Clinical Description and Course

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Bipolar affective disorder, formerly known as manic-depressive illness, is a psychiatric disorder involving wideranging fluctuations in mood, activity, and cognition. It affects between 0.8% and 1.4% of the population. When depressed, bipolar persons experience a sad mood, loss of interests, fatigue, psychomotor retardation or agitation, loss of concentration, insomnia, feelings of worthlessness, and suicidality. During manias, patients experience euphoric, elevated or irritable mood states, racing of thoughts (or the verbal concomitant, "flight of ideas"), pressure of speech, increased activity and energy, impulsive and high-

risk behaviors, an inflated sense of self-worth or grandiose delusions, distractibility, and a decreased need for sleep (American Psychiatric Association, 2000). Manic episodes are generally more damaging to bipolar persons and those around them than are depressive episodes.

Bipolar I patients alternate between the two extremes of mania and depression, or they experience mania and depression simultaneously in mixed affective episodes. Bipolar II patients experience debilitating depressions that alternate with hypomanic episodes. Hypomania is an attenuated form of mania. It is not associated with significant functional impairment, psychosis, or the need for hospital-ization.

Bipolar I Disorder affects men and women with equal frequency, but bipolar II patients are more frequently women. Women appear to have a preponderance of depressive episodes over manic or hypomanic episodes, whereas the reverse appears true of men. Similarly, the first onset of bipolar disorder is usually a depressive episode in a woman and a manic episode in a man.

The course of the disorder varies considerably from person to person. Some bipolar persons return to a euthymic, normal mood state between episodes. However, by some estimates (e.g., Harrow, Goldberg, Grossman, & Meltzer, 1990), more than half of patients have significant symptoms during the intervals between major episodes. The average duration of episodes varies from 4 to 13 months, with longer durations reported in studies from the pre-pharmacological era (Goodwin & Jamison, 1990). Episode duration has decreased significantly since the advent of mood-stabilizing agents such as lithium carbonate or the anticonvulsants (see following). But even with active medication, about 40% of bipolar patients have a recurrence of their illness in a 1-year period, and 73% over 5 years (Gitlin, Swendsen, Heller, & Hammen, 1995).

Between 13% and 20% of patients are rapid cyclers (Cal-abrese, Fatemi, Kujawa, & Woyshville, 1996), who experience four or more episodes of depression, mania, hypomania, or mixed affective disorder in a single year; these patients are disproportionately women. There are several known predictors of increased cycling of the disorder, including medication nonadherence, presence of psychosis, alcohol and drug abuse, sleep deprivation, and, in some patients, the use of antidepressant medications.

Bipolar disorder is associated with high personal, social, and economic costs. About 33% of bipolar I patients cannot maintain employment in the 6 months after a manic episode; over 50% show declines in occupational functioning over the 5 years after an episode. The suicide rate is believed to be about 30 times greater than the normal population. Bipolar disorder is also associated with marital dysfunction and high rates of divorce, general health complications, legal problems, and problems in the adjustment of children (Coryell, Andreasen, Endicott, & Keller, 1987; Coryell et al., 1993; Goldberg, Harrow, & Grossman,

1995; Dion, Tohen, Anthony, & Waternaux, 1988; Hammen, Burge, Burney, & Adrian, 1990; Silverstone & Romans-Clarkson, 1989). In 1991, the economic costs of bipolar disorder were $45 billion in the United States alone (Wyatt & Henter, 1995).

Most bipolar patients develop the illness between the ages of 19 and 23. However, prepubertal and adolescent onsets of the disorder are being increasingly recognized. In fact, the age at onset of the disorder is becoming younger in successive generations. Between 20% and 40% of bipolar patients have their first onset in childhood or adolescence, and about 20% of depressed adolescents eventually switch into mania. The early-onset form of the disease appears to have a stronger genetic liability (greater familial aggregation) than the later-onset forms. It is also frequently characterized by mixed symptoms, rapid cycling, psychosis, and other poor prognostic attributes. If bipolar teenagers are not treated early, they can fall behind, sometimes irreparably, in social, school, and work functioning (Geller & Luby, 1997; McClellan & Werry, 1997).

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Understanding And Treating Bipolar Disorders

Understanding And Treating Bipolar Disorders

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