Bipolar Disorder I: Causes and Treatment - Research Paper Example

? Bipolar Disorder I Introduction Bipolar disorder is a mental disease that has been categorized as a mood disorder in psychiatry (Pomeroy and Wamba, 2002); this mental illness is a lifelong disorder because lasts throughout one’s lifetime and it is mood disorders are the most prevalent chronic psychiatric disorders of adult life (Craddock & Forty, 2006). There are several types of bipolar disorders including bipolar I disorder and bipolar II disorder; both of them are characterized by alternating episodes of depression and mania (Pomeroy and Wamba, 2002), which is a heightened or exaggerated mood. Other names for this mental condition include bipolar affective disorder and manic-depressive disorder, though sometimes it is simply referred to as manic depression. Individuals with bipolar disorder experience mania at different levels of severity ranging from mild, the most productive state commonly described as ‘hypomania’, to extremely high levels that lead to erratic and impulsive actions. The bipolar disorder is present in about 4% of the global population, with an equal prevalence in both men and women irrespective of cultural and ethno linguistic differences. This research paper will address aspects of the bipolar I disorder such its etiology including genetic, biological, psychological, and social factors; additionally, this paper will highlight and critique both the pros and cons of two significant assessment tools used in the diagnosis of this disorder. Ultimately, the research will also explore the various treatment options or interventions that are best suitable for treating people with the bipolar mental disorder. Etiology There are several causes of the bipolar disorder, among them genetic, biological, psychological, and social factors; all these factors contribute to the prevalence of this illness in the populations. Genetic factors Bipolar I disorder has been linked to the genes ANK3, CLOCK, as well as the CACNAIC gene, and several forms of evidence support the significant role played by genetics in the bipolar disorder (Soreff, 2013). Evidently, first degree relatives such as immediate family members of individuals with this condition are predisposed to the bipolar I disorder about 7 times more than the rest of the population. Parents with this disorder give forth children with a 50% chance of having other leading Psychiatric disorders and twin studies reveal that identical twins have a 33-90% chance of bipolar I disorder. Adoption studies have also demonstrated that a common environment is not the sole determiner of bipolar disorder in families as children whose parents suffer Bipolar disorder or major psychological illnesses stand a greater risk of suffering the same. A group of scientists has managed to demonstrate that schizoaffective disorder and other mental disorders such as manic and schizoaffective syndromes are caused by similar genetic risk factors. Apart from that, gene expression reviews have also shown that the expression of genes, which are related to oligodendrocyte-myelin in individuals with the bipolar mental disorder, depression, and schizophrenics, is reduced along a similar scale. In addition to that, these individuals also have a similar reduction in the abnormalities of white matter in several areas of the brain. As it is emerging in these various instances, the bipolar I disorder is largely associated with the genetic component, an indicator of the strong connection that exists between the two. Biological factors Biological factors refer to all the potential imbalances in the biochemical composition of the brain that predisposes an individual to unprecedented mood swings; in such cases, any disruption in the equilibrium of the chemical composition of the brain or a dysfunction of these chemicals may cause alternating episodes of high or low moods. The bipolar disorder has been linked to several biochemical causes, thus, the exercise of singling out one particular disorder is such a daunting task; if you consider the different ways in which patients react to psychoactive agents, more than one neurotransmitter have been associated with the bipolar disorder. For instance, mania can be a sign of rising levels of monoamines such as serotonin, dopamine, or even norepinephrine in the body, which could potentially be triggered by medication used to manage depression and drugs of abuse such as cocaine. In yet another case scenario, bipolar I disorder and depression have both been found to be highly linked to high levels of glutamate, while a disruption of calcium regulation in neurons has been largely accused for the onset of mania. A number of neurologic upsets such as excessive glutaminergic transmission or ischemia are part of the potential risk factors for the disruption of calcium regulation. In addition, hormonal imbalances and disruptions of the equilibrium in homeostasis, in addition to the response to stress have been mentioned as part of the factors that contribute to bipolar disorder in previous findings. From the biological perspective, the bipolar disorder primarily occurs in a specific area of the brain and is due to the loss of essential functions by certain neurotransmitters, simply known as the chemical messengers in the brain. The bipolar disorder may be dormant for long if it appears as a biological disorder and may be activated by factors on the outside such as psychological stress. Psychological factors In recent developments, many practitioners have suggested that to understand the complex dynamics of the manic-depressive illness, one has to start from a framework that links to a common pathway; to this effect, depression is the physical manifestation of losses. For instance, depression in bipolar patients is a physical manifestation of the loss of