I. Introduction.

Bipolar disorder, also known as manic-depression, affects at least 2 million Americans at any given time. For those who have this disorder, it can be extremely distressing and disruptive. The people who are afflicted with some form of bipolar disorder can expect to have some type of episode in their lifetime as a result. While people should not suspect that they have bipolar disorder simply because they are occasionally depressed (who isn’t?), a person experiencing the symptoms described below on a long-term basis should seek professional help to determine if treatment for bipolar disorder is appropriate. This paper will provide an overview of what bipolar disorder is, the various types in which it can manifest itself, the suspected causes and genetic relationship, as well a discussion of what types of treatment have proven to be the most effective in minimizing the effects of this disorder.

II. What is Bipolar Disorder?

Bipolar disorder is often not recognized by the patient, relatives, friends, or even physicians. An early sign of manic-depressive illness may be hypomania (this is a state in which the person shows a high level of energy, excessive moodiness or irritability, and impulsive or reckless behavior). According to the healthcare professionals, hypomania may actually feel good to the person who experiences it and therefore, even when family and friends learn to recognize the mood swings which are a part of the bipolar disorder, the individual often will deny that anything is wrong. "In its early stages, bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work performance. However, if the condition is left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression. There are several types of bipolar disorder, depending on the nature of the illness. The main types are (extracted from "What is Bipolar Affective Disorder," n. pag.):

A. Bipolar I disorder is a condition in which individuals have had at least one full manic or mixed mood episode, and may or may not suffer from episodes of depression.

B. Bipolar II disorder in which individuals have at least one depressive episode and at least one hypo manic episode, but never experience a full manic or mixed mood episode. Bipolar II can go unrecognized because the hypo manic symptoms may not appear that unusual.

C. Cyclothymic disorder is a condition in which individuals have suffered numerous hypo manic and depressive symptoms over a period of at least 2 years that are not severe enough or not long enough in duration to meet the criteria for a mood episode. In this type of bipolar disorder, a person’s mood alternates between mild depression and mild mania. Some people with cyclothymic disorder later develop full-blown bipolar disorder.

III. Overview of Symptoms and Subtypes.

According to the American Medical Association’s Diagnostic and Statistical Manual of Mental Disorders, "In its early stages, bipolar disorder may masquerade as a problem other than mental illness. For example, it may first appear as alcohol or drug abuse, or poor school or work performance. If left untreated, bipolar disorder tends to worsen, and the person experiences episodes of full-fledged mania and clinical depression" ("Bipolar Symptoms," n. pag.).

A. Symptoms. Bipolar disorder generally characterized by recurrent episodes of mania and major depression. The cycle is described as one in which an affected person's mood can swing from excessive highs (mania) to profound hopelessness (depression), usually with periods of normal behavior and moods in between. "Some individuals may exhibit mixed symptoms of both mania and depression at the same time, while others may have more moderate symptoms of mania (hypo mania). The type, severity and duration of mood episodes experienced can vary" ("What is Bipolar Disorder," n. pag.). Complicating the diagnosis of individuals demonstrating these types of behaviors are the tendencies of sufferers to ". . . have a predominance of either mania or depression, whereas some sufferers may experience equal numbers of both." Typically, a person with bipolar disorder can expect an average of ten episodes of mania or depression in his or her lifetime but some sufferers experience much more frequent mood episodes. The frequency of episodes tends to increase with time and individuals who experience four or more episodes in a year are said to have rapid cycling (see discussion below) ("What is Bipolar Disorder?," n. pag.).

B. Subtypes of Bipolar Disorder.

1. Rapid cycling: Individuals who experience more frequent mood episodes ( 4 or more per year) are called rapid cyclers. Rapid-cycling sufferers represent 5 to 15 percent of all cases. These people experience four or more mood episodes within a year and may have little or no normal functioning in between episodes. In rare cases, swings between mania and depression occur over a period of days.

