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Treatment of Bipolar Disorder Episodes

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Introduction

In any given year, one in five people in Canada will experience a mental health problem or illness, and about one percent of Canadians will experience Bipolar Disorder. Bipolar 1 Disorder formerly known as “manic depressive” disorder is characterized by one manic episode, which is usually followed by a major depressive episode but not always. “A person experiencing a manic episode often has feelings of self importance, elation, talkativeness, coupled with the characteristics of irritability, impulsiveness, and a decreased need for sleep”. Sometimes a person may experience both manic and depressive episodes at the same time, those are called mixed episodes. Someone experiencing a mixed episode may feel extremely energized while at the same time feeling sad, agitated, they may have changes in appetite as well as reoccurring suicidal thoughts. This paper will explore Bipolar 1 Disorder such as manic episodes, depressive episodes, mixed episodes, along with the recommended treatment.

Bipolar 1 Disorder

Bipolar 1 Disorder once known as “manic depressive disorder” is a mental disorder and a “bio-chemical condition that results in an imbalance of neurotransmitters in the brain.” People who suffer from Bipolar 1 disorder have periods of significant elevated moods which is known as manic episodes, and periods of “sad or hopeless” moods known as depressive episodes. “Sometimes a mood episode includes symptoms of both mania and depression, this is called a mixed episode.” Psychotherapy and medications such as mood stabilizers and antipsychotics are most commonly used for treatment. To treat bipolar, some psychotherapy treatments may be used such as Cognitive Behavioural Therapy (CBT), family-focused therapy, or interpersonal and social rhythm therapy.

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Manic Episodes

A person who suffers from Bipolar 1 Disorder can have periods of elevated moods, known as mania. Mania can bring on an intense feeling of energy and the person may feel “wired” or “jumpy”. Someone experiencing mania may have an “exaggerated sense of well-being and self confidence”. Some criteria for manic episodes according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition would be “inflated self-esteem or grandiosity, a decrease need for sleep, they may be more talkative then usual, their thoughts could be racing and they can seem very distracted, they may also have an increased involvement of goal-directed activity, and excessive involvement in pleasurable activities that have a high potential for painful consequences.” Bipolar symptoms in children and adolescents are different then those experienced by an adult. Within this age group manic episodes, may show more psychotic symptoms which can sometimes lead to being misdiagnosed with schizophrenia. Also, dysphoric mania is common in adolescents and is characterized by irritability and anger instead of elation. Certain people with Bipolar Disorder experience a less severe type of mania called hypomania. During a hypomanic episode a person may feel good, be very productive, and seem to be functioning well. “But friends and family may recognize the mood swings as possible signs of bipolar disorder.” Hypomania can develop into severe mania or depression if not properly treated.

Treatment

There are many different treatment options for someone who is experiencing a manic episode, certain medications may work while others may not. “Lithium plus an atypical antipsychotic lorazepam is indicated. For cases presenting with nonresponse to lithium, dysphoric mania, or rapid cycling, valproate is recommended.” “Lithium was the first mood stabilizer approved by the U.S Food and Drug administration (FDA) for the treatment of mania and the prevention of both manic and depressive episodes”. Lithium should not be used for mixed episodes, as well it can take up to ten days to start working within the bloodstream, so it is often paired with “neuroleptics and/or benzodiazepines” for a more immediate relief of manic episode.

Depressive Episodes

Some criteria for a diagnosis of a major depressive episode according to the DSM-IV-TR would be a “depressed mood, markedly diminished interest or pleasure in all, or almost all activities, weight loss when not dieting, insomnia or hypersomnia, fatigue or loss of energy, feelings of worthless or excessive inappropriate guilt, diminished ability to think or concentrate and reoccurring thoughts of death.” Manic and depressive episodes may last from days to months, and “run the spectrum from mild to severe.” A Bipolar depressive episode may be harder to distinguish from a major depressive episode. People who experience bipolar depression tend to have very low energy, their mental and physical processes may slow down, and have more profound fatigue. “An example would be hypersomnia, a sleep disorder marked by a need for excessive sleep, or sleepiness when awake.”

“Suicide is a major complication with Bipolar Disorder and is a result of the duration of the depressive episode. The longer the depressive episode lasts, the higher chance of suicidal tendencies to appear. Alcoholics and patience with other chronic medical diseases are particularly prone to planning and implementing a suicide attempt.” Research has shown that there are four groups that are most likely to plan and carry out a suicide attempt and those are, individuals who are overwhelmed by life problems. In this group suicide is related to aggression and impulsive behaviours and not major depressive episodes. Individuals that attempt to control others. Individuals that are very ill with other medical health issues. And individuals with other types of psychotic illness, paranoia, and delusions.

Treatment

“Antidepressants are sometimes used to treat symptoms of depression in Bipolar Disorder.” Some antidepressants that may be used to treat depression in Bipolar are: Fluoxetine sometimes known as Prozac, Paroxetine also known as Paxil, Sertraline or Zoloft and Bupropion or sometimes known as Wellbutrin. Doctors recommend taking mood stabilizers along with antidepressants to prevent switching to mania or develop rapid cycling. There are also side effects from taking antidepressants and side effects may include headache, nausea, agitation as well, antidepressants may cause sexual health problems in both men and women.

