Bipolar disorder (BD) is a mental illness that manifests in manic and depressive states, causing changes in mood, sleep, appetite, speech, behavior, and cognitive functioning. There are three types of bipolar disorders: Bipolar I, Bipolar II, and cyclothymic. Each type having its own diagnostic criteria relating to the variances in mood episodes. Manic episodes, also referred to as mania, cause an individual with bipolar disorder to have an increased energy and activity while depressive episodes leave the individual with feelings of sadness and hopelessness. Bipolar I disorder is defined by having both manic episodes that last at least one week and depressive episodes. Bipolar II disorder is defined by hypomania and depression. Hypomania is less severe and less out of control symptoms compared to mania. Cyclothymic disorder is defined by “numerous periods of hypomanic symptoms as well numerous periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents)” (NIMH, 2016). Also, another subtype of bipolar disorder is rapid cycling. Rapid cycling occurs when there are four or more episodes that happen within a 12-month period.
Etiologies
There are multiple causes in the development of bipolar disorders including biological, psychological, and environmental factors. Biological factors will include genetics, neurobiologic, and neuroendocrine.
Biological
BD is a highly genetic and inheritable illness. Lifetime risk of bipolar disorder increases in first degree relatives, 40-70% for monozygotic twins and 5-10% for other first degree relatives (Müller, Berghöfer, & Bauer, 2002). The disorder is likely to have multiple genes that contribute to its development. According to Ivleva, (as cited in Halter, 2014), it also exhibits irregularities on chromosomes 12 and 15. Neurotransmitters such as norepinephrine, dopamine, and serotonin have a play in the cause of bipolar disorder. In simplest terms, the deficiency of these neurotransmitters will result in depression as an over-supply will result in mania. Structural changes in the brain seem to cause the disorder, and vice versa. A neuroendocrine aspect to the cause of BD is hypothyroidism. Hypothyroidism is associated with depressed mood and rapid cycling. Treatment includes high-dose thyroxine.
Psychological Factors
Psychological factors such as stress and trauma may play a role in those who have genetic factors. Examples of stressful events are death of a loved one, financial troubles, divorce, and giving birth. Stressful events vary between individuals as stress depends on each one’s perspective. In the absence of stressful events, the disease may not be triggered in an individual with genetic vulnerability.
Environmental Factors
Although unclear, upper socioeconomic class is associated with BD. These patients Additionally, the risk for development is increased with having a genetic predisposition for children in stressful environments.
Pathophysiology
The prefrontal cortex and limbic system is associated with bipolar disorder. The prefrontal cortex is related to cognitive function and the limbic system is related to emotional processes. With dysregulation in these neural pathways, symptoms of this disorder can be explained. The decreased activity in the frontal cortex can explain the symptoms of impulsivity and the lack of insight. The increase activity in the limbic system can explain the maladaptive symptoms in emotion, motivation, and fear in hypomania and mania. Müller, Berghöfer, and Bauer (2002) mentions another hypothesis of the development of BD that dates back to the 1970’s which suggests that a change in electrolyte fluxes in individuals with bipolar disorder is caused by a deficiency in the membrane sodium potassium ATPase. Müller et al. (2002) also states the association of hypothyroidism and bipolar disorder. Abnormalities in thyroid function seems to have an impact on the individual with rapid cycling. These abnormalities effect the mood and behavior of these individuals. The Diathesis Stress Model explains how genetics and the environment work with each other in creating mental illness. Diathesis takes into account the genetic component in this model and stress being the environmental factors.
A quantitative meta-analysis of fMRI studies in bipolar disorder
Functional magnetic resonance imaging is used to find brain abnormalities. Chen, Suckling, Lennox, Ooi, and Bullmore’s (2011) meta-analysis combined data from 65 fMRI studies comparing normal volunteers (n=1074) and individuals with bipolar disorder (n=1040). The study did not include the pediatric or geriatric population due to other factors that relate to the population such as brain development. In comparison of both individuals, results show an under-activated inferior frontal cortex (IFG) and over-activated limbic areas in volunteers with BD. This leads to how it is known that there are emotional and cognitive functioning abnormalities in those with bipolar disorder. Abnormalities in the IFG manifested through cognitive and emotional processing where as increased limbic activation manifested through only emotional processing. It was seen that decreased activity in the IFG was seen in mania, but not in euthymic. This indicates improvement in brain structure abnormalities and cognitive function in remission (Chen et al., 2011). This research tested current theories of bipolar disorder. The data can be used to understand that individuals with bipolar disorder undergo brain changes when in manic, euthymic, and depressed state. It is important that research of theories on bipolar disorder is continuous to show support that these theories still apply today and that treatment can be continued to be developed in relation to these theories.
