Download Running Head: BIPOLAR DISORDER - People

Living with Bipolar
Running head: BIPOLAR DISORDER
Living with Bipolar Disorder
Mary T. Johnson
Creighton University
1
Living with Bipolar
2
Abstract
This paper discusses Bipolar Disorder, including the differences between Bipolar I and
Bipolar II Disorders, as well as the characteristics and behavior of certain episodes
associated with the disorders. The DSM-IV-TR is used to characterize each disorder and
episode accurately. The paper provides information regarding the biological evidence and
possible genetic predispositions and links of the disorder, personal accounts of individual
people who suffer from Bipolar Disorder, how it affects their lives, and the stigmas
placed upon people with mental illness by our society.
Living with Bipolar
3
Living with Bipolar Disorder
Every human is different despite the thousands of genes we all have in common.
From the color of our eyes, to the straightness of our hair, to the brittleness of our
fingernails, each human has a unique make-up of genes to create the person we are. Some
people have genes that possess a disposition to certain diseases like Huntington’s
Disease. There are multitudes of diseases people live with on a daily basis for which
scientists are searching for a genetic link. Bipolar Disorder falls into this category.
Studies emphasizing the search for a specific gene or allele to predispose a person to
Bipolar Disorder, as well as the examination of potential familial risk of the disease, have
emerged in recent years. Scientists have devoted much time and effort to the disease to
discover that Bipolar Disorder is a varied disorder, affecting each person differently, but
creating the same patterns of behavior and making them feel the same extremes of
emotions.
Bipolar Disorder is a disease characterized by cycles of depression and mania.
There are two varying degrees of Bipolar Disorder, each characterized slightly differently
as Bipolar I or Bipolar II. Bipolar I Disorder, as described by the DSM-IV-TR (American
Psychiatric Association, 1994), is “a clinical course that is characterized by the
occurrence of one or more Manic Episodes or Mixed Episodes.” Bipolar II Disorder is “a
clinical course that is characterized by the occurrence of one or more Major Depressive
Episodes accompanied by at least one Hypomanic Episode,” as stated in the DSM-IV-TR
(American Psychiatric Association, 1994, p. 392).
Major depressive episodes are periods when a person undergoes a number of
symptoms, including change of mood, loss of interest or pleasure in his/her usual
Living with Bipolar
4
activities, diminished ability to think or concentrate, insomnia or hypersomnia, and
recurrent thoughts of death or suicidal ideation. Manic episodes are periods of
abnormally and persistently elevated and/or irritated mood with symptoms including
inflated self-esteem, flight of ideas, decreased need for sleep, ease of distraction, and
engagement in activities with potentially risky consequences. The episode must be severe
enough to cause impairment in occupational functioning or necessitate hospitalization to
prevent harm to the person or others. Mixed episodes are periods when a person
fluctuates between symptoms of both a Manic episode and a Major depressive episode
nearly every day in a one week time span. Hypomanic episodes are periods very similar
to Manic episodes but without the severity of the episode to necessitate hospitalization
(American Psychiatric Association, 1994).
As with many diseases today, there is an ongoing investigation to discover where
Bipolar Disorder comes from and whether or not it is genetically linked. A study
conducted on families with Bipolar Disorder in New Zealand tested the frequency of
Manic and Depressive episodes in persons diagnosed with Bipolar Disorder and their
relatives (Edmonds, 1998). The 44 persons interviewed with Bipolar I Disorder compared
with 1 person of the 67 relatives interviewed who also had Bipolar I Disorder. The
eleven people with Bipolar II Disorder had four relatives who were also diagnosed with
Bipolar II Disorder. Of the 67 relatives interviewed in the study, 34.3% (23 people) met
the DSM-IV criteria for major depression. An additional 16.4% (11 people) of the
relatives met qualifications for sub-threshold depression. This study shows a fairly high
rate of relatives suffering symptoms of psychological affective disorders similar to their
relatives with either Bipolar I or Bipolar II Disorder.
Living with Bipolar
5
In addition to the aforementioned study, other studies have been conducted to find
the concordance rate in monozygotic twins to be greater than 65% while dizygotic twin
concordance ranges around 14% (Kakiuchi et al., 2003). Kakiuchi et al. (2003) conducted
a study to monitor two genes as genetic risks for Bipolar Disorder in Japanese people. In
the study, the expression of ATF6, SBP1 and HSPA5 in lymphoblastoid cells was tested
by quantitative RT-PCR. The results showed that after ER (a protein folding system)
stress “was induced by thapsigargin…the cells derived from individuals with bipolar
disorder had a significantly smaller increase in XBP1 and HSPA5 mRNA levels but no
difference in the ATF6 levels” (p. 172). This increase in mRNA levels suggests the XBP1
region could be responsible for an impaired response in people with Bipolar Disorder.
