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| '''For patient information click [[Bipolar disorder (patient information)|here]]''' | | '''For patient information click [[Bipolar disorder (patient information)|here]]''' |
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| {{Bipolar disorder}} | | {{Bipolar disorder}} |
| {{CMG}} | | {{CMG}} {{AE}} {{nuha}} |
| == [[Bipolar disorder overview|Overview]] ==
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| == [[Bipolar disorder historical perspective|Historical Perspective]] ==
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| == [[Bipolar disorder classification|Classification]] ==
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| == [[Bipolar disorder pathophysiology|Pathophysiology]] ==
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| == [[Bipolar disorder causes|Causes]] ==
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| == [[Bipolar disorder differentiating Bipolar disorder from other diseases|Differentiating Bipolar disorder from other Diseases]] == | | {{SK}} Manic depression; bipolar affective disorder |
| | ==[[Bipolar disorder overview|Overview]]== |
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| == [[Bipolar disorder epidemiology and demographics|Epidemiology and Demographics]] == | | ==[[Bipolar disorder historical perspective|Historical Perspective]]== |
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| == [[Bipolar disorder risk factors|Risk Factors]] == | | ==[[Bipolar disorder classification|Classification]]== |
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| == [[Bipolar disorder complications and prognosis|Complications and Prognosis]] == | | ==[[Bipolar disorder pathophysiology|Pathophysiology]]== |
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| == Diagnosis == | | ==[[Bipolar disorder causes|Causes]]== |
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| [[Bipolar disorder history and symptoms|History and Symptoms]] | [[Bipolar disorder physical examination|Physical Examination]] | [[Bipolar disorder laboratory findings|Laboratory Findings]] | [[Bipolar disorder electrocardiogram|ECG]] | [[Bipolar disorder CT|CT]] | [[Bipolar disorder MRI|MRI]] | [[Bipolar disorder other diagnostic studies|Other Diagnostic Studies]] | | ==[[Bipolar disorder differentiating Bipolar disorder from other diseases|Differentiating Bipolar disorder from other Diseases]]== |
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| == Treatment == | | ==[[Bipolar disorder epidemiology and demographics|Epidemiology and Demographics]]== |
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| [[Bipolar disorder medical therapy|Medical Therapy]] | [[Bipolar disordercost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Bipolar disorder future or investigational therapies|Future or Investigational Therapies]] | | ==[[Bipolar disorder risk factors|Risk Factors]]== |
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| ==Overview== | | ==[[Bipolar disorder complications and prognosis|Complications and Prognosis]]== |
| '''Bipolar disorder''' is a [[psychiatric]] condition defined as recurrent episodes of significant disturbance in [[mood]]. These disturbances can occur on a [[Bipolar spectrum|spectrum]] that ranges from debilitating [[clinical_depression|depression]] to unbridled [[mania]]. Individuals suffering from bipolar disorder typically experience fluid states of [[mania]], [[hypomania]] or what is referred to as a [[Mixed state (psychiatry)|mixed state]] in conjunction with [[clinical depression|depressive]] episodes. These clinical states typically alternate with a normal range of mood. The disorder has been subdivided into [[bipolar I]], bipolar II and [[cyclothymia]], with both bipolar I and bipolar II potentially presenting with [[Bipolar disorder#Rapid cycling|rapid cycling]].
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| Also called '''bipolar affective disorder''' until recently, the current name is of fairly recent origin and refers to the cycling between high and low episodes; it has replaced the older term '''manic-depressive illness''' coined by [[Emil Kraepelin]] (1856-1926) in the late nineteenth century.[http://www.kraepelin.org/] The new term is designed to be neutral, to avoid the stigma in the non-mental health community that comes from conflating "manic" and "depression."
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| Onset of symptoms generally occurs in young adulthood. Diagnosis is based on the person's self-reported experiences, as well as observed behavior. Episodes of illness are associated with distress and disruption, and a relatively high risk of [[suicide]].<ref>
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| {{Citation
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| | last = Ösby
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| | first = U
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| | last2 = Brandt
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| | first2 = L
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| | last3 = Correia
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| | last4 = Ekbom
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| | first4 = A
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| | last5 = Sparén
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| | first5 = P
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| | title = Excess Mortality in Bipolar and Unipolar Disorder in Sweden
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| | journal = Archives of General Psychiatry
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| | volume = 58
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| | issue = 9
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| | pages = 844-850
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| | year = 2001
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| | url = http://archpsyc.ama-assn.org/cgi/content/abstract/58/9/844
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| }}
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| </ref>
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| Studies suggest that [[genetics]], early environment, [[neurobiology]], and psychological and social processes are important contributory factors. Psychiatric research is focused on the role of neurobiology, but a clear organic cause has not been found. Bipolar disorder is usually treated with medications and/or therapy or counseling. The mainstay of medication are a number of drugs termed '[[mood stabilizer]]s', in particular [[Lithium pharmacology|lithium]] and [[sodium valproate]] ; these are a group of unrelated medications used to prevent relapses of further episodes. [[Antipsychotic]] medications, sometimes called [[neuroleptic]]s, in particular [[olanzapine]], are used in the treatment of manic episodes and in maintenance. The benefits of using [[antidepressant]]s in depressive episodes is unclear. In serious cases where there is risk to self and others involuntary hospitalization may be necessary; these generally involve severe manic episodes with dangerous behaviour or depressive episodes with suicidal ideation. Hospital stays are less frequent and for shorter periods than they were in previous years.
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| Some studies have suggested a significant correlation between [[creativity]] and bipolar disorder. However, the relationship between the disorder and creativity is still very unclear.<ref name="santosa2006"> Santosa et al. Enhanced creativity in bipolar disorder patients: A controlled study. ''J Affect Disord.'' 2006 [[23 November]]; PMID 17126406.
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| </ref><ref name="rihmer2006">
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| Rihmer et al. Creativity and mental illness. ''Psychiatr Hung.'' 2006;21(4):288-94. PMID 17170470.
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| </ref><ref name="nowakowska2006">Nowakowska et al. Temperamental commonalities and differences in euthymic mood disorder patients, creative controls, and healthy controls. ''J Affect Disord.'' 2005 Mar;85(1-2):207-15. PMID 15780691.
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| </ref> One study indicated increased striving for, and sometimes obtaining, goals and achievements.<ref>Johnson SL. (2005) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15642648 Mania and dysregulation in goal pursuit: a review.] ''Clin Psychol Rev.'' Feb;25(2):241-62.</ref>
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| ==History==
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| {{main|History of bipolar disorder}}
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| Varying moods and energy levels have been a part of the human experience since time immemorial. The words "[[melancholia]]" (an old word for [[depression (mood)|depression]]) and "mania" have their [[etymologies]] in [[Ancient Greek]]. The word melancholia is derived from ''melas''/μελας, meaning "black", and ''chole''/χολη, meaning "bile" or "gall",<ref name="Liddell 1980">{{cite book |author = [[Henry George Liddell|Liddell, Henry George]] and [[Robert Scott (philologist)|Robert Scott]] | year = 1980 | title = [[A Greek-English Lexicon]] (Abridged Edition) | publisher = [[Oxford University Press]] | location = United Kingdom | id = ISBN 0-19-910207-4}}</ref> indicative of the term’s origins in pre-[[Hippocrates|Hippocratic]] [[humoral]] theories. Within the humoral theories, mania was viewed as arising from an excess of [[yellow bile]], or a mixture of black and yellow bile. The [[linguistic]]origins of mania, however, are not so clear-cut. Several etymologies are proposed by the [[Ancient Rome|Roman]] physician [[Caelius Aurelianus]], including the Greek word ‘ania’, meaning to produce great mental anguish, and ‘manos’, meaning relaxed or loose, which would contextually approximate to an excessive relaxing of the mind or soul (Angst and Marneros 2001). There are at least five other candidates, and part of the confusion surrounding the exact etymology of the word mania is its varied usage in the pre-Hippocratic[[poetry]] and [[mythology|mythologies]] (Angst and Marneros 2001).
