Amy Wallace
									12-5-99
									Psychology 472
									Final Paper


	"And always, when will it happen again?  Which of my 
feelings are real?  Which of the me's is me?  The wild, 
impulsive, chaotic, energetic, and crazy one?  Or the shy, 
withdrawn, desperate, suicidal, doomed, and tired one?  
Probably a bit of both, hopefully much that is neither." 
(1)
The symptoms of what is now labeled bipolar disorder 
have been recorded in history up to 2,000 years ago.  A man 
named Kraepelin first called it manic depressive disorder 
in 1913.  It is the most fatal affective disorder: 
approximately 15-20% of people afflicted with bipolar 
disorder commit suicide.  Although 1.2 million Americans 
are diagnosed with it every year, it remains today the most 
unrecognized, untreated of all psychiatric disorders.
	Bipolar disorder is characterized by periods of 
depression alternating with manic episodes.  Patients 
describe depressions as feeling slow, hopeless, and unable 
to experience any type of pleasure.  One patient says in 
describing depression (in reference to her brain,)  "the 
wretched convoluted thing works only well enough to torment 
me with a dreary litany of my inadequacies and shortcomings 
of character, and to haunt me with the total, the desperate 
hopelessness of it all."  (1)
Manic periods are described as feeling hyper, fast and 
energetic.  Manic states are divided into two categories: 
"mania", which refers to drastic changes and a heightening 
in mood, speech, energy, and cognitive and physical 
activity.  The person sleeps less (or not at all), becomes 
irritable, irrational, impulsive, and possibly paranoid and 
delusional. A patient describing a past, particularly 
intense manic episode writes, "I was a messiah.  I was 
going to the Orient to bring an end to the evil of 
Communism and bring the religions of the Orient into line 
with Christianity.  I was saying, 'All right, all the 
whites over here, all the blacks over there.  We're going 
to have us a Chinese fire drill!' So in comes the security 
and takes me into the quiet room.  And down there I was 
spitting on a light bulb, thinking if I watched the saliva 
burn, the different colors and shapes, I could find the key 
to the cure for cancer." (1)
"Hypomania" is a diluted form of mania, characterized 
mainly by extra energy, and a sense of hope and well being.  
Some people diagnosed with bipolar disorder enjoy the 
periods of hypomania, even to the point of discontinuing 
medication to restore the highs.  A 19 year old was 
informed of his diagnosis during such a period and replied, 
"If I'm ill, this is the most wonderful illness I've ever 
had." (1)
Bipolar disorder has been categorized into two groups: 
bipolar I and bipolar II.  Bipolar I is the more severe 
form, depression is very intense (described by philosophers 
as melancholia for centuries), and the individual may 
become  psychotic in the manic phase.  Delusions of 
grandeur and auditory hallucinations may occur.  Bipolar II 
is marked by chronic depression intermixed with hypomanic 
episodes, never reaching the terrifying manic stage.  
However, anxiety and obsessive compulsive tendencies are 
sometimes effects of the hypomanic state.  The transitional 
period between the two extremes is referred to as "mixed 
mania" or dysphoric mania, including feelings of 
excitement, agitation, and depression. 
	According to a recent survey, only an estimated 27% of 
bipolar individuals are treated, the lowest of all 
psychiatric disorders.  Both types are theorized to be 
genetic: usually approximately 20% of patient's relatives 
have some affective disorder.  The top four most common 
disorders diagnosed in relatives are: bipolar I and II, 
unipolar depression, schizoaffective disorder, and suicidal 
tendencies.  An exact gene that causes bipolar disorder has 
not been discovered.  Some researchers believe a 
contribution to developing bipolarity is exposure to 
intimate relatives that exhibit chaotic behaviors.  Alcohol 
and drug abuse has also been continuously prominent in many 
families of bipolar people, also with individual patients.  
Studies estimate 31.5% of bipolar I and 20.8% of bipolar II 
patients are addicted to alcohol.  One theory attempting to 
explain why alcoholism is so prevalent in people with 
bipolar disorder is a genetic explanation.  The "assortive 
mating" hypothesis states that bipolar patients are more 
likely to marry people with alcoholism.  Another line of 
thinking is that alcohol consumption may be a result of 
manic behavior, possibly as an attempt at self-
medication,(which is actually counter productive,) or 
simply the product of "an expansive lifestyle" seen in many 
manic patients. (4)
	More women than men are diagnosed with this disorder, 
and the average age of onset is late adolescence to young 
