Bipolar Disorder Treatment

Bipolar Disorder
Bipolar disorder is a category of mood disorders, formerly known as PMD manic-depressive psychosis.

The relationship between creativity, melancholy or periods of hypomania (a state of enthusiasm) have been known since antiquity. Aristotle, the first arose the question of the relationship between engineering (creativity) and mania (madness).

It is a long-known and already described in antiquity. In the second century BC, Aretea of Cappadocia was the first to use the word to describe the way patients' laughing, singing, dance night and day, who are in public and walk head crowned with flowers, as if they returned to winning some games. " He had noticed that, thereafter, they changed mood to become languid, sad, taciturn. " However, it Théophile Bonet who made the link between the two extreme moods and in 1686 coined the term Latin manico-melancolicus.

The alternating mania-depression is also reported by T. Willis (1622-1675). Baillarge in 1854 described the madness dual form which is characterized by "two regular periods, one for depression and other excitement." Falret simultaneously published an article devoted to the circular madness. Kraepelin devised a classification system of mania and depression based on symptoms. It identifies 18 types of scalable manic-depressive insanity, including unipolar and bipolar forms, without objection for the same. Subsequently, Kleist and Leonard divided forms unipolar (depression) and bipolar forms. This dichotomous conception of the disorder is joined by Perris, Winokur and Angst.

Bipolar disorder is characterized by abnormal fluctuations in mood, which fluctuates between periods of marked excitement (mania) and deep sadness (depression), interspersed with periods of stability.

The mood is a fundamental emotional disposition that manifests itself at three levels. First it gives a nice color or unpleasant events that we live, then it affects how we feel, think and act, and finally, the mood affects the energy level of our organization.

The mood of each depends on many factors, both "internal" and "external" brain biochemistry, events, experiences, moods, light, personal history, hormonal changes, sleep. But the "normal" therefore fluctuates up or down, but these variations are limited in duration and intensity, they are generally a response to particular events and do not prevent the person from working.

When the mood fluctuations exceed in intensity or duration of those normal mood and lead to deterioration of functioning or distress, we speak of mood disorder.

Bipolar disorder is a disease that affects the balance and regulation of mood. Those who suffer are subject to excessive fluctuations in mood, even extreme, but there is necessarily an external event triggers. They often respond disproportionately to this event.

Bipolar people experience periods when their mood is excessively "high": this is called hypomania (hypo-means "less than" or "under") the elevation of mood is relatively moderate and there is talk of " manic state "if it is very important. But people with bipolar disorder may also experience periods when their mood is low: one speaks of "depression" moderate or severe. All bipolar people do not present period of depression, but it was the presence in their history a period when the mood is "abnormally high" which is to evoke the diagnosis. Nevertheless, periods of high mood and low mood alternating most often interspersed with periods of normal mood.

The term refers to the bipolar mania and depression, which are the two extremes (poles) from which the mood swings. The dramatic swing of mood is sometimes called thymic episode. The frequency, intensity and duration of episodes thymic vary from one person to another. In the absence of treatment or care, the frequency of oscillations and the severity of this chronic disease may increase.

The danger of this disease is the risk of suicide during phases melancholy and difficulties in social adjustment during the different access.

Classifications official DSM IV and ICD-10 distinguish between three types of bipolar disorder:

* 1 bipolar disorder is characterized by one or more manic or mixed episodes and depressive episodes of varying intensity (the diagnosis can be made even in the absence of depressive disorder). An organic cause, toxic or iatrogenic does not accept this diagnosis.
* 2 bipolar disorder is defined by the existence of one or more hypomanic episodes and one or more major depressive episodes.
* In the cyclothymia, which often begins in adolescence, there are many periods of mild depression or hypomania few days or weeks. Isolated in 1882 by Kahlbaum, cyclothymic disorder is an attenuated form of bipolar disorder.