self-esteem and sense of worthlessness. In this regard, mania is a self-defense mechanism that aims to protect an individual from feeling extremely depressed; a number of psychodynamic approaches have been put forwards to account for the etiology of bipolar depression. All these models begin from the assumption that the primary concern in bipolar disorder is depression, and that the manic episodes serve the purpose of safeguarding patients from depression. Taking a Freudian perspective, depression results from aggression from the struggle between the self, and the id; these episodes of depression represent the id’s dominance over the ego and super ego. On the other hand, the manic phase represents the ego’s struggle to defend itself from the id through defense mechanisms that are based on denial. In this regard, the manic phase is often characterized by exaggerated self-esteem and magnificent delusions; the ego invents fantasies that involve successes and power that aim to protect individuals from feelings of low self-esteem and worthlessness. The ego-defense perspective of the bipolar disorder is consistent with a number of clinical observations and one of the major contributors to this psychodynamic understanding of the bipolar disorder is known as Melanie Klein. Social factors External factors in the social environment of individuals such as stress or significant life events have also been identified as one of the factors contributing to bipolar disorder (Lauren et al, 2005); a genetic predisposition may be triggered by these factors or they may cause possible biological reactions that lead to bipolar disorder. Twin studies have highlighted the potential contribution of environmental factors to bipolar disorder because they have revealed that it is possible for one twin to have bipolar while the other does not. In this regard, it is clear that even though identical twins may both carry susceptibility genes due to their 100% DNA match, there is no guarantee that they may both turn out to have bipolar disorder. This implies that the environment plays a role in bipolar disorder because if this mental illness is purely genetic then it would mean that identical twins would automatically have bipolar, which is not the case. The sociological environment may cause bipolar disorder in various ways, for instance, a life event may elicit a mood swing in a person that is genetically pre-disposed to bipolar disorder (Steven and Nick, 2005). Still, in the absence of clear genetic factors, any alterations in health behavior, hormonal imbalances as well as alcohol and/or substance abuse may elicit mood swings. Bipolar disorder risk is further aggravated if an individual is abused or if they undergo mental stress, and if they suffer a significant loss or any traumatic event during their lifetime. For instance, traumatic events that could potentially elicit bipolar disorder include the loss of a loved one or a job, the birth of newborn, among others (Warren et al, 2005). Experts agree that given the same variables, many factors in the social environment may trigger bipolar disorder and despite that different individuals react to situations differently, once a bipolar disorder is triggered, it progresses on. Bipolar disorder Assessment tools The two most significant bipolar disorder screening tools that have been validated in the primary health care setting include the Mood Disorder Questionnaire (MDQ) and the Composite International Diagnostic Interview (CIDI) (American Psychiatric Association, 2013). These two screening instruments are useful tools in the evaluation and differentiation of mood symptoms experienced by patients after their symptoms, family history, course of treatment and even response to treatment have been examined. The Mood Disorder Questionnaire The MDQ tool is a structured patients’ self-report (Gerard et al, 2007), which is designed specifically to help the clinicians in the screening of both the mania and hypomania episodes experienced by their patients both at the present time and in the past (American Psychiatric Association, 2013). Using this tool in primary healthcare settings enables practitioners to identify those patients who are most likely to have bipolar disorder from the populations. This tool is built on three significant questions and the first question is further subdivided into 13 items, which describe mood and/or behavior; the patient is simply required to tick appropriately stating whether the said items were manifest in the previous period of mood swings. The remaining two questions that follow determine whether there is agreement between any of the symptoms identified by the patient in the first question and the level to which functions have been impaired by the symptoms. The MDQ screen is positive if a patient endorses not less than 7 symptomatic items, in addition to linking at least 2 of the symptoms identified with the severe functional impairment; the patient should also be able to rate at which their functions have been impaired on a scale ranging from mild to severe. Studies have shown that the MDQ has a sensitivity of 58% and about 93% specificity in screening of bipolar disorder in primary care; this validation matched closely with an earlier one that done in an outpatient psychiatric hospital. Critique of the Mood Disorder Questionnaire As discussed above, the MDQ screening instrument has been validated as a valuable tool that helps clinicians in primary care to identify patients with the highest predisposition to bipolar disorder. The MDQ bipolar screening instrument requires patients to give their own personal reports of manic symptoms and related function impairment to arrive at a manic episode. Nonetheless, the MDQ bipolar disorder screening instrument has both advantages and disadvantages in nearly equal measures. Advantages