Mania
In a manic sate, behaviors and mood cause an impairment in social and occupational functioning. Psychotic features may be present and hospitalization is needed as there is an increase in danger to self and others. A manic episode will include three of the following behaviors: extreme drive and energy, inflated sense of self-importance, drastically reduced sleep requirements, excessive talking with pressured speech, flight of ideas, distractibility, obsession with goals, purposeless arousal and movement, and participating in dangerous behaviors (Halter, 2014). This individual is energetic and optimistic, with endless talking. They will have extravagant ideas and plans, give away money and personal items, throw parties, and become overly friendly with strangers. Mania can be euphoric, feeling wonderful in the beginning turning dark toward a loss of control, or dysphoric, having depressive symptoms with mania (Halter, 2014).
Hypomania
This state is similar to mania but not outside of the norm nor out of proportion behaviors related to situation. For example, this individual will have an increased self-esteem rather than mania’s grandiosity. This individual may seem intimidating to others, but will not have psychosis. They are euphoric, having an increased energy for four days and at least three of the mania behaviors listed above (Halter, 2014). A person with hypomania will also alternate with symptoms of mild to moderate depression of at least two years in adults, or one in children and adolescents. This leading to a risk of suicide, where priority interventions are safety. It is not severe enough to cause serious impairment in social or occupational functioning. Hospitalization is not necessary for a patient in a hypomanic state.
Depression
In the depressive state, there is a deficiency in the neurotransmitters norepinephrine, dopamine, and serotonin. During this state, safety is priority. There is a risk for suicide in this individual. Sign and symptoms include dysphoria, anhedonia, negativity, fatigue, decreased appetite, insomnia, and decreased libido. Patient may also exhibit psychomotor retardation.
Interventions
Safety and self-care needs
Safety is the priority intervention for bipolar disorder, as with all other mental disorders. There is a risk for danger to self and danger to others when in either the manic or depressive state. In this population, there is a lifetime risk of suicide of 15 times greater than the general population (SAMHSA, 2017). Ways to reduce harm is the use of medication, seclusion, and restraints. Offering community resources such as Depression and Bipolar Support Alliance (DBSA) and providing a suicide hotline number is also a part of this intervention. Self-care needs include sleep and personal hygiene. Sleep hygiene is vital as early signs of manic phase include reduced sleep. During a depressive phase, a patient might lack the energy to bathe or perform ADL’s. At this point, it would helpful to supervise or give step by step directions. During a manic phase, a patient might not eat or be too preoccupied with ideas to provide themselves with proper nutrition so it is important to increase food and fluid intake. It might also be necessary to document intake and output.
Psychopharmacologic Interventions
The pharmacological interventions for bipolar disorders include the use of Lithium Carbonate (mood stabilizer), anticonvulsant, anti-anxiety, and second generation antipsychotic drugs. According to Sadock and Sadock (as cited in Halter, 2014), lithium carbonate is effective in bipolar disorders because it “inhibits about 80% of acute manic and hypomanic episodes within 10 to 21 days.” Although reaching the therapeutic level of this medication, there is a risk due to the narrow therapeutic level increasing the risk of toxicity. It is important to look for early signs of toxicity which include persistent nausea and vomiting, diarrhea, polyuria, thirst, slurred speech, and muscle weakness. Long term risk includes hypothyroidism and inability to concentrate urine in which regular monitoring of thyroid and kidney function is assessed. As lithium’s effectiveness is not rapid, there will be a need to use antipsychotics such as olanzapine or risperidone. The two second generation antipsychotics will be able to help with the symptoms of the disorder while waiting for the lithium to take effect. These symptoms include sleep disturbances, anxiety, and psychomotor agitation. Anticonvulsant drugs such as valproate, carbamazepine, and lamotrigine are effective in symptom improvement and in those who are treatment-resistant. Liver function and platelet count should be watched for when taking these medications, also for a life-threatening rash when taking lamotrigine. Last, there are the anti-anxiety drugs, clonazepam and lorazepam, to help with psychomotor agitation. These drugs are used in caution or avoided in patients who have a history of substance abuse. In a depressive episode, it is not recommended to use anti-depressant as it can cause hypomania or mania. “Treatment of antidepressants, particularly tricyclics, is complicated by the risk of a rapid switch to mania, or by the induction and acceleration of rapid cycling” (Müller et al.,2002). Although, it also mentioned that there is some evidence that SSRI antidepressants can reduce the risk of switching to a manic or rapid cycling.