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| The idea of a relationship between mania and melancholia can be traced back to at least the [[2nd century AD]][http://www.k12academics.com/bipolar_history.htm]. [[Soranus (Greek Physician)|Soranus]] of Ephesus (98-177 AD) described mania and melancholia as distinct diseases with separate[[etiologies]][http://assets.cambridge.org/97805218/35176/excerpt/9780521835176_excerpt.pdf]; however, he acknowledged that “many others consider melancholia a form of the disease of mania” (Cited in Mondimore 2005 p.49).
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| A clear understanding of bipolar disorder as a mental illness was recognized by early Chinese authors. The encyclopedist [[Gao Lian]] (c. 1583) describes the malady in his ''Eight Treatises on the Nurturing of Life'' (Ts'un-sheng pa-chien).[http://www.nmh.gov.tw/nmh_web/english_version/exhibition/exhibition_s0703.cfm]
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| The earliest written descriptions of a relationship between mania and melancholia are attributed to [[Aretaeus of Cappadocia]]. Aretaeus was an [[Eclectic medicine|eclectic]] medical philosopher who lived in [[Alexandria]] somewhere between 30 and [[150]] AD (Roccatagliata 1986; Akiskal 1996). Aretaeus is recognized as having authored most of the surviving texts referring to a unified concept of manic-depressive illness, viewing both melancholia and mania as having a common origin in ‘black bile’ (Akiskal 1996; Marneros 2001).
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| [[Image:Emil Kraepelin.png|left|thumb|[[Emil Kraepelin]] (1856–1926) refined the concept of [[psychosis]].]]
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| The contemporary psychiatric conceptualisation of manic-depressive illness is typically traced back to the [[1850s]]. Marneros (2001) describes the concepts emerging out of this period as the “rebirth of bipolarity in the modern era”. On [[January 31]],[[1854]], [[Jules Baillarger]] described to the French Imperial [[Academy of Medicine]] a [[biphasic]] [[mental illness]] causing recurrent oscillations between mania and depression. Two weeks later, on [[February 14]], [[1854]], [[Jean-Pierre Falret]] presented a description to the Academy on what was essentially the same disorder. This illness was designated ''folie circulaire'' (‘circular[[insanity]]’) by Falret, and ''folie à double forme'' (‘dual-form insanity’) by Baillarger (Sedler 1983).
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| [[Emil Kraepelin]] ([[1856]]-[[1926]]), a German [[psychiatrist]] categorized and studied the natural course of untreated bipolar patients long before [[mood stabilizer]]s were discovered. Describing these patients in 1902, he coined the term ''manic depressive[[psychosis]]''. He noted in his patient observations that intervals of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals in which the patient was able to function normally.<ref>[[Emil Kraepelin|Kraepelin, Emil]] (1921) ''Manic-depressive Insanity and Paranoia'' ISBN 0-405-07441-7 </ref>
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| After [[World War II]], Dr. [[John Cade]], an Australian [[psychiatrist]], was investigating the effects of various compounds on veteran patients with manic depressive psychosis. In 1949 , Cade discovered that [[lithium carbonate]] could be used as a successful treatment of manic depressive psychosis.<ref>{{cite journal
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| | title = Lithium salts in the treatment of psychotic excitement
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| | author = Cade J. F. J.
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| | journal = Medical Journal of Australia
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| | year = 1949
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| | volume = 2
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| | issue =
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| | pages = 349–352
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| | url = http://www.who.int/docstore/bulletin/pdf/2000/issue4/classics.pdf}}</ref> Because there was a fear that table salt substitutes could lead to toxicity or death, Cade's findings did not immediately lead to treatments. In the 1950s, U.S. hospitals began experimenting with lithium on their patients. By the mid-'60s, reports started appearing in the medical literature regarding lithium's effectiveness. The U.S. Food and Drug Administration did not approve of lithium's use until 1970.<ref>{{cite journal
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| | title =Lithium treatment for bipolar disorder
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| | author = P. B. Mitchell, D. Hadzi-Pavlovic
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| | journal = Bulletin of the World Health Organization
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| | year = 2000
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| | volume = 78
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| | issue =4
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| | pages = 515-519
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| | url = http://www.who.int/docstore/bulletin/pdf/2000/issue4/classics.pdf}}</ref>
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| The term "manic-depressive ''reaction''" appeared in the first [[American Psychiatric Association]] Diagnostic Manual in 1952, influenced by the legacy of [[Adolf Meyer (psychiatrist)|Adolf Meyer]] who had introduced the paradigm illness as a reaction of biogenetic factors to psychological and social influences.<ref>Goodwin & Jamison. p60-61</ref> Subclassification of bipolar disorder was first proposed by German psychiatrist [[Karl Leonhard]] in 1957; he was also the first to introduce the terms ''bipolar'' (for those with mania) and ''unipolar'' (for those with depressive episodes only).<ref>Goodwin & Jamison. p62</ref>
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| In 1968, both the newly revised classification systems ICD-8 and DSM-II termed the condition "manic-depressive ''illness''" as biological thinking came to the fore.<ref>Goodwin & Jamison. p88</ref>
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| The current [[nosology]], bipolar disorder, became popular only recently, and some individuals prefer the older term because it provides a better description of a continually changing multi-dimensional illness.
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| ==Epidemiology==
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| Clinical depression and bipolar disorder are classified as separate illnesses. Some researchers increasingly view them as part of an overlapping spectrum that also includes anxiety and psychosis.
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| According to Hagop Akiskal, [[M.D.]], at the one end of the spectrum is bipolar type [[schizoaffective disorder]], and at the other end is [[unipolar depression]] (recurrent or not recurrent), with the anxiety disorders present across the spectrum. Also included in this view is [[premenstrual dysphoric disorder]], [[postpartum depression]], and [[postpartum psychosis]]. This view helps to explain why many people who have the illness do not have first-degree relatives with clear-cut "bipolar disorder", but who have family members with a history of these other disorders.
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| In a 2003 study, Hagop Akiskal M.D. and Lew Judd M.D. re-examined data from the landmark [[Epidemiologic]] [[Catchment]] Area study from two decades before.<ref name=Judd_and_Akiskal_2003>{{cite journal | first = Lewis L. | last = Judd | coauthors = Hagop S. Akiskal | month = January | year = 2003 | title = The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases | journal = Journal of Affective Disorders | volume = 73 |issue = 1-2 | pages = 123-131 | id = {{DOI|10.1016/S0165-0327(02)00332-4}}|url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=12507745&dopt=ExternalLink}}</ref> The original study found that 0.8 percent of the population surveyed had experienced a [[manic episode]] at least once (the diagnostic threshold for [[bipolar I]]) and 0.5 a [[hypomanic]]episode (the diagnostic threshold for bipolar II).
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| By tabulating survey responses to include sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, the authors arrived at an additional 5.1 percent of the population, adding up to a total of 6.4 percent of the entire population who can be thought of as having a bipolar spectrum disorder. This and similar recent studies have been interpreted by some prominent bipolar disorders researchers as evidence for a much higher [[prevalence]] of bipolar conditions in the general population than previously thought.
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| However these re-analyses should be interpreted cautiously because of substantive as well as methodological study limitations. Indeed, prevalence studies of bipolar disorder are carried out by lay interviewers (that is, not by expert[[clinician]]s/psychiatrists who are more costly to employ) who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity.
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| Furthermore, a well-known statistical problem arises when ascertaining disorders and conditions with a relatively low population prevalence or base-rate, such as bipolar disorder: even assuming that lay interviews diagnoses are highly accurate in terms of[[Sensitivity (tests)|sensitivity]] and [[Specificity (tests)|specificity]] and their corresponding area under the [[ROC curve]](that is, [[AUC]], or area under the [[receiver operating characteristic]] curve), a condition with a relatively low prevalence or base-rate is bound to yield high [[Type I and type II errors|false positive]] rates, which exceed [[Type I and type II errors|false negative]] rates; in such a circumstance a limited [[positive predictive value]], PPV, yields high [[false positive]] rates even in presence of a specificity which is very close to 100%.<ref name=Baldessarini1993>{{cite journal | first = Ross J. | last = Baldessarini | coauthors = Finklestein S., Arana G. W.| month = May | year = 1983 | title =
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| The predictive power of diagnostic tests and the effect of prevalence of illness | journal = Archives of General Psychiatry | volume = 40 | issue = 5 | pages = 569-573 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=6838334&dopt=ExternalLink}}</ref>
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| To simplify, it can be said that a very small error applied over a very large number of individuals (that is, those who are *not affected* by the condition in the general population during their lifetime; for example, over 95%) produces a relevant, non-negligible number of subjects who are incorrectly classified as having the condition or any other condition which is the object of a survey study: these subjects are the so-called false positives; such reasoning applies to the 'false positive' but not the 'false negative' problem where we have an error applied over a relatively very small number of individuals to begin with (that is, those who are *affected* by the condition in the general population; for example, less than 5%).