The first advantage of this tool is that it has a high sensitivity of about 58% and high specificity that is nearly 100% in the screening of bipolar disorder in primary care. This implies that MDQ screening has the potential to yield screens that have a strong concurrence with the symptoms of bipolar disorder identified in the first question; it also implies that this screening establishes the most truthful reflection of the severity of function impairment. Secondly, the MDQ screening instrument is highly sensitive to, and therefore the most effective diagnostic tool for type I bipolar disorder (Zimmerman & Galione, 2011), which is depression and mania. This is so particularly because MDQ asks about periods of exaggerated or heightened mood episodes, which typify bipolar I disorder and patients with this illness are happy to endorse these questions. Disadvantages One of the disadvantages of this screening instrument is that it is only best at diagnosing bipolar I disorder, but when it comes to the bipolar II disorder and other unspecified types, MDQ remains fairly insensitive. This limitation of the MDQ screening instrument can be attributed to the failure by bipolar II patients to endorse questions that ask about periods of elevated or exaggerated mood episodes. This is so particularly because bipolar II patients perceive their hypomanic episodes as their most productive periods where they experience relative normalcy. In this regard, bipolar II disorder patients are less likely to endorse questions that ask them about periods of elevated or exaggerated mood episodes leading to imprecise negative screens. In addition, the MDQ screening tool does not account for mania in the screening of bipolar illness, which is a very contentious issue overlooked by the DSM-IV, yet it is largely considered to be diagnostic. Averagely, MDQ is indeed a commendable milestone in the bipolar screening and despite its shortcomings, MDQ is a valuable tool that can be improved gradually over time through subsequent validation studies in the current setting and scope of patients today. The Composite International Diagnostic Interview (CIDI) The CIDI-based screening instrument is also a valuable tool for clinicians in the primary care of patients especially because it can provide an accurate measure of both the threshold in addition to the sub-threshold bipolar disorder (American Psychiatric Association, 2013). Previous clinical studies validate that the CIDI-based screening tool detected between 67%-96% true cases; this instrument is administered in form of a structured clinical interview composed of two significant questions. Ideally, these two questions are designed specifically to point out the varied episodes of exaggerated or enduring irritable mood. Using this screening tool, a criterion B screening question is used to confirm whether a patient who responds affirmatively to the stem question is presenting with symptoms of mania. In the event that a patient responds to this screening question in the positive, they are called upon to respond to 15 yes or no Criterion B symptom questions; when a patient confirms the presence of at least three symptoms, they are further asked extra questions. These additional questions are meant to establish a number of things among them the length of episodes of elevated or exaggerated mood, the level of function impairment, as well as the potential organic causes. Previous studies have confirmed that the DICI-based screening instrument has a good discriminatory ability for the recognition of bipolar disorder, which is dependent on the number of symptoms for mania a patient confirms in the Criterion B symptom questions. Validation for this measure establishes that it has the ability to inform the primary care physician on the most suitable clinical interview using bipolar disorder questions that are carefully designed to offer proper diagnosis. Like in the MDQ case, the results obtained by this instrument are only helpful when analyzed in correlation with the clinical interview conducted at the beginning of the session. Critique of the Composite International Diagnostic Interview (CIDI) Like in the case of MDQ, the CIDI-based bipolar screening instrument is also a valuable tool that clinicians in primary care can explore in the diagnosis of bipolar cases. Unlike MDQ, the CIDI-based bipolar screening tool first identifies the episodes that either continuously elevated or troubled the mood and endorses the associated manic symptoms (Kessler et al, 2013 pg1626). This diagnostic tool has a number of advantages over the MDQ bipolar screening instrument but hardly any significant limitations. Advantages The most significant advantage of the CIDI-based bipolar screening instrument is that it has a highly discriminative ability that is vital for the effective screening of bipolar disorders; for this matter, the CIDI-based bipolar screening instrument has the incredible capacity to accurately identify and distinguish between both the threshold and sub-threshold bipolar disorder. According to clinical studies, the CIDI-based screening instrument has helped to diagnose between 67% and 96% of all the cases of bipolar disorder that turned out to be true; if these clinical studies are anything to go by, then the CIDI-based screening can achieve a much more accurate diagnosis than the MDQ screening. This screening instrument also has high concordance rates for the diagnosis of bipolar disorder with a positive predicative value that lies between 41%-88% whose variable is the bipolar spectrum disorder. Additionally, this screening instrument has an added advantage over MDQ because it educates the physicians in primary care on the clinical interview that achieves proper diagnosis. Disadvantages Unlike the MDQ that has a number of limitations despite its various