 12 actual shocks, given over a period of 2 to 3 weeks.
After treatment the patient is typically given a course of anti – depressants to reduce the likelihood of relapse.

Shock treatment to the brain induces a grand mal seizure in the brain. Seizures are similar to Epileptic convulsions in which the brains electrical pathways all fire at the same time. The seizures alter many chemical aspects of the brain both during and after seizure activity.

In a review of the clinical literature the conclusion has been made that ETC is a very effective treatment for specific Disorders, at least in the short term, with success rates of 60% - 80%. The main advantages of ETC are that it:

Works on patients that have failed to respond to other types of therapy.
Produces positive effects far more quickly compared to other treatments. (Within weeks compared to months).
Can be used in cases where drug therapy is not appropriate e.g. pregnant women or patients who suffer severe reactions to anti depressants.

TMS is an alternative to ECT that's in the final stages of development. This procedure involves transmitting magnetic, rather than electrical, impulses to the brain.

Although the initial response to ETC is good there is a fifty per cent relapse rate within six months unless anti depressants or further ECTS are given as follow up treatments. The side effects during ETC include increased blood pressure and pulse as well as irregular heart beat. There is a small risk of associated death (1 in 100, 000). If the patient aspirates (breathes in) or saliva or vomit during treatment they could develop pneumonia. In around 1 in 2, 000 treatments patients experience spontaneous seizures at the end of the treatment. Post treatment side effects include Retrograde amnesia, impaired ability to form new memories, sleep disturbances and disorientation and confusion.

One of the main criticisms of ECT is that there is no convincing scientific explanation of how it works, only a number of unsubstantiated theories. The Neuropsychological theory suggests that ECT stimulates the long term production of neurotransmitters, thus acting like a prolonged course of anti depressants. Another theory which attempts to discredit ETC claims that the shock administered causes brain damage which disrupts memory engrams. This causes the patient to temporarily forget their problems. (Breggin 1979) The Punishment hypothesis is based on evidence from ‘sham ETC’ where patients are taken through the whole procedure but are not actually given any shock. It suggests that patients see the treatment as a punishment for their current behaviour and stop ‘acting’ depressed to avoid further punishment. The evidence for this is weak as nearly all studies show that patients who receive real shocks show far greater improvements. (West 1981)

CT and MRI scans taken before and after ECT show no structural changes to the patients brain.

As outlined, Any patients preparing to undergo ECT should give informed consent. Ethical issues can arise when a person is suffering such a severe depressive episode it is questionable if he or she can give informed consent. This is a paradox, as it is only these patients who really require this level of treatment.

ETC is widely considered to be an appropriate treatment for those patients whom have exhausted all other possibilities and are still suffering from Bipolar to an extent that their lives are being debilitated by the Disorder. It is also appropriate for individuals who are at a high risk of suicide, this is because the positive effects are rapid.

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—are helpful in providing support, education, and guidance to people with Bipolar Disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalisations, and improved functioning in several areas. A licensed psychologist, social worker, or counsellor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions are based on the treatment needs of each person.

Psychosocial interventions commonly used for Bipolar Disorder are cognitive behavioural therapy, psycho education, family therapy, and a newer technique, interpersonal and social rhythm therapy. Researchers are studying how these interventions compare to one another when added to medication treatment for Bipolar Disorder.

Cognitive behavioural therapy helps people with Bipolar Disorder learn to change inappropriate or negative thought patterns and behaviours associated with the illness. Psycho education involves teaching people with Bipolar Disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psycho education also may be helpful for family members.

Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms. Interpersonal and social rhythm therapy helps people with Bipolar Disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules can help protect against manic episodes.

St John's Wort is a herbal remedy, also known as hypericum. It has been used for centuries for depression and anxiety. It is commonly used in Germany and other parts of the world. The flowers and leaves of the St John's Wort plant (Hypericum perforatum) are used to make the herbal remedies. These flowers and leaves contain many different compounds including hypericin, which is thought to be one of the compounds that makes St John's Wort helpful for depression and anxiety. These compounds are extracted from the plant matter using alcohol.

St John's Wort looks very promising as a treatment for mild to moderate depression. There have been comparisons of St John's Wort with other medicines for depression such as imipramine and amitriptyline (tricyclic antidepressants) in tests. These studies have been fairly positive for St John's Wort, indicating that St John's Wort helps with depression and does not have many side effects.

It is not known how St John's Wort works. It is thought that it may affect serotonin, Noradrenaline and dopamine uptake. Trials into its effectiveness of treating depression have been only for short periods of time (e.g. 4 or 8 weeks), so it is not certain how well St John's Wort will work or whether there will be more side effects over a longer period of use. These studies have usually been carried out with only small numbers of patients, which is also a disadvantage.

St John's Wort has been compared with older tricyclic antidepressants (e.g. imipramine and amitriptyline), and has generally shown fewer side effects than the tricyclic antidepressants. It would be useful to compare St John's Wort with newer antidepressants such as fluoxetine (Prozac) and paroxetine (Aropax) to see if St John's Wort works as well and if St John's Wort has as few or less side effects, as these medicines are used so commonly now.

This remedy does not seem to have many problems with side effects, however possible side effects are listed below:

Allergy.
Increased skin sensitivity to the sun is extremely rare.
St John's Wort generally does not seem to cause drowsiness and affect the ability to drive, however a very small percentage of people taking it may feel tired.
Increased sensitivity to touch, temperature and pain is a possibility.

Likely interactions include (but are not limited to):

Certain antidepressants including fluoxetine (Prozac), paroxetine (Aropax), other SSRI antidepressants.
Warfarin/coumarins/anti-coagulants (for thinning the blood).
Digoxin (for the heart).
Cyclosporin (for transplants and some diseases such as psoriasis and arthritis).
Theophylline (for asthma).
Migraine medicines called triptans, e.g. Imigran (sumatriptan).
Some medicines used to treat HIV.
Oral Contraceptives ("the pill").
It is also thought possible that there could be an interaction with some epilepsy medicines that sometimes are also used for pain, or Bipolar Disorder e.g. carbamazepine, phenytoin, and phenobarbitone.

It is very likely that there are other interactions that are not yet known.

It is possible that this form of treatment could be helpful for sufferers of moderate unipolar or for individuals who are successfully managing the depressive elements of Bi Polar but due to the severity of symptoms associated with Bipolar, relief of symptoms whilst using St Johns Wort would be rare. As mentioned before, how this treatments works has not been addressed and the number of medications which could be affected by the use of this treatment make it an ineffective method of managing Bipolar Disorder.

Each form of treatment has it’s drawbacks but effectively prescribed and used in conjunction with one another, the management of Bipolar is successful in all but the most severe cases. If a patient is monitored effectively and treatment tailored to the individual need life with Bipolar can be as easy to deal with as life with out.

Appendix 1