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| Hence, a very high percentage of subjects who seem to have a history of bipolar disorder at the interview are false positives for such a medical condition and apparently never suffered a fully [[clinical]] [[syndrome]] (that is, bipolar disorder type I): the population prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, continues to be estimated at 1%.<ref name=Soldani2005>{{cite journal | first = Federico | last = Soldani | coauthors = Sullivan P. F. Pedersen N. L. | month = Apr | year = 2005 | title = Mania in the Swedish Twin Registry: criterion validity and prevalence | journal = Australian and New Zealand of Psychiatry | volume = 39 | issue = 4 | pages = 235-243 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=15777359&dopt=ExternalLink}}</ref> "Mild-to-severe versions of bipolar disorder afflict nearly 4 percent of adults at some time in their lives."<ref>Bipolar Surprise, Science News, [[March 31]] [[2007]], vol. 171, #13, p.196</ref>
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| A different but related problem in evaluating the public health significance of psychiatric conditions has been highlighted by[[Robert Spitzer (psychiatrist)|Robert Spitzer]] of [[Columbia University]]: fulfillment of [[diagnostic criteria]] and the resulting [[diagnosis]] do not necessarily imply need for treatment.<ref name=Spitzer1998>{{cite journal | first = Robert | last = Spitzer | month = Feb | year = 1998 | title = Diagnosis and need for treatment are not the same | journal = Archives of General Psychiatry | volume = 55 | issue = 2 | pages = 120 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=9477924&dopt=ExternalLink}}</ref> As a consequence, subjects who experience bipolar symptoms but not a full-blown, impairing bipolar syndrome should not be automatically considered as patients in need of treatment.
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| Recent studies have indicated that at least 50% of adult sufferers report manifestation of symptoms before the age of 17. Moreover, there is a growing consensus that bipolar disorder originates in childhood. In young children the illness is now referred to as[[pediatric]] bipolar disorder. Today about 0.5% of children under 18 are believed to have the condition. For children, the main concern is that bipolar disorder needs to be diagnosed correctly and treated properly because it can look like unipolar depression,[[ADHD]], or [[conduct disorder]]. Young children, [[adolescent]]s and [[adult]]s each express the condition differently according to child and adolescent bipolar disorders expert [http://www.bipolarchild.com/articles.html Demitri Papolos M.D.] and the[http://www.bpkids.org Child and Adolescent Bipolar Foundation]. There is, however, controversy about this last point<ref>{{cite web|title=Bipolar Disorder in Children and Adolescents: a Caution|url=http://www.psycheducation.org/depression/SoboOnKids.htm|accessdate= |format= |work= |publisher=psycheducation.org}}</ref>
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| Bipolar disorder manifests in late life as well. Some individuals with "hyperthymic" temperament (or "hypomanic" personality style) who experience depression in later life appear to have a form of bipolar disorder. Much more needs to be elucidated about late-life bipolar disorder.
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| Approximately 50% of children in the U.S. child welfare system who have [[reactive attachment disorder]] also have comorbid[[Bipolar I]] disorder according to research by John Alston, MD.
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| ==Etiology==
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| According to the U.S. government's [[National Institute of Mental Health]] (NIMH), "There is no single cause for bipolar disorder—rather, many factors act together to produce the illness." "Because bipolar disorder tends to run in families, researchers have been searching for specific [[gene]]s passed down through generations that may increase a person's chance of developing the illness." "In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.".<ref>{{cite web |url=http://www.nimh.nih.gov/publicat/bipolar.cfm#bp5 |title=What Causes Bipolar Disorder? |accessdate= |format= |work= |author=NIMH}}</ref>
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| It is well established that bipolar disorder is a genetically influenced condition which can respond very well to medication (Johnson & Leahy, 2004; Miklowitz & Goldstein, 1997; Frank, 2005).
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| (See [[treatment of bipolar disorder]] for a more detailed discussion of treatment.)
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| Psychological factors also play a strong role in both the [[psychopathology]] of the disorder and the [[psychotherapeutic]] factors aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing[[prodromal]] symptoms before full-blown recurrence, and, practising the factors that lead to maintenance of [[remission (medicine)|remission]] (Lam et al, 1999; Johnson & Leahy, 2004; Basco & Rush, 2005; Miklowitz & Goldstein, 1997; Frank, 2005). Modern [[evidence based medicine|evidence based]] psychotherapies designed specifically for bipolar disorder when used in combination with standard medication treatment increase the time the individual stays well significantly longer than medications alone (Frank, 2005). These psychotherapies are [[interpersonal and social rhythm therapy]] for bipolar disorder, family focused therapy for bipolar disorder, psychoeducation, [[cognitive therapy]] for bipolar disorder, and [[prodrome]] detection. All except psychoeducation and prodrome detection are available as books.
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| Abnormalities in brain function have been related to feelings of [[anxiety]] and lower stress resilience. When faced with a very stressful, negative major life event, such as a failure in an important area, an individual may have his first major depression. Conversely, when an individual accomplishes a major achievement he may experience his first [[hypomanic]] or [[manic]] episode. Individuals with bipolar disorder tend to experience episode triggers involving either [[interpersonal]] or achievement-related life events. An example of interpersonal-life events include [[falling in love]] or, conversely, the death of a close friend. Achievement-related life events include acceptance into an elite [[graduate school]] or by contrast, being fired from work (Miklowitz & Goldstein, 1997). [[Childbirth]] can also trigger a [[postpartum psychosis]] for bipolar women, which can lead in the worse cases to [[infanticide]].
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| The "[[kindling]]" theory<ref name=kindling>[http://www.bpinfo.net/kindling_theory.htm Link and reference involving kindling theory]</ref> asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and becomes recurrent) by itself. Not all individuals experience subsequent mood episodes in the absence of positive or negative life events, however.
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| Individuals with late-[[adolescent]]/early [[adult]] onset of the disorder will very likely have experienced [[childhood]] anxiety and depression. Some argue that childhood-onset bipolar disorder should be treated early.
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| A [[family history (medicine)|family history]] of [[bipolar spectrum]] disorders can impart a genetic predisposition towards developing a bipolar spectrum disorder.<ref name=Genetic_Likelihood>[http://www.psycheducation.org/depression/risk.htm Genetics and Risk] PsychEducation.org</ref> Since bipolar disorders are [[polygenic]] (involving many genes), there are apt to be many unipolar and bipolar disordered individuals in the same family pedigree. This is very often the case (Barondes, 1998). [[Anxiety disorders]], clinical depression, [[eating disorders]], [[premenstrual dysphoric disorder]], [[postpartum depression]], [[postpartum psychosis]]and/or [[schizophrenia]] may be part of the patient's family history and reflects a term called "genetic loading".
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| Bipolar disorder is not either environmental or physiological, it is multifactorial; that is, many genes and [[environmental factors]] conspire to create the disorder (Johnson & Leahy, 2004).
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| Since bipolar disorder is so [[heterogeneous]], it is likely that people experience different pathways towards the illness (Miklowitz & Goldstein, 1997).
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| Recent research done in Japan indicates a hypothesis of dysfunctional mitochondria in the brain (Stork & Renshaw, 2005)''
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| ===Heritability or inheritance===
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| The disorder runs in families.<ref>
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| {{Citation
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| | last = McGuffin
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| | last2 = Rijsdijk
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| | first2 = F
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| | last3 = Andrew
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| | last4 = Sham
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| | last5 = Katz
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| | first5 = R
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| | last6 = Cardno
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| | first6 = A
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| | title = The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression
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| | journal = Archives of General Psychiatry
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| | volume = 60
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| | issue = 5
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| | pages = 497-502
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| | year = 2003
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| | url = http://archpsyc.ama-assn.org/cgi/content/abstract/60/5/497
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| }}
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| </ref> More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression.