adulthood.  Early treatment is considered best and most 
effective, for the obvious reason that this is a painful, 
harmful illness, but also due to the "kindling" hypothesis.  
This theory proposes that the more an individual has manic 
and depressed episodes, the more their neurophysiology 
becomes accustom to these states.  Therefore, they are more 
likely to reoccur.
	Bipolar disorder is a reality, affecting millions of 
lives each year.  Much is known about the behavioral, 
emotional, and cognitive effects.  However, the question 
plaguing many remains: what exactly is occurring 
physiologically in bipolar disorder?  The answer is 
evasive.  Biochemical, anatomical and neurological theories 
attempt to explain the organic basis for such an illness.  
None are completely conclusive, but following are some of 
the intriguing and more accepted hypothesis.
Some researches believe that a lack of serotonin in 
the limbic system causes hypersensitivity in neurons.  This 
would possibly lead to "exaggerated behavioral response" in 
the individual.  An electrolyte and membrane hypothesis 
posits that neuron membrane differences (bipolar patients 
had protein structural abnormalities in some studies) may 
be responsible for the chemical imbalance.  There are a 
plethora of amine theories, some describing catecholoamine 
deficiency.  Others examine changes in levels of dopamine, 
norepinephrine, seratonin, and acetylcholine.  
Phenylethylamine is the only trace amine studied 
extensively by psychiatry because of its similar 
construction to amphetamine and its dramatic emotional 
effects.  The data is more conclusive for unipolar 
depressed patients than bipolar, however.  It has been 
noted that hypothyroidism has been associated with 
depression and sometimes mania; poorly regulated thyroid 
function involves many characteristics of depression such 
as changes in sleeping patterns and loss of appetite.  
Sleeplessness, in fact, is a major precipitator of a manic 
episode in bipolar patients, and benzodiazepines have been 
proven very effective when given in addition to Lithium as 
an antimanic and sleep inducing agent.
Anticonvulsants such as carbamazepine and ECT have 
been increasingly popular in treating bipolar disorder.  
ECT has been proven very effective with both depressive and 
manic episodes, in breaking a particularly, perhaps 
suicidal episode, and effective in treating patients who 
are unresponsive to other drugs.  It is also effective in 
treating mixed mania, and safe for pregnant women. (2) 
Brain tumors and lesions provide us with interesting 
data.  In a study done with 85 people having a tumor in 
their frontal lobe, 13 were depressed and 5 were manic or 
hypomanic.  Another study with 110 individuals with tumors 
in their temporal lobes revealed 21 were depressed and 6 
were hypomanic.  Dichotic listening studies show 
(inconclusively) impaired functioning in the right 
hemisphere of the brain.  One study on handidness indicated 
people with bipolar disorder more likely than normal to be 
left handed.  Two patients apparently switched hand 
preference when transitioning from depression to mania.
Central blood flow (CBF) and metabolism has been 
studied in correlation to the disease.  Two "rapid cycling" 
patients (meaning they switched from depressed to manic 
states rapidly) showed approximately 36% higher global 
metabolic rates on a subjective good, happy day than on a 
bad day.  However, on average, metabolism in the frontal 
lobe was 40% lower than normal.  This indicates lessened 
activity in the frontal lobe may be associated with bipolar 
depression.  A "robust finding" due to MRI research showed 
that the caudate nucleus in the affective disorder group 
got smaller.  New technological advances such as these are 
radically adding to knowledge about brain activity and 
physiology.  (1)
Other theories point to the importance of 
(predominantly natural) light and people's sensitivity to 
it.  It is thought that bipolar patients perhaps have a 
very high vulnerability to external stresses.  As with SAD 
(Seasonal Affective Disorder), depressions occur less 
during the summer months in bipolar patients.  Bipolar 
patients are poorly prepared for changes in circadian 
rhythms such as night, day, summer, and winter.  This 
proposes disturbances of regulatory and adaptive 
mechanisms. Some patients may respond positively from such 
simple treatment as using a light box on days when they are 
depressed.(2)
As discussed before, the rate of bipolar patients who 
abuse alcohol and drugs is high.  Some researches theorize 
that cocaine use may be directly linked to the earlier age 
of onset in bipolar disease.  This leads to the more 
inclusive "cohort effect", which describes how there are 
more affective disorders diagnosed now than ever before, 