2. Ultra-Rapid Cycling. This is the same as rapid cycling, only the cycles are more frequent. (4 or more per week, and can cycle as rapidly as 4 or more per day)

3. Seasonal pattern. Some individuals have predictable patterns as to the onset of mood episodes based on the season of the year. In other words, bipolar disorder may follow a seasonal pattern, with a person typically experiencing depression in the fall and winter and mania in the spring or summer (this is sometimes called Seasonal Affective Disorder).

4. Post-partum onset. Mood disturbance occurs within 4 weeks of childbirth.

IV. Bipolar Disorders and Personality Types

In North America and Europe, about 1 percent of people experience bipolar disorder during their lives. Rates of bipolar disorder are similar throughout the world. In comparison, at least 8 percent of people experience serious depression during their lives. Bipolar disorder affects men and women about equally and is somewhat more common in higher socioeconomic classes. At least 15 percent of people with bipolar disorder commit suicide. This rate roughly equals the rate for people with major depression, the most severe form of depression. Some research suggests that highly creative people such as artists, sculptors, musicians, composers, writers, and poets show unusually high rates of bipolar disorder, and that periods of mania fuel their creativity. For example, some famous artists and writers who probably suffered from bipolar disorder include poets Lord Byron and Anne Sexton, novelists Virginia Woolf and Ernest Hemingway, composers Peter Ilich Tchaikovsky and Sergey Rachmaninoff, and painters Amedeo Modigliani and Jackson Pollock (Cohen, n. pag.). However, critics of this research note that many creative people do not suffer from bipolar disorder, and that most people with bipolar disorder are not particularly creative. Since "creativity" is such a subjective analysis, who is to say to what extent bipolar disorder contributes to or detracts from someone’s creativity. However, the debate concerning creativity and bipolar disorder is a consistent theme which runs through the much of the research.

V. Onset of Bipolar Disorder..

Bipolar disorder typically begins in adolescence or early adulthood and continues throughout life. It is often not recognized as a serious disorder, and people who have it may suffer needlessly for years or even decades. According to the research on bipolar disorders, "Men usually experience mania as the first mood episode, whereas women typically experience depression first. Episodes of mania and depression usually last from several weeks to several months" (Cohen, n. pag.). By and large, people suffering from untreated bipolar disorder experience four episodes of mania or depression over any given 10-year period; however, many people with bipolar disorder function normally between episodes.

VI. Depressive and Manic Types of Bipolar Disorder.

A. Depressive Phase. People in the depressive phase of bipolar disorder feel intensely sad or profoundly indifferent to work, activities, and people that once brought them pleasure. They think slowly, concentrate poorly, feel tired, and experience changes (usually an increase) in their appetite and sleep patterns. These people often feel a sense of worthlessness or helplessness. In addition, they may feel pessimistic or hopeless about the future and may think about or attempt suicide. In some cases of severe depression, people may experience psychotic symptoms, such as delusions (or false beliefs) or hallucinations (which may consist of false sensory perceptions or manifestations of other psychoses).

B. Manic Phase. In the manic phase of bipolar disorder, on the other hand, people feel intensely and inappropriately happy, self-important, and irritable. In this highly energized state they sleep less, have racing thoughts, and talk in rapid-fire speech that goes off in many directions. They tend to have inflated self-esteem and confidence and may even have delusions of grandeur. Mania may make people impatient and abrasive, and when frustrated, physically abusive. They often behave in socially inappropriate ways, think irrationally, and show impaired judgment. For example, they may take airplane trips all over the country, make indecent sexual advances, and formulate plans involving imprudent or questionable investments of money.