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| Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes, using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.
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| ==Classification==
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| Bipolar disorder is commonly categorized as either bipolar type I, where an individual experiences full-blown [[mania]], or bipolar type II, in which the [[hypomanic]] "highs" do not go to the extremes of mania. The latter is much more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression. [[Psychosis]] can occur, particularly in manic periods. There are also 'rapid cycling' subtypes. Because there is so much variation in the severity and nature of mood-related problems, the concept of a [[bipolar spectrum]] is often employed, which includes [[cyclothymia]]. There is no consensus as to how many 'types' of bipolar disorder exist.<ref>{{cite journal|author=Akiskal HS, Benazzi F |year=2006 |month=May |title= The DSM-IV and ICD-10 categories of recurrent [major] depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum.|journal= J Affect Disord.|volume=92 |issue=1|pages=45-54|PMID = 16488021 |url=http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16488021&ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum(abstract) |accessdate = 2007-06-29}}</ref> Many people with bipolar disorder experience severe [[anxiety]] and are very irritable (to the point of rage) when in a manic state, while others are [[Euphoria (emotion)|euphoric]] and grandiose.
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| ===Depressive phase===
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| {{main|Clinical depression}}
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| Signs and symptoms of the depressive phase of bipolar disorder include: persistent feelings of [[sadness]], [[anxiety]], [[guilt]],[[anger]], [[isolation]] and/or hopelessness, disturbances in [[sleep]] and [[appetite]], [[fatigue (physical)|fatigue]] and loss of interest in usually enjoyed activities, problems concentrating, [[loneliness]], self-loathing, apathy or indifference,[[depersonalization]], loss of interest in sexual activity, [[shyness]] or [[social anxiety]], [[irritability]], [[chronic pain]](with or without a known cause), lack of motivation, and morbid/[[suicidal ideation]].<ref name="Mayo-dsection2">{{cite web|url=http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=2 |title=Bipolar Disorder: Signs and symptoms|publisher=Mayo Clinic |accessdate= |format= |work= }}</ref>
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| ===Mania===
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| {{main|Mania}}
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| Mania is generally characterized by a distinct period of an elevated, expansive or irritable mood state. People commonly experience an increase in energy and a decreased need for sleep. A person's speech may be pressured, with thoughts experienced as racing. Attention span is low and a person in a manic state may be easily distracted. People may feel they have been 'chosen', or are 'on a special mission', which are considered grandiose or delusional ideas. At more extreme phases, a person in a manic state can begin to experience [[psychosis]], or a break with reality, where thinking is affected along with mood. In order to be diagnosed with mania according to DSM-IV, a person must experience this state of elevated or irritable mood as well as other symptoms for two or more weeks.
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| ===Hypomania===
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| {{main|Hypomania}}
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| Hypomania is generally a less extreme state than mania, and people in the hypomanic phase generally experience fewer of the symptoms of mania than those in a full-blown manic episode. During an episode of Hypomania, one might feel an uncontrollable impulse to laugh at things he or she does not normally find funny. The duration is usually also shorter than in mania. This is often a very 'artistic' state of the disorder, where there is a flight of ideas, extremely clever thinking, and an increase in energy.
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| ===Mixed state===
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| {{main|Mixed state (psychiatry)}}
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| In the context of bipolar disorder, a mixed state is a condition during which symptoms of [[mania]] and [[clinical depression]]occur simultaneously (for example, [[agitation (emotion)|agitation]], [[anxiety]], aggressiveness or belligerence, confusion, [[fatigue (physical)|fatigue]], [[Wiktionary:impulsiveness|impulsiveness]], [[insomnia]], [[irritability]], morbid and/or[[suicidal ideation]], [[panic]], [[paranoia]], persecutory delusions, pressured speech, racing thoughts, restlessness, and [[Rage (emotion)|rage]]).<ref>{{cite web |url=http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=7 |title=Bipolar Disorder: Complications |accessdate= |format= |work= |publisher=Mayo Clinic}}</ref>
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| Mixed episodes can be the most volatile of the bipolar states, as moods can easily and quickly be triggered or shifted. Suicide attempts, substance abuse, and self-mutilation may occur during this state.
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| ===Rapid cycling===
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| Rapid cycling, defined as having four or more episodes per year, is found in a significant fraction of patients with bipolar disorder. It has been associated with greater disability or a worse prognosis, due to the confusing changeability and difficulty in establishing a stable state. Rapid cycling can be induced or made worse by [[antidepressant]]s, unless there is adjunctive treatment with a mood stabilizer.<ref>{{cite web|url=http://www.wpic.pitt.edu/stanley/1stbipconf/bipolar2.htm#trtref|title=Treatment of refractory and rapid-cycling bipolar disorder}}</ref><ref>Sachs, GS, MD, et al (2007)[http://content.nejm.org/cgi/content/abstract/356/17/1711 Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression] ''New England Journal of Medicine'', Volume 356:1711-1722 (Abstract)</ref>
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| The definition of rapid cycling most frequently cited in the literature is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period. <ref>
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| {{Citation
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| | last = Mackin
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| | first = P
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| | last2 = Young
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| | first2 = AH
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| | title = Rapid cycling bipolar disorder: historical overview and focus on emerging treatments
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| | journal = Bipolar Disorders
| |
| | volume = 6
| |
| | issue = 6
| |
| | pages = 523–529
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| | year = 2004
| |
| | doi = 10.1111/j.1399-5618.2004.00156.x
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| }}
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| </ref> There are references that describe very rapid (ultra-rapid) or extremely rapid <ref>
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| {{Citation
| |
| | last = Papolos
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| | first = DF
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| | last2 = Veit
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| | first2 = S
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| | last3 = Faedda
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| | first3 = GL
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| | last4 = Saito
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| | first4 = T
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| | last5 = Lachman
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| | first5 = HM
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| | title = Ultra-ultra rapid cycling bipolar disorder is associated with the low activity catecholamine-O-methyltransferase allele
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| | journal = Molecular Psychiatry
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| | volume = 3
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| | issue = 4
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| | pages = 346-349
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| | year = 1998
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| | url = http://www.nature.com/mp/journal/v3/n4/abs/4000410a.html
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| }}
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| </ref> (ultra-ultra or ultraradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24-48 hour period.