Klerman in 1981 are six categories of bipolar disorder: the bipolar I and II, as classically defined, the bipolar III in which the manic or hypomanic states were induced by drug treatment, the corresponding IV bipolar disorder in cyclothymic the bipolar V presenting a family history of bipolar disorder and bipolar VI are characterized by manic recurrences.

20 years later, Akiskal and Pinto individualise 8 different forms:

Bipolar disorder * 1 / 2: schizoaffective bipolar disorder
* Bipolar disorder I: manic-depressive illness
Bipolar disorder I * 1 / 2: prolonged depression with hypomania
* Bipolar II disorder: depression associated with discrete spontaneous hypomanic phases
* Bipolar disorder II 1 / 2: depression on the bottom of cyclothymic temperament
* Bipolar disorder III: depression with hypomania induced by antidepressants or other treatment
* Bipolar disorder III 1 / 2: marked swings of mood associated with an addiction or alcohol abuse
* Bipolar disorder IV: depression on the bottom of temperament hyperthymique

The version of the DSM V should include bipolar I and II, as currently defined, the BP II 1 / 2 would be represented by cyclothymic disorder, bipolar III the statements which include manic or hypomanic induced by treatment and the bipolar IV correspond to hyperthymies.

In recent classifications show the trend of extending the concept of bipolar disorder, which brings together under the term bipolar spectrum various disorders, personalities and temperaments.

The spectrum of bipolar disorder has recently expanded by integrating and cyclothymic temperaments hyperthymiques, seasonal disorders and forms evolving brief. The different categories of disorders that belong to the bipolar spectrum do not warrant the same treatment and are not the same criteria of severity.

Is also seen as bipolar disorder Syndrome Kleine-Levin, a rare disease that primarily affects adolescents and young adults. Atypical form of bipolar disorder, is characterized by cycles of hypersomnia important, up to twenty hours of sleep per day, marked by behavioral disorders, bulimia, irritability, disorientation, hallucinations, puffs delirious of hypersexuality (disinhibition), a total lack of energy, emotional absence and a withdrawal into oneself. There is also often a hypersensitivity to noise and light. In many cases, crises last few days or weeks and fade over time and disappear into the thirties.


* TB 1: 1%.
TB * 2: 0.5 to 2.5%
* Cyclothymia: 2 to 3%.

The authors argue that bipolar disorder has a prevalence of 2 to 8% of the population.

United States, the prevalence among the youth under 20 was muliple by 40 between 1994 and 2003 and a little less than 2 during the same period in adults. The reasons for this increase are not clear. It is possible that this diagnosis is sometimes worn in excess, the criteria are not strictly respected.

Bipolar disorder affects both men and women, whatever their socio-cultural or socio-economic levels. However there are more episodes of depression in women and more than unipolar mania in humans.

The association with another psychological disorder (comorbid) psychiatric important, it affects 60% of bipolar patients treated with one third of subjects of type I (Colom et al.2006).

Anxiety disorders occupy a special place, over 50% of patients had at least one anxiety disorder associated (Henry, 2003; Perlis 2005).

The generalized anxiety disorder TAG is in second place. The association between bipolar disorder and TAG is estimated 6% to 32% according to studies (Gorwood, 2004).

Obsessive-compulsive disorder is in third place. For some, it concerns only 10% of bipolar patients (Akiskal, Marremmani and Placidi, 1998).

The frequency of social phobia is more difficult to assess. The prevalence by advanced studies ranging from 9% to 16%.

The incidence of addiction in patients suffering from bipolar disorder is 6.6 times that of a subject in the general population (Rouillon, 1997). This is by far the abuse of alcohol which leads with a prevalence of 42%, with women being particularly affected, while the consumption of cannabis is 16% (Mc Elroy et al.2005).

Personality disorders are associated with approximately 30% of bipolar subjects (Colom, 2006). In a study of Shiavone et al. (2004), personality disorders most often associated with bipolar disorder include: borderline personality (41%), narcissistic personality (20.5%), dependent personality (12.8%), histrionic personality (10.3% ).