Similarly, Kakiuchi et al. (2003) found in Japanese case-control samples
“genotype frequency of individuals with bipolar disorder did not meet the HardyWeinberg equilibrium because the C/G genotype was rare in this group” (p. 172). They
concluded that “either the G allele is a risk allele for bipolar disorder or the C/C genotype
is a protective factor” (p. 172). Their study pushed thinking forward to pinpoint either an
allele that can greatly influence a person to have Bipolar Disorder, or a certain genotype
that would potentially prevent a person from having Bipolar Disorder.
Based on genetic studies, rough estimates of risk have been developed and
predicted for family members with Bipolar Disorder. Castle (2003) reports that “80 to 90
percent of people with bipolar disorder have one or more family members with a mood
disorder” (p. 121). A child of either a mother or father with Bipolar Disorder runs a 1530% risk of developing the disorder, while if the both of the child’s parents are Bipolar,
he or she runs a 50-75% risk. A sibling of a Bipolar person that is not a twin has the same
Living with Bipolar
risk as if one parent were Bipolar, 15-30%, and a second-degree relative has a 3-7% risk
(Castle, 2003).
Aside from genetic components and behavioral differences, Bipolar Disorder
manifests itself in the brain as well. A study was conducted to compare differences
between Bipolar people and non-Bipolar people regarding the volume of the amygdala
and hippocampus in each person (Blumberg, 2003). After measuring amygdala and
hippocampal volumes on high-resolution anatomic magnetic resonance imaging scans
and comparing across a sample, Blumberg et al. (2003) suggest Bipolar Disorder is
associated “with decreased volumes of medial temporal lobe structures, with greater
effect sizes in the amygdala than in the hippocampus” (p. 1201). The findings were
consistent in both adolescents and adults with the disease.
These findings are interesting because of the implications of the structures
influenced by the disorder. The amygdala regulates emotion, assigning meaning to
objects and events, and issuing even the most subtle of emotions. The hippocampus
relays information between other parts of the limbic system and the cerebral cortex
(Castle, 2003). It helps “link emotions to images, memory, and learning. Together the
amygdala and hippocampus help you assess the environment, tap into your senses, and
generate and encode emotions. A properly functioning hippocampus helps you maintain
emotional equilibrium by regulating extreme arousal states” (pp. 106-107). If these two
are not functioning properly or are decreased in volume sizes, it is easy to see how a
person’s feelings can become out of control and irregular, similar to the emotional roller
coaster a Bipolar person rides in his or her lifetime.
6
Living with Bipolar
7
In another study, using magnetic resonance spectroscopy of the frontal cortex,
frontal white matter, and the cerebellar vermis, metabolite ratios and concentrations were
measured in groups of children with mood disorders with a Bipolar parent and compared
with those of healthy children (Cecil, DelBello, Sellars & Strakowski, 2003). The results
found that the trend in concentration levels of NAA (N-acetylaspartate) and Cr (creatine
and phosphocreatine) within the cerebellar vermis was about 8% lower for children with
a mood disorder than for children without a mood disorder. “The frontal cortex in
children with a mood disorder revealed elevated mI [myo-inositol] concentration levels,
approximately 16% increased, compared with healthy children” (Cecil, et al., 2003, p.
545). Cecil et al. (2003) found results similar to those in adults with Bipolar Disorders,
with neurochemical abnormalities within the frontal cortext and the cerebellar vermis in
children with a mood disorder and familial risk for Bipolar Disorder.
Brain chemistry, too, can show insight into Bipolar Disorder. Dopamine is a
neurotransmitter that “appears to underlie addictive behaviors that often accompany
mood disorders…Chronically low dopamine levels lead to difficulty experiencing
emotional or physical satisfaction” (Castle, 2003, p. 113). It also affects motor
movements, learning, thinking, memory, attention span, motivation, and sexual impulses.
Norepinephrine influences and promotes the fight-or-flight response when humans are
under stress, similar to adrenaline, and also helps form long-term memories. However,
“[T]oo much dopamine and norepinephrine can lead to mania and psychosis; too little
can produce depressive symptoms and negativity…” (Castle, 2003, p. 114). This
correlation shows another aspect of Bipolar Disorder and how variation from the norm
Living with Bipolar
8
could lead to reactions and symptoms like those suffered by people with Bipolar
Disorder.