VII. Genetic Connection to Bipolar Disorder

There is a preponderance of research evidence which demonstrates that there is a genetic connection to the incidence of bipolar disorders within the general population in the United States. The specific results of this research to date reflects a paucity of concrete data in this regard, however, and additional research into the causation and connection of genetics and bipolar disorder is urgently needed. Some of the studies which have established a genetic connection (without knowing precisely why) follow:

A. Identical Twin Studies. The genes that a person inherits seem to have a strong influence on whether the person will develop bipolar disorder. Studies of twins provide evidence for this genetic influence. Among genetically identical twins where one twin has bipolar disorder, the other twin has the disorder in more than 70 percent of cases. However, among pairs of fraternal twins, who have about half their genes in common, both twins have bipolar disorder in less than 15 percent of cases in which one twin has the disorder. This degree of genetic similarity seems to account for the difference between identical and fraternal twins. Moreover, further evidence for a genetic influence comes from studies of adopted children with bipolar disorder. These studies demonstrate that biological relatives of the children have a higher incidence of bipolar disorder than do people in the general population and thus, bipolar disorder seems to run in families for genetic reasons (Cohen, n. pag.). For example, one study examined the children of identical twins in which only one member of each pair of twins had bipolar disorder. The researchers determined that regardless of whether the parent had bipolar disorder or not, all of the children had the same high 10-percent rate of bipolar disorder. This observation clearly suggests that risk for bipolar illness comes from genetic influence, "not from exposure to a parent’s bipolar illness or from family problems caused by that illness" (Cohen, n. pag.).

B. Genetic Connection to Higher Incidence of Pathological Mood Swings. Bipolar disorder results in pathological mood swings from mania to depression, with a tendency to recur and remit spontaneously. Either the manic or the depressive episodes can predominate and produce few mood swings, or the patterns of mood swings may be cyclic. In bipolar disorder (manic), the manic phase is the current or most recent phase of the illness. The manic phase is characterized by elation, hyperactivity, over-involvement in activities, inflated self-esteem, a tendency to be easily distracted, and little need for sleep. The manic episodes may last from several days to months. "In the depressive phase there is inertia, loss of self-esteem, withdrawal, sadness, and a risk of suicide. In either phase, there is frequently a dependence on alcohol or other substances of abuse" (Cohen, n. pag.). Although the cause is unknown, hereditary and psychological factors may play a role. The incidence is higher in relatives of people with bipolar disorders again lending credence to the genetic connection theories.

C. Other Genetic Aspects of Bipolar Disorders. Often, families of patients with bipolar disorder include members with other psychiatric problems, including schizoaffective disorder and major depression, which many experts believe are variants along a single disease spectrum. Some studies indicate that a combination of bipolar and panic disorder may be a specific inherited condition. For example, it has long been observed that children of bipolar disorder parents often have a more severe form of the disorder than do their parents. "Another recent study indicated that a daughter with bipolar disorder is at particularly high risk for developing a more severe form if her mother has the disorder" ("Who Gets Bipolar," n. pag.).

VIII. Bipolar Disorder Therapies.

Today, much more is known about the causes and treatment of bipolar disorders and the problems associated with the condition. For example, "We know that there are biological and psychological components to every bipolar disorder and that the best form of treatment is a combination of medication and psychotherapy. Contrary to the popular misconceptions about bipolar disorder today, it is not a purely biochemical or medical disorder. Different therapies may shorten, delay, or even prevent the extreme moods caused by the various bipolar disorders" (emphasis author’s) ("All About Bipolar Disorder," n. pag.). Some of the common therapies are discussed below.

A. Lithium. Lithium carbonate is a natural mineral salt which can help control both mania and depression in bipolar disorder. Lithium is used to "control the manic and hypomanic episodes in manic-depressive clients. Prophylaxis of bipolar depression" (Spratto, p. 752). The drug generally takes two to three weeks to become effective. People with bipolar disorder may take lithium during periods when they are experiencing relatively normal moods in order to delay or prevent subsequent episodes of mania or depression in the prophylaxis application discussed by Spratto. Some of the common side effects of lithium include nausea, increased thirst and urination, vertigo, loss of appetite, and muscle weakness. In addition, the long-term use of lithium can significantly impair the proper functioning of the kidneys. For this reason, doctors do not prescribe lithium to bipolar patients who also have any type of kidney disease. "Many people find the side effects so unpleasant that they stop taking the medication, which often results in relapse. From 20 to 40 percent of people do not respond to lithium therapy. For these people, two anticonvulsant drugs may help dampen severe manic episodes" ("Lithium," n. pag.). Additionally, patients receiving lithium therapy must be closely monitored by their healthcare professionals, since the treatment dosages and toxicity levels can be closely related. The Physician’s Desk Reference warns that, "Lithium toxicity is closely related to serum lithium levels, and can occur at doses close to therapeutic levels. Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy" (emphasis added) (p. 2021).