Bipolar disorder can be expressed differently and not be recognized from the outset. This is unfortunately the most frequent. Some epidemiological data illustrate this reality: 9 years of evolution before the diagnosis has been made correctly and that a specific treatment has been established, intervention 4 to 5 different doctors.

The search for periods of excitement is a good way to establish the diagnosis, but it is not always obvious to the patient to understand that the times when he felt particularly well have the same origin as the periods when he felt ill .

Given the frequency of bipolar disorder and the importance of prognostic challenge, looking for signs of bipolarity should be systematic in any depressive episode. It should respond to a consolidation in order to facilitate the diagnosis:

* Taking into account family history that is not confined simply to look for mood disorders among ascendants and collaterals. The existence or not of a alcoholism, abnormal behavior, a unique, suicide or attempted suicide, anxiety disorders, from eating disorders, obsessive disorders should be sought.

* Some personal background, the events may reflect a mood disorder diagnosis may guide to bipolar disorder: the period of euphoria and excitement, excessive spending, the original behavior, trouble with the law, alcohol at-risk or excessive crises of violence or aggression, the concept of a break compared to the previous state, a change, a change in the character, the notion of a shift in mood during a prior prescription antidepressants ...

* An age of onset of symptoms early, at the time of adolescence or early adulthood, is also an index to take into account, unipolar disorder (depression) with a later onset.

* In women, mood disorders occurring in the aftermath of the birth and before the return of layers will be very much in favor of a bipolar.

* A basic temperament type hyperthymique characterized by hyperactivity, hypersyntonie, multiple projects, an excessive sociability may influence the diagnosis. Other personality traits are frequently found in bipolar patients: hypersensitivity, emotional dependency, seeking thrill ... Some studies have also highlighted a correlation between bipolar disorder and creativity, although this relationship remains uncertain and poorly explained.

* The symptoms suggestive of bipolar depression may be one or more specific: psychotic symptoms, alteration of circadian rhythm with psychomotor inhibition major reduction in the morning and late in the day, symptoms of atypical depression: hypersomnia, hyperphagia, psychomotor inhibition up blocking of thought, lability of mood.

* It is also recommended to conduct an interview with a family member and encourage the patient to make self-assessments.

Other symptoms have no specificity but are often observed: irritability, aggressiveness, reaction of anger, excessive sensitivity, emotional emoussement up to an inability to cry and / or express negative emotions.

At present, still not known with certainty the causes of bipolar disorder, the biopsychosocial model applies to this trouble focusing on the concept of vulnerability that is expressed both in terms of genetics than to personality, environment, playing mostly as a detonator.

It is clear that biological factors are involved because we know the existence of anomalies in the production and transmission of brain chemicals called neurotransmitters and hormonal abnormalities, including cortisol also involved in stress. These anomalies are themselves associated with genetic factors, which explains the predisposition family. Thus the interaction of biological and environmental factors that best explains the emergence of bipolar disorder.

The existence of a genetic vulnerability vis-a-vis the bipolar disorder has long been established. The risk of bipolar disorder if one parent primary target is 10% compared to the prevalence of 1 to 2% in the general population. The role of psychological and environmental factors in triggering the disease and access has long been minimized, the condition being treated as endogenous. Debilitating environmental factors are better identified. Genetic studies liaison identify chromosomal regions carrying genes involved in this disease, in particular the regions 13q31 and 22q12.

Other risk factors may relate to early life events, such as the mourning of a parent, a lack of emotional or sexual abuse in childhood. Longitudinal studies show that before the outbreak of the disease, there are localized cognitive deficits, including visuospatial function. These cognitive deficits probably refer to neurodevelopmental abnormalities in relation to genetic risk factors. The functional neuroimaging studies show dysfunction in the execution of cognitive tasks including on the fronto-striatal circuit.

In life there are other precipitating factors such as the painful events of life (marital, occupational or financial problem ...) and repeated stress (professional burnout, lack of sleep, non-compliance of biological rhythms) . It was also shown a level of high emotional expression in families (or angry cries for minor events) was a precipitating factor of the disease.