Treatment options are available to people affected by Bipolar Disorder. From
taking mild measures in medication and talk therapy to extreme measures in
electroconvulsive therapy, transcranial magnetic stimulation, and vagral nerve
stimulation, treating Bipolar Disorder is as personal as experiencing the disorder. A
certain class of medications used to treat Bipolar Disorder primarily is called
psychotropic medicines (Castle, 2003). These medications that affect the mind include
mood-stabilizing agents, mood-stabilizing anticonvulsants, antidepressants,
antipsychotics, antianxiety agents, and hypnotics. To determine which medications are
correct for each patient, “doctors use a treatment algorithm – or flowchart” (Castle, 2003,
p. 195). Mood stabilizing agents are most often used for Bipolar Disorder sufferers to
help both control and prevent the cycles of mania and depression. Lithium is currently the
only natural and pure mood stabilizer available (Castle, 2003). “In addition to interacting
with neurotransmitter receptors and presynaptic reuptake pumps on nerve cells surfaces,
as many psychotropic medications do, lithium…appears to work inside neurons
themselves, essentially reprogramming them” (Castle, 2003, p. 195). Many scientists
believe lithium prevents the early stages of developing further mood episodes. Doctors
often prescribe antidepressants, which relieve depressive symptoms, with mood
stabilizers to control and prevent mood swings, as for many Bipolar Disorder patients one
medication will not relieve all symptoms (Castle, 2003). There are many other
medication options for people with Bipolar Disorder, the efficacy of which is dependent
upon the symptoms and severity of the disorder.
Living with Bipolar
9
In the future, it may be advisable for scientists to continue their studies in
pinpointing a specific gene or allele that may predispose, or even prevent disposition, to
the disorder. If people were alerted of the disorder early in life, perhaps talk therapy
could be utilized to ensure the potentially-affected person will maintain a healthy lifestyle
and have all the resources available to him or her while growing up. As for treatment of
the disease, if scientists continued to focus on the neurotransmitter receptor sites and
neurochemistry within the brain to see the different reactions from different chemicals
and hormones, more helpful and effective medications could be developed to help people
with Bipolar Disorder live a stable and happy life undisturbed of depression and
excessive mania.
Outside of the biological and scientific explanation for Bipolar Disorder is the
experience of a person with the disorder and the way it affects his/her life. Reading what
the symptoms to characterize Bipolar Disorder are and experiencing them are greatly
differently situations. The Manic and Depressive episodes place a person with Bipolar on
a veritable emotional rollercoaster, soaring above the clouds in extreme euphoria to be
quickly dropped beneath the ground in a dark tunnel of unhappiness. Lana Castle (2003)
describes her battle with Bipolar and the intense feelings of the Manic and Depressive
episodes as a tightrope she must walk. According to her experiences, mania makes
Bipolar people believe, “Fear is silly! Fear is for fools! There’s no need to be
afraid…Today you will not fall; you won’t so much as slip! Today you will perform as
no one has before…At long last, your life is working!” (p. 10). She even dissects the
feelings of a Depressive episode and how “[A] clutching blackness surrounds you. You
try to escape, but it’s as if your legs are encased in thick cement. All is darkness, grief,
Living with Bipolar
10
and pain. Tears flow in rivulets from your eyes. The only relief you can imagine is
sleep—or, better yet, death” (p. 23). The experience of a Bipolar person is an intense
struggle compared to the tame words which diagnose the disorder.
Another woman, whose anonymity has been requested, described her experience
with the disorder. Without medical treatment, her suicidal tendencies would consume her.
Her depressive states would dominate and overwhelm her, drawing her closer to her
suicidal tendencies. She says the manic stage is when she felt normal. This manic period
is when she had good moods, when she was finally happy. She loves the mania, the
“energetic, happy, elated feeling when she could do anything she wanted” (Johnson,
2004, p. 1). In her mania, she took ideas for projects and turned them into something
amazing, not stopping until they were finished, not sleeping until she felt they were all
done. “The creative flow kept going; it never stopped. There were never any
interruptions. She went pedal to the metal until completion” (p. 2). Her life is a constant
struggle trying to balance the exalted feeling of mania with the downtrodden, oppressive
sadness of depression.
Bipolar Disorder also affects the people around those diagnosed with the disorder.