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| ===Cognition===
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| Recent studies have found that bipolar disorder involves certain [[cognitive deficit]]s or impairments, even in states of[[remission (medicine)|remission]].<ref>
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| {{Citation
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| | last = Martínez-Arán
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| | first = A
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| | last2 = Vieta
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| | first2 = E
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| | last3 = Reinares
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| | first3 = M
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| | last4 = Colom
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| | first4 = F
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| | last5 = Torrent
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| | first5 = C
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| | last6 = Sánchez-Moreno
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| | first6 = J
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| | last7 = Benabarre
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| | first7 = A
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| | last8 = Goikolea
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| | first8 = JM
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| | last9 = Comes
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| | first9 = M
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| | last10 = Salamero
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| | first10 = M
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| | title = Cognitive Function Across Manic or Hypomanic, Depressed, and Euthymic States in Bipolar Disorder
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| | journal = American Journal of Psychiatry
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| | volume = 161
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| | issue = 2
| |
| | pages = 262-270
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| | year = 2004
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| | date = February 2004
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| | url = http://ajp.psychiatryonline.org/cgi/content/abstract/161/2/262
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| }}
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| </ref><ref>
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| {{Citation
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| | last = Rossi
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| | first = A
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| | last2 = Arduini
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| | first2 = L
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| | last3 = Daneluzzo
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| | first3 = E
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| | last4 = Bustini
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| | first4 = M
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| | last5 = Prosperini
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| | first5 = P
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| | last6 = Stratta
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| | first6 = P
| |
| | title = Cognitive function in euthymic bipolar patients, stabilized schizophrenic patients, and healthy controls
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| | journal = Journal of Psychiatric Research
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| | volume = 34
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| | issue = 4-5
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| | pages = 333-339
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| | date = July 2000
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| | year = 2000
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| | doi = 10.1016/S0022-3956(00)00025-X
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| }}
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| </ref><ref>
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| {{Citation
| |
| | title = Second Biennial Conference of the International Society for Bipolar Disorders, 2–[[4 August]] [[2006]], Edinburgh, Scotland, Thursday, [[August 3]], 09:00-10:00, Cognitive Function in BD
| |
| | journal = Bipolar Disorders
| |
| | volume = 8
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| | issue = Supplement 1
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| | pages = 2–3
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| | date = August 2006
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| | doi = 10.1111/j.1399-5618.2006.00379_2.x
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| }}
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| </ref><ref>
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| {{Citation
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| | last = Zubieta
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| | first = J-K
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| | last2 = Huguelet
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| | first2 = P
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| | last3 = O'Neil
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| | first3 = RL
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| | last4 = Giordani
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| | first4 = BJ
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| | title = Cognitive function in euthymic Bipolar I Disorder
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| | journal = Psychiatry Research
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| | volume = 102
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| | issue = 1
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| | pages = 9-20
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| | date = [[10 May]] [[2001]]
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| | doi = 10.1016/S0165-1781(01)00242-6
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| }}
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| </ref>
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| Deborah Yurgelun-Todd <!--PhD--> of [[McLean Hospital]] in [[Belmont, Massachusetts|Belmont]], [[Massachusetts]] has argued these deficits should be included as a core feature of bipolar disorder. According to McIntyre et al. (2006), <blockquote>
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| Study results now press the point that neurocognitive deficits are a primary feature of BD; they are highly prevalent and persist in the absence of overt symptomatology. Although disparate neurocognitive abnormalities have been reported, disturbances in attention,[[visual memory]], and [[executive function]] are most consistently reported.<ref name=cog_[[17 November]]>{{cite journal|author=Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski|year=2006|title=Bipolar Disorder: Defining Remission and Selecting Treatment|journal=Psychiatric Times|cite= October 2006, Vol. XXIII, No. 11 |url=http://www.psychiatrictimes.com/article/showArticle.jhtml?articleId=193400986}}. </ref>
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| </blockquote> However, in the April-June 2007 issue of the Journal of Psychiatric Research, Spanish researchers reported that people with bipolar 1 who have a history of psychotic symptoms do not necessarily experience an increase in cognitive impairment.
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| | |
| ===Creativity===
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| {{main|Creativity and mental illness}}
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| A number of recent studies have observed a correlation between creativity and bipolar disorder,<ref name="santosa2006"/><ref name="rihmer2006"/><ref name="nowakowska2006"/> although it is unclear in which direction the cause lies, or whether both conditions are caused by some third, unknown, factor.
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| It has been hypothesized that temperament may be one such factor.
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| | |
| ==Signs and symptoms==
| |
| Bipolar disorder is a cyclic illness where people periodically exhibit elevated (Manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting 3-6 months.<ref>
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| {{Citation
| |
| | last = Kessler
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| | first = RC
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| | last2 = McGonagle
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| | first2 = KA
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| | first3 = S
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| | last4 = Nelson
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| | first4 = CB
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| | last5 = Hughes
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| | first5 = M
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| | last6 = Eshleman
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| | first6 = S
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| | last7 = Wittchen
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| | first7 = HU
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| | last8 = Kendler
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| | first8 = KS
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| | title = Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States
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| | journal = Archives of General Psychiatry
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| | volume = 51
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| | issue = 1
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| | pages = 8-19
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| | year = 1994
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| | url = http://archpsyc.ama-assn.org/cgi/content/abstract/51/1/8
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| }}
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| </ref><ref>
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| {{Citation
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| | last = Angst
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| | first = J
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| | author-link =
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| | last2 = Selloro
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| | first2 = R
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| | title = Historical perspectives and natural history of bipolar disorder
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| | journal = Biological Psychiatry
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| | volume = 48
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| | issue = 6
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| | pages = 445-457
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| | date = [[15 September]] [[2000]]
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| | doi = 10.1016/S0006-3223(00)00909-4
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| }}
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| </ref> Late adolescence and early adulthood are peak years for the onset of the illness.<ref name ="Christie88">{{cite journal |author=Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ |year=1988 |title=Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults |journal=Am J Psychiatry |volume=145 |pages=971-975 |id= |url=http://www.ajp.psychiatryonline.org/cgi/content/abstract/145/8/971 (abstract) |accessdate = 2007-07-01 }}</ref><ref>Goodwin & Jamison. p121</ref> These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.
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|
| ==Diagnosis== | | ==Diagnosis== |
| Diagnosis is based on the self-reported experiences of the patient as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a [[psychiatrist]], [[social worker]], [[clinical psychologist]] or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.
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|
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| An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm bipolar disorder, tests are carried out to exclude medical illnesses which may rarely present with psychiatric symptoms. These include blood tests measuring [[Thyroid-stimulating hormone|TSH]] to exclude [[hypothyroidism|hypo-]] or [[hyperthyroidism]], [[Blood tests#Blood chemistry tests|basic electrolytes]] and serum [[calcium]] to rule out a metabolic disturbance, [[Complete blood count|full blood count]] including [[Erythrocyte sedimentation rate|ESR]] to rule out a systemic infection or chronic disease, and [[serology]] to exclude [[syphilis]] or [[HIV]] infection; two commonly ordered investigations are [[Electroencephalography|EEG]] to exclude [[epilepsy]], and a [[Computed tomography|CT scan]] of the head to exclude brain lesions. There are several psychiatric illnesses which may present with similar symptoms; these include [[schizophrenia]],<ref>Pope HG (1983). Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports. Hospital and Community Psychiatry, 34: 322–328.</ref> drug intoxication, brief drug-induced psychosis, [[schizophreniform disorder]] and [[borderline personality disorder]].
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|
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| The last is important as both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months (notwithstanding Rapid Cycling variant of greater than four episodes a year). The term in borderline personality refers to the marked [[Affective_lability|lability]] and reactivity of mood, known as [[emotional dysregulation]], due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.<ref>Goodwin & Jamison. p108-110</ref>
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|
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| The relationship between bipolar disorder and borderline personality disorder has been debated; some hold that the latter represents a subthreshold form of affective disorder,<ref>{{cite journal |author=Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H |year=1985 |title=The nosologic status of borderline personality: Clinical and polysomnographic study |journal=Am J Psychiatry |volume=142 |pages=192-198}}</ref><ref>{{cite journal |author=Gunderson JG, Elliott GR |year=1985 |title=The interface between borderline personality disorder and affective disorder |journal=Am J Psychiatry |volume=142 |pages=277-288}}</ref> while others maintain the distinctness, though noting they often coexist.<ref>{{cite journal |last=McGlashan |first=TH |year=1983 |title=The borderline syndrome:Is it a variant of schizophrenia or affective disorder? |journal=Arch Gen Psychiatry |volume=40 |pages=1319-1323}}</ref><ref>{{cite journal |author= Pope HG Jr, Jonas JM, Hudson JI, Cohen BM, Gunderson JG|year=1983 |title=The validity of DSM-III borderline personality disorder: A phenomenologic, family history, treatment response, and long term follow up study |journal= Arch Gen Psychiatry|volume=40 |pages=23-30}}</ref>
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|
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| Investigations are not generally repeated for relapse unless there is a specific ''medical'' indication. These may include serum [[BSL]] if [[olanzapine]] has previously been prescribed, lithium or valproate level to check compliance or toxicity with those medications, renal or thyroid function if lithium has been previously prescribed and taken regularly. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.
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|
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| The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's [[Diagnostic and Statistical Manual of Mental Disorders]], the current version being DSM-IV-TR, and the [[World Health Organization|World Health Organization's]] [[ICD|International Statistical Classification of Diseases and Related Health Problems]], currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies.
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|
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| ===Diagnostic criteria===
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| {{main|Current diagnostic criteria for bipolar disorder}}
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| [[Flow (psychology)|Flux]] is the fundamental nature of bipolar disorder. Both within and between individuals with the illness, energy, [[mood]], thought, sleep, and activity are among the continually changing [[biological markers]] of the disorder. The [[diagnostic]] [[subtypes]] of bipolar disorder are thus static descriptions—snapshots, perhaps—of an illness in continual change, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness. The DSM V, to be published in 2011 , will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).