On a theoretical level, one can describe a causal succession: life events have led to disruption of social rhythms, generating disturbances of biological rhythms, which themselves cause the recurrence of depression and mania. In the conceptualization of the evolution of access thymic bipolar disorder according to the cognitive-behavioral model, we consider episodes of decompensation in mood as the beginning of a vicious circle that comes from changes in thoughts and emotions generated by the change in mood and will lead to changes in behavior, these changes will not delay to degrade the functioning of the person and generate psychosocial problems which in turn will create stress and effects on sleep ... thus intensify loops already present symptoms or precipitate a new access in the future.

It is established that the disruption of social rhythms, effects of events more or less severe, to the risk of recurrence of thymic disorders. The literature data mainly sleep. They relate to sleep deprivation and induction of mania on manias induced travel east-west on manias induced by disruption of social rhythms. Sleep deprivation is known to have antidepressant properties and may cause a relapse because the bipolar denied a night of sleep are indeed prone to manic decompensation. The "phase shift" that may exist between social rhythms and biological rhythms is also a cause of recurrence.

The influence of life events tend to decrease with the number of recurrences because the succession of episodes cause sensitization (or kindling), ie increasing biological vulnerability vis-a-vis the events or triggers precipitant.

There are certainly a neuronal dysfunction and loss of neurons in the hippocampus of patients with bipolar disorder. Thus, a study with proton MR spectroscopy showed that the concentration of N-acetyl aspartate, an amino acid normally present in the hippocampus is decreased in patients with bipolar disorder and worsens with the length of the disorder. Other anomalies are found, particularly at the level of the anterior cingulate gyrus where there is a malfunction in the regulation of neurons glutamaergiques. There are also morphological abnormalities, including the cerebellum, found in patients with bipolar several episodes of mood disorder. Thus, the study of Mills et al. (Mills, 2005), compares the volume of the cerebellum in patients after a bipolar episode and after several episodes of the disease by MRI and shows that it is smaller in patients with several episodes. Similarly, a ventricular enlargement was found in patients with multiple manic episodes.

There seems to be a common genetic cause of schizophrenia, parents and relatives of people with schizophrenia have a higher risk of bipolar disorder and vice versa, research shows, so ask some of the real distinction between the two syndromes. Note that the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the International Classification of Diseases (ICD) are currently in review process (the publication of DSM-V is expected in 2012), they consider that the design of these binary two diseases should be abandoned in future editions.

Evolution of bipolar disorder

In general:

* Cyclicality tends to worsen over time with the appearance of short cycles. Quick cyclicality is associated with an early onset of age, a concomitant anxiety disorder, substance abuse, history of suicide attempts, use of antidepressants and a family history of rapid cycler. They talk about bipolar disorder with rapid cycles when there is more than 4 episodes of mania and / or depression for at least two weeks per year. The cycles are quick associated with panic disorder and family history of panic disorder.
* The nature of the episodes changes with mixed manic and depressive symptoms: we call them mixed episodes;
* The average mood tends to become increasingly depressed and the patient will have fewer episodes of mania;
* Note on the evolution with a decrease in cognitive abilities.

This can be alleviated by appropriate treatment instituted as early as possible.

The base salary is made up of one or more thymoregulators salts of lithium, anticonvulsants, lamotrigine, which vary according to type. Antidepressants should be prescribed only occasionally (risk turning manic reaction or anxious), neuroleptics Similarly mania (risk turning depression), this is unfortunately not yet used in France.

For the pharmacological treatment of bipolar depression, prescription of antidepressants as monotherapy undoubtedly worsens the prognosis of bipolar disorder by inducing turns manic and mixed episodes, rapid cycles, and by promoting resistance treatment.Il should therefore first optimize treatment thymoregulator conducting Serum and adjusting the best rate to the therapy recommended upper limits, provided that this does not have side effects. The appeal, if necessary, in a second step, a second treatment thymoregulator aim to restore normothymie while protecting the patient against the risk of destabilization of mood. Antidepressants in bipolar depression are usually justified only in cases of severe depressions, and intensity in combination with a thymoregulator.