Psychotherapy (Cognitive-behavioral therapy)
Cognitive-behavioral therapy (CBT) focuses on how a person’s thoughts can influence behaviors. It focuses on changing the way a person thinks to become healthier so that the right actions and behaviors will be made by the person with bipolar disorder. The negative views are what trigger the depressive moods and behaviors. This type of psychotherapy “focuses on the adherence to the medication regimen, early detection and intervention for manic or depressive episodes, stress and lifestyle management, and the treatment of depression and comorbid conditions” (Halter, 2014). Some people question the helpfulness of CBT in bipolar disorder but there has been research in if CBT is effective in lowering relapse rates in bipolar disorder.
Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials
Nineteen studies were eligible in participating in the meta-analysis all meeting the requirements of being a randomized control trial, patients being over 18 years old, and the presence of two study groups receiving treatment and the other receiving treatment and CBT (Chiang et al., 2017). In this meta-analysis, analysis of the CBT approaches, patients, and therapists were done to see the impact in its efficacy. Of the nineteen studies, there were a total of 716 patients with CBT and 668 controls (Chiang et al.,2017). The CBT group received 8 to 30 CBT sessions lasting 45-120 minutes each (Chiang et al., 2017). Outcomes in this meta-analysis lead to the discussion of CBT having a more favorable response in decreased depression levels compared to the control group and showed significant lower rates of relapse at follow-up. The results of this meta-analysis can help provide support and evidence in the use of CBT. To some, CBT may be seen as not effective. Research and studies that continue to support CBT will help individuals seek out this therapy in adjunct with the ordered medication regimen. This therapy can be effective in helping patients or individuals with bipolar disorder gather thoughts together in a healthy and effective manner to help cope with their disease and also prevent relapse. This data will be used to make a positive impact on individuals with bipolar disorder.
Synopsis of Audiovisuals
Here One Day
This documentary follows Kathy Leichter, a woman who listens to her mother’s audiotapes years after her suicide. Her mother, Nina, was a creative individual who was a political activist, a mental health advocate, and a poet. Throughout the audiotapes, Nina is heard switching from manic to depressive states with her triggers including isolation from her husband, a state senator, and her own mother passing away. Interviews with Nina’s husband, children, and friends are shown discussing her manic phases of going out late at three in the morning, on the phone laughing, and talking in inappropriate ways to her child daughter about love and sex. In her audiotapes, she includes statements feeling depressed, exhausted, having no desire to do anything. With these interviews, home footage, photos, and interviews, Nina’s difficult journey living with the disorder is seen and heard but in the end succumbing to her illness. The documentary raises awareness of mental illness and suicide and the effects of these on family members.
Bipolarized: Rethinking mental illness
This documentary follows Ross McKenzie as he takes a journey of detoxing from lithium, pursing alternate treatments, and discovering the root causes of his mental disorder. The documentary starts off with Ross explaining one of his manic episodes driving from Los Angeles to Toronto, with days without sleep which led him to hit a deer at 70 miles per hour. With 16 years of lithium treatment, Ross goes to Costa Rica for a detox program. He tries alternative treatment such as meditation, cupping, acupuncture, and the use of spirits. The documentary also discusses how drug markets capitalize off of mental illnesses with the use of the expanding definitions of disorders in Diagnostic and Statistical Manual of Mental Disorders. Ross discusses with other health professionals of the misdiagnosis and overtreatment of psychotropic drugs in mental illness. Within his research to attain a normal life, Ross struggles to live the normal up and downs of living, but feels a new sense of living.
Feelings and Comments
The audiovisuals provided real life situations of bipolar disorder. I have learned about the impact of BD and how not only do treatments reduce symptoms of the disorder but cause a blurring and feeling of not living life fully. In Here one day, I saw the struggle of trying to stabilize and take control of the disorder. But even with treatment, stabilizing can still be a battle. In Bipolarized, I felt that there needs to be more research done on how mental illnesses should be redefined to reduce the number of misdiagnosis and overtreatment of psychotropic drugs. With these two documentaries in mind, I will take to practice in education of those with bipolar disorder to learn how to cope effectively so that certain triggers will not cause a manic or depressive state. I learned how being direct with suicidal ideation is vital because an individual might not show these type of depressive behaviors. I think that education should be ongoing treatment to help with coping and understanding the fullness of the mental disorder. I also want to raise awareness on how often more than not people are misdiagnosed with mental disorders such as confusing schizophrenia with bipolar disorder, or confusing bipolar disorder with post-traumatic stress disorder. I want to use the information and knowledge of different mental illnesses to assess these patients, the disorders, and treatment to provide optimal care to the patient. In my personal life, the audiovisuals have helped me become more empathetic by understanding more fully the disease of bipolar disorder.