B. Carbamazepine (Tegretol) and valproate (Depakene). According to the research, the routine use of traditional antidepressants to treat bipolar disorder carries risks of triggering a manic episode or a rapid-cycling pattern (Cohen, n. pag.). Valproate (Depakote), also called valproic acid, and carbamazepine (Epitol, Tegretol) are drugs ordinarily used for epilepsy; either one may be an alternative for patients who do not tolerate or respond to lithium. Valproate is, in fact, more effective than lithium for depressive mania. One study found that valproate appears to work more quickly than many other bipolar drugs. The pharmacological efficacy of lithium and valproate may be similar, but valproate has demonstrated advantages in some cases. "Although both valproate and carbamazepine are comparable to lithium in long-term effectiveness, patients face a higher risk for breakthrough depression with the anti-epileptics than they do with lithium" (emphasis added). Generally speaking, the side effects of valproate are usually minor, occur early in therapy, and then subside. However, some amount of discomfort is routinely associated with this drug’s use in treating bipolar disorder. "In some studies, nearly half the patients taking valproate initially experienced gastrointestinal problems (nausea, vomiting, heartburn). Women may experience menstrual irregularities, and the risk for polycystic ovaries seems to increase. (These side effects also appear in women using other anti-epileptic drugs, but the risk for those taking valproate may be higher.) Valproate is, however, the preferred drug for women taking oral contraceptives" ("What are Lithium and Other Major Drugs," n. pag.). Valproate significantly increases the risk for birth defects when taken by pregnant women and other serious, but rare, side effects include liver damage, convulsions, and coma. "A study of epileptic patients who had taken valproate for longer than a year found a greater incidence of cognitive impairment and symptoms of Parkinson's disease; these disturbing side effects resolved after valproate therapy was discontinued" ("What are Lithium and Other Major Drugs," n. pag.).

C. Family-Focused Treatment Approach. One approach which has been used in an attempt to minimize and resolve the harmful effects of bipolar disorders on the hundreds of thousands of sufferers in the United States and their family members is described in a book by David Miklowitz and Michael Goldstein entitled Bipolar Disorder: A Family-Focused Treatment Approach. The process is described in the foreword as being ". . . the first treatment approach for bipolar disorder that truly integrates the use of medication and family intervention" (Wynne, n. pag.). The authors advocate the use of a "psychotherapeutic attitude" in the treatment of bipolar disorders in which the ". . . experience, stories, and special life circumstances of the family members are given attention." Dr. Ellen Frank, Professor of Psychiatry and Psychology at the University of Pittsburgh School of Medicine, says this approach will be useful, "Whether such clinicians typically treat individuals, couples, or entire families, they will benefit enormously from the perspective offered here and find much to incorporate into their work with patients suffering from bipolar disorder" (Frank, n. pag.).

D. Cognitive-Behavioral Therapy. Another approach which is advocated by Monica Ramirez Basco and A. John Rush in their book, Cognitive-Behavioral Therapy for Bipolar Disorder, provides a ". . . conceptual framework and step-by-step instructions for using cognitive-behavioral techniques to enhance pharmacotherapy in the management of bipolar disorder" ("Book News Inc., n. pag.). The authors first describe the benefits of using the pharmacotherapy approach and then review the diagnosis, course, and characteristics of bipolar disorders. The approach emphasized the use of ". . . homework assignments for patients, and interventions, and discusses methods for facilitating communication and solving daily problems" ("Book News Inc., n. pag.). Cognitive behavioral therapy (CBT) is a structured, conscious method that aims to help a patient recognize negative thoughts and behavioral patterns and to change them. CBT is known to be helpful for other mood disorders, including depression and anxiety, and small studies are finding that it benefits bipolar patients as well (emphasis added). Some experts initially start patients on CBT after their erratic mood has been stabilized by using these drug therapies. However, there is more to it than just the drug therapy. "CBT involves educating the patient, partners, and family members on bipolar disorder, helping them accept the condition and their need for medications, and setting up methods to protect them financially during manic episodes" and "CBT offers skills that the patient can use to endure depression and to recognize manic episodes before they become full-blown" ("What are the Psychologic and Other Non-Drug Approaches," n. pag.).