Along with psychotropic treatments may be offered new approaches to psychological treatments: psycho-educational measures; therapies based on interpersonal social rhythms (IPSRT), as well as cognitive-behavioral therapies and focus on the family. These therapies can limit the functional impact of the disease, because although the disease can be well controlled by medication, it is difficult to remove all its effects as the changes in the social sphere, family, professional and psychological importance.

Psychoanalytic therapy, very frequent, have not proven methodology to be effective in bipolar disorder or depression.

The measures are part psychoeducational with cognitive-behavioral treatment of psychological well documented and for which there is a level of evidence of high efficiency. The benefits of this complementary approach are many: early recognition of symptoms that herald a relapse, quality improvement compliance, better management of social life, professional and emotional control and precipitating factors, compliance with rules of lifestyle ... are also objectified fewer recurrences and relapses, a decrease in length of hospital stay, a better balance of family life, improved quality of life. Preventive treatment, eg in the framework of psycho-education, aims to assess the social patterns of the subject, limiting the impact events, limited situations by limiting the excitement and stimulation to restore stability social rhythms. These psychotherapeutic techniques should be implemented as soon as the identification of disruptive events, to prevent the deterioration of social rhythms and sleep.

The accompaniment is also very important, relatives are often helpless in front of a bipolar person. But their presence is a factor in the success of improving the physical and psychological illness.

The diagnosis and treatment of bipolar disorder will avoid the troubles that are often associated, one speaks of comorbid or co-morbidity.

It is important and should be considered as bipolar disorder. It concerns mainly:

* Syndrome alcohol abuse, also common, found mainly in the depressive phases. A recent study estimates the risk at 30% for women and 50% for men suffering from bipolar disorder. As the syndrome of abuse / dependence on alcohol is much more common in men than in women, being bipolar, multiply by 7.5 the risk for a woman to have a diagnosis of abuse / alcohol for only a multiplicative factor of 2.75 for men. It is worth recalling that before any alcohol, we must seek and bipolar disorder, especially among women.
* Anxiety disorders, particularly panic disorder (20% in the ECA study): the prevalence of lifetime anxiety disorders is approximately one to two bipolar patient. They are particularly associated with younger age of onset, a greater tendency to attempt suicide.

Other disorders frequently occur along with bipolar disorder (comorbidity): Agoraphobia, claustrophobia, manic symptoms along with symptoms of depressive mixed states, fears and anxiety, excessive consumption of alcohol and cannabis. There is also often inadequate treatment through the inappropriate use of neuroleptics and antidepressants in particular, lack of thymoregulator or prescription drugs incompatible. The refusal of treatment adherence or irregular drift is also a widespread, encouraged by the nostalgia of the phases of (hypo) mania.

Persons who have undergone several cycles of the disease are hypersensitive and they trigger the disorder lowered (theory of kindling). Strict lifestyle is recommended.

There are also somatic comorbidities:

* Overweight and obesity

Overweight (determined by body mass index, BMI greater than 25) affects 58% of patients bipolaires.Différentes possibilities were discussed: the involvement of drugs and mood especially antipsychotics.

The weight gain is to monitor as many people stop treatment because of this especially during long treatment. More overweight is in itself a problem. It can involve risks such as diabetes not requiring insulin, cardiovascular disease, rheumatic, hypertriglyceridaemia, ..

* Diabetes and Endocrine disorders

Some studies conducted in patients hospitalized bipolar estimate the prevalence of type II diabetes in patients with bipolar disorder to nearly 10%, whereas it is only 3 to 4% in the general population.

* Cardiovascular Disease

Cardiovascular diseases are also more common in bipolar and may be related to the relatively greater risk in these patients to develop diabetes and obesity, presenting an anxiety disorder or difficulty complying with the rules of hygiene life (including alcohol)

Psychiatric comorbidity alters the expression and the evolutionary course of bipolar disorder.

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