Mixed Episodes

“During a mixed state you may feel very agitated, have trouble sleeping, experience major changes in appetite, and have suicidal thoughts. People in a mixed state may feel very sad or hopeless while at the same time feeling very energized”. Valproate is one of the few drugs available that has proven to treat rapid cycling bipolar and mixed episodes. It is prescribed by its self or with carbamazepine and or lithium. The combination of depression, energy, and agitation makes someone experiencing a mixed episode at a higher risk for suicide.

Rapid Cycling

“Rapid cycling occurs in up to twenty percent of bipolar individuals. In rapid cycling, at least four manic and depressive mood swings must occur within twelve months. In some cases of ultra-rapid cycling, the individual may bounce manic and depressive states several times within twenty-four-hour period.” Rapid cycling is very severe as it can impair your ability to function as well as lower your quality of life. “Rapid cycling seems to be more common in people who have their first bipolar episode at a younger age.” More women are affected by Rapid Cycling then men.

Psychotic Symptoms and Psychosis

Major episodes of depression or mania can also include symptoms of psychosis. Psychotic symptoms can include auditory or visual “hallucinations and delusions.” Psychotic symptoms in bipolar are a result of the current major mood episode. When a person is experiencing a manic episode, some psychotic symptoms may include grandiosity, the belief of having special powers or extreme wealth or power. During a depressive episode, psychotic symptoms may include paranoia, fears of being poisoned or attacked, or belief that one has committed a crime. Because of these symptoms sometimes bipolar is misdiagnosed as schizophrenia.

“Psychosis is defined as the loss of contact with reality, during which time a person can not tell the difference between what is real and what is imagined.””During a period of psychosis, a person’s thoughts and perceptions are disturbed. Other symptoms include incoherent or nonsense speech, and behaviour that is inappropriate for the situation.” Psychosis is usually accompanied by severe mania but can also come with depression, and include symptoms of delusions, and hallucinations. During a psychotic episode, atypical antipsychotics may be used to treat psychotic symptoms and acute mania and contribute in stabilizing the mood.

Psychotherapy

“When done in combination with medication, psychotherapy can be an effective treatment for bipolar disorder”. Psychotherapy provides education, support as well as guidance to people suffering with the disorder. Some psychotherapy treatments would include Cognitive Behavioural Therapy (CBT), which can help individuals learn how to change harmful or negative behaviour and thought patterns. Family focused therapy which involves family members, it helps improve communication with family members, it also helps families learn coping strategies such as “recognizing new episodes early” so they can help. Interpersonal and social rhythm therapy which helps individuals improve their personal relationships along with “managing their daily routines”.

Following a regular daily schedule, and a good sleep schedule, can help prevent manic episodes. Psychoeducation teaches people about their illness and treatment. It can help individuals recognize signs that an episode is coming on early and get treatment “before a full-blown episode occurs”. Sometimes medication and psychotherapy may not work, when that happens Electroconvulsive Therapy (ECT) may be used. ECT formerly known as “shock therapy” had a bad reputation at one time but has improved in recent years. Electroconvulsive therapy can provide relief for a person with Bipolar disorder who has tried other medications that have not worked. ECT is a highly effective treatment for major depressive, manic and mixed episodes, but it “not used as a first-line treatment”.

Causes

The source of Bipolar Disorder has not yet been identified clearly, but research shows genetic and environmental factors seem to be involved when it comes to triggering episodes. “Bipolar tends to run in families, some research has suggested that people with certain genes are more likely to develop Bipolar disorder than others.” Children who has a parent with Bipolar Disorder is at a greater risk for developing the disease. Many studies show “possible genetic connections to the predisposition of bipolar disorder.” A study done in Sweden that was reported in 2009, showed that bipolar disorder and schizophrenia seem to “share similar genetic causes.” Substance abuse is common in people with Bipolar Disorder, but it is still unknown to why. “It seems people with bipolar disorder may try to treat their symptoms with drugs and alcohol. However, substance abuse may trigger or prolong bipolar symptoms, and problems with controlling behavior associated with mania can lead to a person drinking to much.” Sometimes manic and depressive episodes coincide with seasonal changes for people with bipolar. During winter and fall, depressive episodes are more common and during the summer and spring months manic episodes seem to be more probable. Individuals that experience this may be “diagnosed with seasonal affective disorder (SAD).”

Conclusion

This paper explored the symptoms of Bipolar 1 Disorder such as mania, depression, and mixed episodes. It also looked at the causes of Bipolar Disorder, psychotic symptoms, and treatments such as medications and psychotherapy. Manic episodes include feeling of euphoria and high energy, the person may act very erratically and talk very fast. Depressive episodes include feeling of sad and hopelessness, the person may have feelings of guilt and may feel worthless. They may be very tired and have reoccurring thoughts of death. And a mixed episode is when someone experiences symptoms of both mania and depression at the same time. They may feel sad and hopeless at the same time feeling very energized. Someone with Bipolar Disorder may also have psychotic symptoms where they loose touch with reality. Because of these complex symptoms, Bipolar Disorder can sometimes be misdiagnosed as schizophrenia. There is no cure for Bipolar Disorder, but it can be effectively treated overtime. When Bipolar Disorder is properly treated, people can gain back control of their lives, and live a much healthier life.

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