qualifications, the CIDI-based bipolar screening instrument barely has any significant failings; this tool has been validated as meeting the appropriate standard because it can provide a diagnosis of a high proportion of true cases. Nevertheless, bipolar disorder patients or even clinicians may prefer either tool in the screening of bipolar disorders for very personal reasons, thus, clinicians in the primary care might find it prudent to apply both screening instruments concurrently. Interventions for bipolar disorder According to current research in medical studies, several treatment options are available for the patients of bipolar disorders; the most significant treatment options or interventions for patients with bipolar disorder include medications, psychotherapy, and support groups. Medications Common medications that are used for bipolar disorder treatment include but are not limited to lithium, anticonvulsants, antipsychotics, and antidepressants. Whereas doctors prescribe lithium particularly for calming the mood by preventing patients from experiencing elevated mood episodes or irritability, anticonvulsants may be used in the treatment of mixed episodes of bipolar disorder. Antipsychotics may substitute anticonvulsants and their side effects may include weight gain; usually, these drugs are prescribed to treat mania or hypomania or as long time mood stabilizers. These particular medicines are mostly recommended in the event of severe symptoms or disturbed behavior; on the other hand, doctors may recommend antidepressants depending on symptoms manifest, though in some cases they may trigger episodes of mania. It usually takes a lot of trial and error to find the right medication for different cases of bipolar disorder for if one does not work well there are alternatives. Psychotherapy Psychotherapy, commonly referred to as ‘talk therapy’ is a very significant intervention in the treatment of bipolar disorder and it because it can provide bipolar patients with support and education, besides guiding them together with their families. Psychotherapy can be distinguished into several forms namely cognitive behavioral therapy, psycho-education, family-focused therapy, interpersonal therapy and group therapy. Professionals such as licensed psychologists and counselors, who work closely with psychiatrists for tracking progress, provide these therapy services; the treatment is organized in sessions but the number, frequency, and type of these sessions will vary depending on the unique treatment needs of each patient. Cognitive behavioral therapy examines the relationship between thoughts and emotions; this type of therapy helps patients to change their negative thought patterns and behaviors into more positive ones to manage symptoms while avoiding triggers for relapse because better insight results to better treatment (Klara, 2012). Psycho-education educates the patients about their condition so they can be better equipped to deal with the illness while family therapy focuses on building positive relationships that promote mental health (Dealy et al, 2012). Support groups Solid support groups can be very effective in helping individuals with bipolar disorder to deal with their condition because it is always very difficult for them to manage this illness on their own. The bonds in support groups gives patients the comfort of belonging to a family of helpful individuals who love, care and appreciate one another without discrimination, thus, they avoid depression due to feelings of being alone. In these support groups, patients get rare opportunities to share their experiences and learn from other people who have better knowledge regarding their condition. Through such interactions, patients are able to build strong, helpful, and long lasting relationships that help them overcome their challenging condition thus they feel more motivated and happy in their lives. Ultimately, bipolar disorder is a mental disorder that presents in patients with feelings of depression or mania in the case of bipolar I disorder, or depression and hypomania for bipolar II disorder. Bipolar I disorder is attributable to a number of etiological factors among them genetic, biological, psychological, and social factors; bipolar I disorder is majorly associated with the genetic component, particularly the genes ANK3, CLOCK, and CACNAIC. Studies have established that close relatives such as family members have a high predisposition to bipolar disorder; however, twin studies have further established that genes alone cannot account for this disorder thereby bringing in the social factor. The sociological environment surrounding an individual may predispose them to factors such as a traumatic event or a significant loss that may trigger bipolar disorder. Biological factors are all the potential imbalances in the biochemical composition of the brain that may predispose an individual to bipolar disorder. The psychological factor accounts for bipolar disorder from the assumption that the manic episodes safeguard patients from depression. Mood Disorder Questionnaire (MDQ) and the Composite International Diagnostic Interview (CIDI) are the two most significant tools used in bipolar disorder screening. MDQ bipolar screening instrument involves patients giving their own reports of manic symptoms and related function impairments to arrive at a manic episode. Conversely, the CIDI-based bipolar screening tool first identifies the episodes that continuously elevate the mood and endorses the associated manic symptoms. Some of the most significant interventions or treatment options available for the patients of bipolar disorders include, but are not limited to, medications, psychotherapy, and support groups. 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Harvard Review of Psychiatry, 19(5), 219-228. Read More