and this might be related to environmental stress.  In the 
last four decades, alcohol consumption, tobacco, and drug 
use has inclined, perhaps catalyzing the onset of these 
illnesses.  Drug use is extremely dangerous in bipolar 
individuals; very commonly it directly induces a manic or 
depressive episode.  In fact, 43% of bipolar patients who 
abuse drugs and alcohol commit suicide.
Fundamentally, we do not yet know what, exactly, 
causes bipolar disorder.  According to popular belief, we 
have learned more in the last 10 years about the 
organization and operation of the brain than ever before.  
As research, testing, and innovative procedures evolve, 
more information is sure to be generated.  
Fortunately, we have found substances that greatly 
help bipolar patients.  By far, the most popular and 
effective treatment is Lithium.  Lithium is sodium based, 
and "alters monoamine metabolism…sustains nerve impulse 
conduction and affects the endocrine system; produces 
significant changes in electrolyte balance and metabolism, 
and it may alter intermediary metabolism." (5) Lithium 
works as an antimanic and antidepressant agent, and also 
works to decrease cycle frequency.  Other drugs, such as 
Carbamazepine and Valproate have been gaining popularity as 
alternatives for Lithium for specific patient needs.  It 
has been stated that for bipolar disorder the generally 
desired outcome of treatment should be "nothing in excess."  
Lithium, for most patients, provides a stable mindset, 
where their mood swings are easier to control.
If Lithium is discontinued approximately 50% of people 
will relapse.  The real problem evolves however, when 
Lithium ceases to perform its duty when given again.  Why 
this happens is not understood, but now it is generally 
accepted that Lithium should not be discontinued (unless 
absolutely necessary or completely ineffective.)      
Approximately 1,000 tests involving Lithium's effects 
are done annually to better understand it, and its 
interaction with other drugs.  Neuroleptics (antipsychotic 
drugs) are sometimes administered if the patient seems to 
be acting in a possibly dangerous way.  Some doctors feel 
that Lithium, given in conjunction with an antidepressant, 
anticonvulsant, or thyroid hormone is the best form of 
treatment.  Fundamentally, each patient is different, and 
should be treated accordingly.  (6)
Diagnosing people with bipolar disorder involves 
recognizing typical characteristics of the illness.  The 
ten most prominent manifestations of the disorder are: 
"suicidal thoughts, insomnia, hypersexuality, grandiosity, 
racing thoughts, confused thinking, irritability, auditory 
hallucinations, drug and alcohol abuse, and poor response 
to standard treatment." (2)
	Informing the patient of their diagnosis in a 
supportive, compassionate way is usually conducive to 
patient compliance, and results in the most beneficial and 
effective treatment possible.  This involves ensuring the 
individual understands that bipolar disease is a chronic 
disorder, and that treatments are not a cure.  Both family 
and people in the work place are affected, sometimes 
acutely.  Working with the family in a therapeutic setting 
is helpful, as is educating the person's loved ones about 
the disease.  Alertness to early symptoms, and information 
about possible side effects is also necessary.  Educating 
the patient about the importance of compliance with 
medicine is also crucial; people with bipolar disorder have 
an almost 50% noncompliance rate. 
	Someday molecular genetic studies may allow us to 
detect a specific chromosomal abnormality that explains 
bipolar disorder.  People could be treated before any 
symptoms of the disease manifested, and the pathophysiology 
of the illness could be explained.  However, this may not 
be possible for another 30 or 40 years, and bipolar 
disorder may never be linked to a specific neurological 
disfunction. 
Fortunately medical science has found effective methods of 
treatment, and is continuing to explore new and innovative 
techniques that will hopefully make bipolar disorder a less 
ominous and enigmatic illness.      
	
Bibliograghy

1. Goodwin, Frederick K.  Manic Depressive Illness
New York: Oxford University Press, 1990.

2."Brain Body Connection" PBS,1997.

3. Goodnick, Paul J.  Mania, Clinical and Research 
Perspectives.
London: American Psychiatric Press, Inc.1998.

4. Goldberg, Joseph.  Bipolar Disorders.
London: American Psychiatric Press, Inc. 1999.

5. Zubin, Joseph.  Disorders of Mood.
Baltimore: The John Hopkins Press, 1969.

6. Georgotas, Anastasios.  Depression and Mania.
New York: Elseveir, 1998.

Copyright © 1999, Dr. John M. Morgan, All rights reserved - This page last edited 13 - December, 1999
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