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|
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| There are four types of bipolar illness. The [[Diagnostic and Statistical Manual of Mental Disorders|''Diagnostic and Statistical Manual of Mental Disorders-IV-TR'' (DSM-IV-TR)]] details four categories of bipolar disorder, [[Bipolar I]], Bipolar II, [[Cyclothymia]], and [[Bipolar Disorder NOS]] (Not Otherwise Specified).
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|
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| For a diagnosis of '''Bipolar I''' disorder according to the [[DSM-IV-TR]], there requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder but it frequently occurs.
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|
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| '''Bipolar II''', which occurs more frequently is usually characterized by at least one episode of [[hypomania]] and at least one depression.
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|
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| A diagnosis of [[cyclothymia|Cyclothymic Disorder]] requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet ''full'' criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning.
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|
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| If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of '''Bipolar Disorder NOS''' (Not Otherwise Specified).
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|
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| Although a patient will most likely be depressed when they first seek help, it is very important to find out from the patient or the patient's family or friends if a manic or hypomanic episode has ever been present, using careful questioning. This will prevent misdiagnosis of Depressive Disorder and avoids the use of an antidepressant which may trigger a "switch" to hypomania or mania or induce rapid cycling. Recent screening tools such as [http://www.bipolarlab.com/hcl the Hypomanic Check List Questionnaire (HCL-32)] have been developed to assist the quite often difficult detection of Bipolar II disorders.
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|
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| ===Delay in diagnosis===
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| The behavioral manifestations of bipolar disorder are often not understood by patients nor recognized by mental health professionals, so people may suffer unnecessarily for over 10 years in some cases before receiving proper treatment.<ref>{{cite web|url=http://www.familyaware.org/expertprofiles/drghaemi4.asp|title=Bipolar Disorder: How long does it usually take for someone to be diagnosed for bipolar disorder?|author=S. Nassir Ghaemi|date=2001|accessdate = 2007-02-20}}</ref>
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|
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| That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Recent [[TV special]]s, for example the BBC's ''The Secret Life of the Manic Depressive'',<ref>{{cite web|url=http://www.bbc.co.uk/health/tv_and_radio/secretlife_index.shtml|title=The Secret Life of the Manic Depressive|publisher=BBC|date=2006|accessdate = 2007-02-20}}</ref> MTV's ''True Life: I'm Bipolar'', talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby further raising public awareness.
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|
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| Despite this increased focus, individuals are still commonly misdiagnosed.<ref>{{cite web|title=Misdiagnosis of Bipolar Disorder|author=Roy H. Perlis|publication=American Journal of Managed Care|url=http://www.ajmc.com/Article.cfm?Menu=1&ID=2969|date=2005|accessdate = 2007-02-20}}
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| </ref>
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|
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| ===Children===
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| {{main|Bipolar disorder in children}}
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| Children with bipolar disorder do not often meet the strict DSM-IV definition. In pediatric cases, the cycling can occur very quickly (see section above on rapid cycling).<ref name=Kranowitz, C.S. & Post, R., (1996)>Kranowitz, C.S. & Post, R., (1996). Ultra-rapid and ultradian cycling in bipolar affective illness. British Journal of Psychiatry, 168, 314-323.</ref>
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|
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| Children with bipolar disorder tend to have rapid-cycling or mixed-cycling. Rapid cycling occurs when the cycles between depression and mania occur quickly, sometimes within the same day or the same hour. When the symptoms of both mania and depression occur simultaneously, mixed cycling occurs.
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|
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| Often other psychiatric conditions are diagnosed in bipolar children. These other diagnoses may be concurrent problems, or they may be misdiagnosed as bipolar disorder. [[Clinical Depression|Depression]], [[ADHD]], [[ODD]], [[schizophrenia]], and [[Tourette syndrome]] are common [[comorbid]] conditions. Furthermore some children with histories of abuse or neglect may have Bipolar I Disorder. There is a high comorbidity between [[Reactive attachment disorder]] and Bipolar I Disorder with about 50% of children in the [[Child Welfare]] System who have Reactive Attachment Disorder also have Bipolar I Disorder<ref> Alston, J., (2000), Correlation between Childhood Biploar I Disorder and Reactive Attachment Disorder, Disinhibited Type. In Attachment Interventions, Edited ty T. Levy, 2000, Academic Press.</ref>
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|
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| Misdiagnosis can lead to incorrect medication.
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|
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|
| On September, 2007, experts (from [[New York]], [[Maryland]] and [[Madrid]]) found that the number of [[United States|American]] [[children]] and [[adolescents]] treated for bipolar disorder increased 40-fold from 1994 to 2003, and it was increasing ever since. However, the increase was due to the fact that [[doctors]] more aggressively applied the [[diagnosis]] to children, and not that the incidence of the [[disorder]] had increased. The study calculated the number of visits which increased, from 20,000 in 1994 to 800,000 in 2003, or 1% of the [[population]] under age 20. <ref>[http://www.nytimes.com/2007/09/04/health/04psych.html?em&ex=1189051200&en=13c932cc4a338702&ei=5087%0A New York Times, Bipolar Illness Soars as a Diagnosis for the Young]</ref>
| | [[Bipolar disorder criteria|Diagnostic Criteria]] | [[Bipolar disorder history and symptoms|History and Symptoms]] | [[Bipolar disorder physical examination|Physical Examination]] | [[Bipolar disorder laboratory findings|Laboratory Findings]] | [[Bipolar disorder electrocardiogram|Electrocardiogram]] | [[Bipolar disorder MRI|MRI]] | [[Bipolar disorder other diagnostic studies|Other Diagnostic Studies]] |
|
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| ==Treatment== | | ==Treatment== |
| {{main|Treatment of bipolar disorder}}
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| <!-- Please DO NOT Add Information Here. Follow the Treatment Link above -->
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| Bipolar disorder cannot be cured, instead the emphasis of treatment is on effective management of acute episodes and prevention of further episodes by use of [[pharmacological]] and [[psychotherapeutic]] techniques.
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|
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| Hospitalization may occur, especially with manic episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or [[involuntary commitment]]). Long-term inpatient stays are now less common due to [[deinstitutionalization]], although can still occur.<ref name="BeckerKilian2006">Becker T, Kilian R. (2006) Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? ''Acta Psychiatrica Scandinavica Supplement'', 429, 9–16. PMID 16445476</ref> Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or [[Assertive Community Treatment]] team, supported employment<ref>McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. ''Am J Psychiatry.'' Mar;164(3):437–41. PMID 17329468</ref> and patient-led support groups.
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| ===Medication===
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| The mainstay of treatment is a mood stabilizer medication; these comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is [[Lithium pharmacology|lithium]],<ref>Poolsup N, Li Wan Po A, de Oliveira IR. (2000) Systematic overview of lithium treatment in acute mania. ''J Clin Pharm Ther'' '''25''': 139-156 PMID: 10849192</ref> while almost as widely used is [[sodium valproate]],<ref name ="Macr02">{{cite journal | author = Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G. | title = Valproate for acute mood episodes in bipolar disorder| journal = The Cochrane Database of Systematic Reviews | volume = | issue = 2 | pages = | publisher = John Wiley and Sons, Ltd. | date = 2002 | url = http://www.cochrane.org/reviews/en/ab004052.html (abstract) | doi = 10.1002/14651858.CD004052| id = ISSN 1464-780X}}</ref> originally used as an [[anticonvulsant]]. Other anticonvulsants used in bipolar disorder include [[carbamazepine]], reportedly more effective in rapid cycling bipolar disorder, and [[lamotrigine]], which is the first one to be shown to be of benefit in bipolar depression.<ref>Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD.(1999) A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. ''J Clin Psychiatry'' '''60''': 79-88</ref>
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| Treatment of the agitation in acute manic episodes has often required the use of [[antipsychotic]] medications, such as [[chlorpromazine]], [[olanzapine]] and [[thioridazine]]. More recently, olanzapine has been approved as an effective monotherapy for the maintenance of bipolar disorder.<ref name=Olanzapine_maintenance_therapy>[http://www.zyprexa.com/common_pages/hcp_maintenance.jsp Now Approved: ZYPREXA for maintenance therapy for bipolar disorder.] Official Zyprexa Website.</ref> A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in [[prophylaxis]].<ref name=Tohen_et_al_2005>{{cite journal | first = Mauricio | last = Tohen | coauthors = Waldemar Greil, Joseph R. Calabrese, Gary S. Sachs, Lakshmi N. Yatham, Bruno Müller Oerlinghausen, Athanasios Koukopoulos, Giovanni B. Cassano, Heinz Grunze, Rasmus W. Licht, Liliana Dell’Osso, Angela R. Evans, Richard Risser, Robert W. Baker, Heidi Crane, Martin R. Dossenbach and Charles L. Bowden | month = July | year = 2005 | title = Olanzapine Versus Lithium in the Maintenance Treatment of Bipolar Disorder: A 12-Month, Randomized, Double-Blind, Controlled Clinical Trial | journal = American Journal of Psychiatry | volume = 162 | issue = 7 | pages = 1281-1290 | url = http://ajp.psychiatryonline.org/cgi/content/full/162/7/1281}}</ref>
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| The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use. However, mood stabilizers are of limited effectiveness in depressive episodes.