Families are put under stress, relationships are tested, and occupational conditions are
tried. The people with whom a person with Bipolar Disorder works can quickly be
affected by the disease while colleagues try to find simple solutions to volatile tempers,
soaring emotions, and rapidly downward-spiraling self-esteem. Relationships are placed
under the gun when a person exhibits Bipolar Disorder. Simple miscommunication can
lead to a fiery exchange of hollow, angry words from one person to the other. The ups
and downs of the Manic and Depressive cycles can wear a person thin as he/she tries to
Living with Bipolar
11
help the afflicted person battle with the depression and subdue the mania. Families,
especially, are placed into a pressured situation as their entire dynamics are thrown into
question and compromise. When one parent or child exhibits Bipolar Disorder, other
family members begin to walk on the proverbial eggshells in order to not upset the person
with Bipolar Disorder. Again, the heated exchanges with a person in mania can lead to
misunderstood intentions as well as confused interpretations or hurt feelings. Lives can
be immensely affected by a person with Bipolar Disorder, especially in close, day-to-day
relationships.
Many diseases in our society come with a label and a myriad of preconceived
notions. Mental illnesses are no exception. Bipolar Disorder is not either. Only since the
1950s have people suffering from mental illness been treated humanely. The history of
mental disease has brought people to being burnt at the stake to having holes drilled in
their skulls to release the demons to being subjected to electroshock therapy (Castle,
2003). People with mental illness travel with a stigma on their chests. “United States
citizens tend to pride themselves on self-sufficiency and therefore sometimes reject and
shun people who can’t do as well. Rather than express empathy and acceptance, those
with healthy brains dole out blame and disapproval” (Castle, 2003, p. 334). Oftentimes
people are branded as crazy, psychotic, or weak-willed because they possess a mental
illness. There is a high degree of misunderstanding among the general public regarding
mental illness. Shorter terms and inaccurate nicknames have been adopted to avoid the
lengthy technical words that precisely explain the situation. More than just name-calling,
“[O]ur society still tends to exclude people with mental illness from the
workplace…Society resists investing in sorely needed services that could improve and
Living with Bipolar
12
save many lives” (Castle, 2003, p. 336). An element of fear of violence and incompetence
keeps society from incorporating and rehabilitating those with mental illness into the
normal social structure. Instead, they are placed on the outsides, scoffed and laughed at,
feeling shame and embarrassment because of who they are. Facing the stigma is an
enormous battle almost as oppressive as dealing with the disorder itself.
Bipolar Disorder is a dynamic disease that affects each afflicted person in a
variety of ways, yet similarly to others with the same disease. The ranges of emotions felt
are often the same, and the lives of those surrounding a person with Bipolar Disorder are
affected likewise. The disorder itself comes with a spectrum of probable causes and
observed evidence within the person and exhibited in his/her behavior. It is a daily battle
to fight Bipolar Disorder, by the person afflicted and those people close to that person.
Although it is a daily battle, it is a battle that can be won.
Living with Bipolar
13
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC: author.
Blumberg, H. P., Kaufman, J., Martin, A., Whiteman, R., Hongyuan Zhang, J., Gore, J. C.,
Charney, D. S., Krystal, J. H. & Peterson, B. S. (2003). Amygdala and
hippocampal volumes in adolescents and adults with bipolar disorder. Archives of
General Psychiatry, 60, 1201-1208.
Castle, L. R. (2003). Bipolar disorder demystified: Master the tightrope of manic
depression. New York, NY: Marlowe.
Cecil, K. M., DelBello, M. P., Sellars, M. C. & Strakowski, S. M. (2003). Proton magnetic
resonance spectroscopy of the frontal lobe and cerebellar vermis in children with
a mood disorder and a familial risk for bipolar disorders. Journal of Child and
Adolescent Psychopharmacology, 13, 545-555.
Edmonds, L. K., Mosley, B. J., Admiraal, A. J., Olds, R. J., Romans, S. E., Silverstone, T.
& Walsh, A. E. S. (1998). Familial bipolar disorder: Preliminary results from the
Otago Familial Bipolar Genetic Study. Australia and New Zealand Journal of
Psychiatry, 32, 823-829.
Johnson, M. T. (2004). Untitled commentary. Retrieved April 4, 2004 from
http://www.icherney.com/Teaching/Courses/Genes/Genes_homepage.htm
Kakiuchi, C., Iwamoto, K., Ishiwata, M., Bundo, Miki, Kasahara, T., Kusumi, I., Tsujita, T.
Okazaki, Y., Nanko, S., Kunugi, H., Sasaki, T. & Kato, T. (2003). Impaired
feedback regulation of XBP1 as a genetic risk factor for bipolar disorder. Nature
Genetics, 35, 171-174.