E. Inpatient Therapy. In some instances, inpatient hospitalization may be required during an acute phase of a bipolar disorder episode in order to control the symptoms. This may be done for the protection of the patient as well as the patient’s family and others. One study suggested that teaching the spouse of a bipolar patient ways to cope with the illness improved the partner's chances of sticking to his or her treatment. "Unlike relatives of alcoholic patients who may be encouraged to get tough, relatives of bipolar patients must be strongly supportive because of the high risk for suicide with this disorder. . . . Certainly, the patient should not be made to feel guilty; bipolar disorder results from an imbalance of chemicals in the brain not from anyone's fault. It should be strongly noted, however, that caregivers must be forceful in getting the patient to comply with treatment, sometimes even threatening hospitalization if the patient fails to do so (emphasis added) ("What Are the Psychologic and Other Non-Drug Therapeutic Approaches to Bipolar Disorder," n. pag.).

IX. Conclusion.

Between one and two million Americans are thought to suffer from bipolar disorder making it the most common psychotic disorder in the United States. Many experts believe that it occurs in one percent of people among all age groups. Researchers are continuing to identify the genetic causes of bipolar disorder and because of the severity of its manifestations and its prevalence in the population, this research must be given a high priority within the medical community.

Works Cited

"All About Bipolar Disorder," Mental Health Net: Disorders and Treatments, <http://bipolar.mentalhelp.net/>, April 11, 2000.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association. National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3679 (1995) in <http://mentalhelp.net/disorders/sx20.htm>, April 11, 2000.

Basco, Monica Rameriz and Rush, A. John, Cognitive-Behavioral Therapy for Bipolar Disorder, Dallas: University of Texas Southwestern Medical Center, 1996.

"Bipolar Disorder," <http://health.yahoo.com/health/Diseases_and_Conditions/ Disease_Feed_Data/Bipolar_disorder__manic_/#CausesAndRisk>, April 12, 2000.

Cohen, David B., "Bipolar Disorder," CD-ROM Microsoft Encarta Encyclopedia, 1998.

Frank, Ellen, PhD., "Editorial Review: Bipolar Disorder: A Family-Focused Treatment Approach, <http://www.amazon.com/exec/obidos/ts/book-reviews/>, April 11, 2000.

Mikowitz, David J., Goldstein, Michael J., and Lyman C. Wynne, Ed., Bipolar Disorder : A Family-Focused Treatment Approach, Guilford Press, 1997.

"Lithium carbonate," Physician’s Desk Reference, Oradell, NJ: Medical Economics Company, Inc., 1993.

Spratto, George R., RN Magazine’s Nurse’s Drug Reference, "Lithium," Albany, NY: Delmar Publishers, Inc., 1997.
"What Are Lithium and Other Major Drugs Used for Bipolar Disorder," Mental Health Net: Disorders and Treatments, <http://bipolar.mentalhelp.net/bipolar/wcg_bipolar7.htm>, April 11, 2000.

"What is Bipolar Affective Disorder, Its Characteristics, and Its Types?," Bipolar Home, <http://www.bipolarhome.org/what.html>, April 12, 2000.

"What are the Psychologic and Other Non-Drug Approaches to Bipolar Disorder?," Mental Health Net: Disorders and Treatments, <http://bipolar.mentalhelp.net/bipolar/wcg_ bipolar8.htm>, April 11, 2000.

"Who Gets Bipolar Disorders," Mental Health Net: Disorders and Treatments, <http://bipolar.mentalhelp.net/bipolar/wcg_bipolar3.htm>, April 11, 2000.