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| ==Research==
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| {{main|Bipolar disorders research}}
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| ===Genetic research===
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| There is increasing evidence for a genetic component in the causation of bipolar disorder, provided by a number of [[twin studies]]and [[gene linkage]] studies.
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| The [[monozygotic]] [[Concordance (genetics)|concordance]] rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. [[Dizygotic]] twins have a 23% concordance rate. These concordance rates are not universally replicated in the literature; recent studies have shown rates of around 40% for monozygotic and <10% for dizygotic twins (see Kieseppa, 2004<ref name=Kieseppa_2004>[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15465978&query_hl=8&itool=pubmed_docsum] Kieseppa T, Partonen T, Haukka J, Kaprio J, Lonnqvist J. (2004) High concordance of bipolar I disorder in a nationwide sample of twins.</ref> and Cardno, 1999<ref name=Cardno_1999>[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10025441&query_hl=8&itool=pubmed_docsum] Cardno AG, Marshall EJ, Coid B, Macdonald AM, Ribchester TR, Davies NJ, Venturi P, Jones LA, Lewis SW, Sham PC, Gottesman II, Farmer AE, McGuffin P, Reveley AM, Murray RM. (1999) Heritability estimates for psychotic disorders: the Maudsley twin psychosis series.</ref>).
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| In 2003 , a group of American and Canadian researchers published a paper that used [[gene linkage]] techniques to identify a[[mutation]] in the [[GRK3]] gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a[[kinase]] [[enzyme]] called G protein receptor kinase 3, which appears to be involved in [[dopamine]] [[metabolism]], and may provide a possible target for new drugs for bipolar disorder.<ref name=Barr_2003>{{cite journal | author = Barrett TB, Hauger RL, Kennedy JL, Sadovnick AD, Remick RA, Keck PE, McElroy SL, Alexander M, Shaw SH, Kelsoe JR. | month = May | year = 2003 | title = Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder | journal = Molecular Psychiatry | volume = 8 | issue = 5 | pages = 546-57| id = {{DOI|10.1038/sj.mp.4001268}} | url =http://www.nature.com/mp/journal/v8/n5/abs/4001268a.html }}</ref>
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| A 2007 gene-linkage study by an international team coordinated by the [[NIMH]]
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| has identified a number of genes as likely to be involved in the etiology of bipolar disorder, suggesting that bipolar disorder may be a [[polygenic]] disease. The researchers at [[NIMH]] have found a correlation between DGKH (diacylglycerol kinase eta) and bipolar disorder.
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| The portion of the genome that encodes DGKH, a key protein in the lithium-sensitive phosphatidyl inositol pathway
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| <ref>
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| {{Citation |
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| |last1 = Baum | first1 = A E
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| |last2 = McMahon | first2 = F J
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| |title= A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and several other genes in the etiology of bipolar disorder.
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| |journal = Molecular Psychiatry
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| |date = [[8 May]] [[2007]]
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| |year = 2007
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| |url = http://www.nature.com/mp/journal/vaop/ncurrent/abs/4002012a.html
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| }}
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| </ref>.
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| The following studies are ongoing, and are recruiting volunteers:
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| [http://www.iop.kcl.ac.uk/twinstudy The Maudsley Bipolar Twin Study], based at the [[Institute of Psychiatry]] in [[London]] is conducting research about the genetic basis of bipolar disorder using twin methodology. Currently recruiting volunteers: identical and non-identical twins pairs, where either one or both twins has a diagnosis of bipolar I or II.
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| [http://www.bipolarlab.com/emonitoring The Maudsley Bipolar eMonitoring Project], another research study based at the [[Institute of Psychiatry]] in [[London]], is conducting novel research on electronic monitoring methodologies (electronic mood diaries and [[actigraphy]]) for tracking bipolar symptom fluctuations in Bipolar individuals who are interested in self-managing their condition. The study is currently recruiting volunteers from all over the world (see [http://www.bipolarlab.com/emonitoring/remote Remote eMonitoring])
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| ===Medical imaging===
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| Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the [[Functional magnetic resonance imaging|functional MRI]] and [[positron emission tomography]]. An important area of [[neuroimaging]] research focuses on identifying and characterizing networks of interconnected [[nerve cell]]s in the [[brain]], interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders, and studies have found [[anatomical]] differences in areas such as the [[prefrontal cortex]]<ref name=>[http://www.neurotransmitter.net/bipolarpfc.html Prefrontal Cortex in Bipolar Disorder] Neurotransmitter.net.</ref> and [[hippocampus]].
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| Better understanding of the [[neural circuit]]s involved in regulating mood states, and genetic factors such as the [[cadherin]] gene ''FAT'' linked to bipolar disorder,<ref name=>{{cite web | author = Emma Young | year = 2006 | url = http://www.newscientist.com/article.ns?id=dn8572&feedId=online-news_rss20 | title = New gene linked to bipolar disorder | work = New Scientist | accessyear = 2006}}</ref> may influence the development of new and better treatments, and may ultimately aid in early diagnosis and even a cure.
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| ===New treatments===
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| In late 2003, researchers at [[McLean Hospital]] found tentative evidence of improvements in mood during echo-[[planar]] [[Magnetic resonance imaging#Magnetic resonance spectroscopy|magnetic resonance spectroscopic imaging]] (EP-MRSI), and attempts are being made to develop this into a form which can be evaluated as a possible treatment.<ref name=echo_planar>[http://www.mclean.harvard.edu/research/neuroimaging/bic/mri-bipolar-summaryepmrsi.php LFMS: Low Field Magnetic Stimulation: Original EP-MRSI Study in Volunteers with Bipolar Disorder] McLean Hospital Neuroimaging Center.</ref><ref name=Rohan_et_al_>{{cite journal | first = Michael | last = Rohan | coauthors = Aimee Parow, Andrew L. Stoll, Christina Demopulos, Seth Friedman, Stephen Dager, John Hennen, Bruce M. Cohen, and Perry F. Renshaw | month = January | year = 2004 | title = Low-Field Magnetic Stimulation in Bipolar Depression Using an MRI-Based Stimulator | journal = American Journal of Psychiatry | volume = 161 | issue = 1 | pages = 93-98 | id = {{PMID|14702256}} | url = http://ajp.psychiatryonline.org/cgi/content/full/161/1/93}}</ref>
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| NIMH has initiated a large-scale study at 20 sites across the [[United States]] to determine the most effective treatment strategies for people with bipolar disorder. This study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), will follow patients and document their treatment outcome for 5-8 years. For more information, visit the [[Clinical Trials]] page of the NIMH Web site.<ref>{{cite web |url=http://www.nimh.nih.gov/studies/studies_ct.cfm?id=4 |title=http://www.nimh.nih.gov/studies/studies_ct.cfm?id=4 |accessdate= |format= |work= }}</ref>
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| [[Transcranial magnetic stimulation]] is another fairly new technique being studied.
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| Pharmaceutical research is extensive and ongoing, as seen at [http://clinicaltrials.gov clinicaltrials.gov].
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| ==Prognosis==
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| A good [[prognosis]] results from good treatment, which, in turn, results from an accurate [[diagnosis]]. Because bipolar disorder continues to have a high rate of both under-diagnosis and [[misdiagnosis]], it is often difficult for individuals with the condition to receive timely and competent treatment.
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| Bipolar disorder can be a severely disabling medical condition. However, with appropriate treatment, many individuals with bipolar disorder can live full and satisfying lives. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.
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| Ultimately one's prognosis depends on many factors, which are, in fact, under the individual's control: the right medicines; the right dose of each; a very informed patient; a good working relationship with a competent medical doctor; a competent, supportive and warm therapist; a supportive family or significant other; and a balanced lifestyle including a regulated stress level, regular exercise and regular sleep and wake times.
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| There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.
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| ==Recurrence==
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| Even when on medication, some people may still experience weaker episodes, or have a complete manic or depressive episode. In fact, a recent study found bipolar disorder to be "characterized by a low rate of recovery, a high rate of recurrence, and poor interepisodic functioning." Worse, the study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately 2-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States."<ref>Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski
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| "Bipolar Disorder: Defining Remission and Selecting Treatment" Vol. XXIII, No. 11 (October 2006)</ref>
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| The following behaviors can lead to depressive or manic recurrence:
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| * Discontinuing or lowering one's dose of [[medication]], without consulting one's physician.
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| * Being under- or over-medicated. Generally, taking a lower dosage of a [[mood stabilizer]] can lead to relapse into mania. Taking a lower dosage of an [[antidepressant]], may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania.
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| * Taking [[hard drugs]]—[[Recreational drug use|recreationally]] or [[Medication|not]]—such as [[cocaine]], [[Ethyl alcohol|alcohol]], [[amphetamine]]s, or [[Opioids|opiates]]. These can cause the condition to worsen.
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| * An inconsistent [[sleep]] schedule can destabilize the illness. Too much sleep (possibly caused by medication) can lead to depression, while too little sleep can lead to mixed states or mania.
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| * [[Caffeine]] can cause destabilization of mood toward irritability, [[dysphoria]], and mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can have effects ranging from anti-depressant to [[mania]]-inducing.
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| * Inadequate [[stress management]] and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress still causes relapse.
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| * Often bipolar individuals are subject to [[self-medication]], the most common drugs being [[alcohol]], and [[cannabis (drug)|marijuana]]. Sometimes they may also turn to [[hard drugs]]. Studies show that [[tobacco smoking]] induces a calming effect on most bipolar people, and a very high percentage suffering from the disorder smoke. [http://adam.about.com/reports/000066_3.htm]
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| Recurrence can be managed by the sufferer with the help of a close friend, based on the occurrence of idiosyncratic prodromal events<ref>Perry A, Tarrier N, Morriss R, McCarthy E, Limb K “Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of recurrence and obtain treatment” BMJ 1999;318:149-153 ([[16 January]])</ref> This theorizes that a close friend could notice which moods, activities, behaviours, thinking processes, or thoughts typically occur at the outset of bipolar episodes. They can then take planned steps to slow or reverse the onset of illness, or take action to prevent the episode from being damaging. <ref> Kelly, M., ''Bipolar and the Art of Roller-coaster Riding,'' Two Trees Media 2000, 2005</ref>
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| ==Mortality==
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| "Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD. The [[standardized mortality ratio]] from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder."<ref name=MortBio_2006>{{cite web|title=Bipolar Disorder: Defining Remission and Selecting Treatment| author=Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski|publisher=Psychiatric Times, October 2006, Vol. XXIII, No. 11|url=http://www.psychiatrictimes.com/article/showArticle.jhtml?articleId=193400986}}</ref>
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| Although many people with bipolar disorder who attempt suicide never actually complete it, the annual average suicide rate in males and females with diagnosed bipolar disorder (0.4%) is 10 to more than 20 times that in the general population.<ref>{{cite web |url=http://www.postgradmed.com/issues/2005/02_05/comm_citrome.htm |title=Bipolar disorder is a potentially fatal disease |author=Leslie Citrome, MD, MPH; Joseph F. Goldberg, MD |accessdate= |format= |work= }}</ref>
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| Individuals with bipolar disorder tend to become [[suicidal]], especially during [[Mixed state (psychiatry)|mixed states]] such as [[dysphoric]] [[mania]] and [[agitated depression]]. Persons suffering from Bipolar II have high rates of suicide compared to persons suffering from other mental health conditions, including Major Depression. Major Depressive episodes are part of the Bipolar II experience, and there is evidence that sufferers of this disorder spend proportionally much more of their life in the depressive phase of the illness than their counterparts with Bipolar I Disorder (Akiskal & Kessler, 2007).
| | [[Bipolar disorder medical therapy|Medical Therapy]] | [[Bipolar disorder cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Bipolar disorder future or investigational therapies|Future or Investigational Therapies]] |
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| ==See also== | | ==See also== |
| * [[Mood (psychology)]]
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| * [[Emotion]]
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| ==References==
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| {{reflist|2}}
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|
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| ===Cited texts===
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| *{{cite book |author= Goodwin FK, Jamison KR|title= Manic-Depressive Illness |year= 1990|publisher= Oxford University Press|location=New York |isbn=0-19-503934-3}}
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|
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| ==Further reading==
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| Contemporary first-person accounts on this subject include
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| * Jamison, Kay Redfield. 1995. ''An Unquiet Mind: A Memoir of Moods and Madness''. New York: Knopf. ISBN 0-330-34651-2.
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| * Simon, Lizzie. 2002. ''Detour: My Bipolar Road Trip in 4-D''. New York: Simon and Schuster. ISBN 0-7434-4659-3.
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| * Behrman, Andy. 2002. ''Electroboy: A Memoir of Mania''. New York: Random House, 2002. ISBN 0-375-50358-7.
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| For a practical guide to living with bipolar disorder from the perspective of the sufferer, see
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| * Kelly, Madeleine [http://www.twotreesmedia.com/beatbipolar.htm ''Bipolar and the Art of Roller-coaster Riding'']. Strathbogie: Two Trees Media 2005 ISBN 0-646-44939-7
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|
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| For a critique of genetic explanations of bipolar disorder, see
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| *Joseph, J. 2006. [http://www.jayjoseph.net/MissingGeneChapters.html ''The Missing Gene: Psychiatry, Heredity, and the Fruitless Search for Genes'']. New York: Algora.
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|
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| For readings regarding bipolar disorder in children, see:
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| * Raeburn, Paul. 2004. ''Acquainted with the Night: A Parent's Quest to Understand Depression and Bipolar Disorder in His Children''.
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| * Earley, Pete. ''Crazy''. 2006. New York: G. P. Putnam's Sons. ISBN 0-399-15313-6. A father's account of his son's bipolar disorder.
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| * About Pediatric Bipolar Disorder: www.bpkids.org/site/PageServer?pagename=lrn_about
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| * The Child and Adolescent Bipolar Foundation: www.bpkids.org
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| * Time Magazine checklist for childhood/adolescent bipolarity: www.time.com/time/covers/1101020819/worksheet/
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| * A Model IEP for a bipolar child's medication that works correctly: http://www.bipolarchild.com/iep.html
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| Classic works on this subject include
| | *[[Mood (psychology)]] |
| * [[Emil Kraepelin|Kraepelin, Emil]]. 1921. ''Manic-depressive Insanity and Paranoia'' ISBN 0-405-07441-7 (English translation of the original German from the earlier eighth edition of Kraepelin's textbook - now outdated, but a work of major historical importance). | | *[[Emotion]] |
| * ''Touched With Fire: Manic-Depressive Illness and the Artistic Temperament'' by Kay Redfield Jamison (The Free Press: Macmillian, Inc., New York, 1993) 1996 reprint: ISBN 0-684-83183-X | |
| * ''Mind Over Mood: Cognitive Treatment Therapy Manual for Clients'' by Christine Padesky, Dennis Greenberger. ISBN 0-89862-128-3
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| {{Mental and behavioural disorders}} | | {{Mental and behavioural disorders}} |