Bipolar Disorder

Formerly called maniaco-depression , the bipolar disorder belongs to the turbid of the mood, to which also the recurring depression belongs (or unipolar disorder). It is to avoid the prejudices associated with the word " maniac " and of its employment very often pejorative that the disease was called turbid bipolar.

In general, it is a disease which comprises two phases: the phase Maniac and the depressive phase. At the time of the access maniac, the person is Hyperactive. She can engage of the ill-considered expenditure, to have remarks and eccentrics attitudes, and to present others turbid behavioral or more simply to live in an excessive way. At the time of the depressive episode, the person on the contrary, presents signs of very large depression. Between these two phases, the person often finds a normal state. The danger of this disease is the risk of Suicide as well as difficulties of social adaptation due to the incomprehension of the entourage of the person reached.

Official classifications DSM-IV and CIM 10 distinguish three types of bipolar disorder:

the bipolar disorder 1 (alternation of periods of manias, major depressions even of mixed disorders mixing mania and depression and of free intervals),
the bipolar disorder 2 (alternation of periods of moderate exaltation called hypomanie, major depressions and free intervals)
and the Cyclothymia (alternation of hypomaniaques periods to symptoms and periods with depressive symptoms). Certain authors (Klerman, Akiskal) identified other types starting from the concept of spectrum bipolar.

Syndrome of Kleine-Levin: rare disease which assigns mainly the teenagers and the young adults. Atypical form of the bipolar disorder, it is characterized by important cycles of hypersomnie, up to twenty hours of sleep per day, marked by behavioral problems, bulimia, of irritabilté, of confusion, hallucinations, delirious puffs, of hypersexuality (désinhibition), of a total lack of energy, emotional absence and a return to oneself. One also often notes an over-sensitiveness with the noise and the light. In many cases, the crises last of a few days to a few weeks and grow blurred with time to disappear completely towards about thirty. Discussion forum - Syndrome of Kleine-Levin (KLS) http://syndromekleinelevin.forumactif.biz/

Diagnosis

In France, the bipolar disorder under-is diagnosed. One needs on average 10 to 12 years and four to five different doctors before the evil is not named. In the same way, it is estimated that 40% of depressive are actually the bipolar ones which are unaware of. The search for periods of exaltation is a good means to establish the diagnosis; but it is not always obvious for the patient to include/understand only the periods when it felt particularly well have the same origin as the periods when he felt badly. This diagnosis can be confirmed by the fact that the depressions of bipolar are often known as atypical (instead of insomnia, for example, depressive the “atypical one” is reached bipolar disease of disorder.

In front of the frequency of the bipolar disorders and the importance of the prognostic stake, the search for signs of bipolarity should be systematic in front of any depressive episode. It should answer a coding in order to facilitate the diagnostic step:

Taken into account of the family antecedents which are not simply limited to seek disorders of mood at ascending and collateral ones. The existence or not of an alcoholism, behavioral problems, of an originality, suicides or suicide attempts, anxious disorders, disorders of the food conduits, obsessional disorders must be required.

Among the personal antecedents, the demonstrations being able to testify to a disorder of mood will be able to direct the diagnosis towards a bipolar disorder: period of euphoria and excitation, excessive expenditure, original behaviors, problems with justice, alcoholism, led to risk or excessive, crises of violence or aggressiveness, the concept of a break compared to the former state, of a change, a modification of the character, the concept of a turn of mood at the time of a preliminary regulation of antidepressants…

At the woman, of the disorders of mood occurring in the continuations of the childbirth and before the return of layers will be very in favor of a bipolarity.

an early age of beginning at the time of adolescence or the beginning of the adulthood is an index to be taken into account, the unipolar disorder having a later beginning.

a basic temperament of hyperthymic type characterized by a hyperactivity, a hypersyntonie, multiple projects, an excessive sociability can direct the diagnosis. Other features of personality are frequently found among bipolar patients: over-sensitiveness, emotional dependence, search for strong feelings…

depressive symptomatology evoking a bipolarity can present one or more characteristics: symptoms psychotics, deterioration of the circadian rate/rhythm with major psychomotor inhibition the morning and attenuation in end-of-day, symptoms of atypical depression: hypersomnie, hyperphagie, psychomotor inhibition being able to go until a blocking of the thought, lability of mood.

Other symptoms do not have clean specificity but are frequently observed: irritability, aggressiveness, reaction of anger, excessive sensitivity, émoussement emotional being able to go until an incapacity to cry and or to express negative affects.

Prevalence

TB 1: 1%.
TB 2: 0,5 to 2,5%
Cyclothymia: 2 to 3%.

According to the authors, the bipolar disorder has a Prévalence from 2 to 8% of the population.

Etiology

Genetic dimension complexes disorder is clearly established. It would offer a particular brittleness of the subject to the stress, which is brought in reaction to develop or not the disorder. There are thus often surrounding factors starting the disorder; then, little by little, the cycles tend to becoming autonomous.

The independent factor of risk is the genetic risk with a relative risk to develop a bipolar disorder of mood multiplied by 14 at the subjects having a relative of the first degree reached of a bipolar disorder. The genetic studies of connection make it possible to identify the chromosomal areas carrying genes probably implied in this disease, in particular the areas 13q31 and 22q12.

The two other clearly identified risk factors are the changes of parental responsibility (orphan, placements, family ruptures) and the concept of sexual abuse in childhood. The longitudinal studies show that before the release of the disease, there exist localized cognitive deficits, concerning in particular the function visuospatiale. These cognitive deficits probably return to anomalies neurodéveloppementales in connection with the genetic risk factors. The studies of functional neuroimagery show dysfonctions during the execution of cognitive spots concerning in particular the circuit fronto-striatal.

There exists certainly a neuronal dysfunction as well as a loss of neurons in the hippocampus of the patients suffering from bipolar disorders. Thus, a study in protonic spectroscopy by IRM showed that the concentration in N-acétyl aspartate, an amino-acid present normally in the hippocampus, is decreased among patients suffering from bipolar disorders and worsens with the seniority of the disorder. Other anomalies are found, in particular on the level of the former part of the gyrus cingulaire where there exists a dysfunction in the regulation of the neurons glutamaergic. There in addition exist morphological anomalies, in particular cerebellum, found among bipolar patients having made several episodes of disorder of mood. Thus, the study of Millets and coll (Millets, 2005), compares, the volume of the cerebellum among bipolar patients after an episode and several episodes of the disease in IRM and watch that this one is smaller among patients having made several episodes. In the same way, a ventricular widening is found among patients having made several episodes maniacs.

References

James B. Potash, Peter P. Zandi, Virginia L. Willour, Tsuo-Hung Lan, Yuqing Huo, Dimitrios Avramopoulos, Yin Y. Shugart, Dean F. MacKinnon, Sylvia G. Simpson, Francis J. McMahon, J. Raymond DePaulo, Jr., and Melvin G. McInnis. Suggestive Linkage to Chromosomal Areas 13q31 and 22q12 in Families With Psychotic Bipolar Disorder. Am J Psychiatry, Apr 2003; 160:680 - 686.
Preben Bo Mortensen, C.B. Pedersen, Mr. Melbye, O. Bit, and H. Ewald. Individual and Family Risk Factors for Bipolar Emotional Disorders in Denmark. Arch Gen Psychiatry, DEC 2003; 60:1209 - 1215.
JESSICA L. GARNO, JOSEPH F. GOLDBERG, PAUL MICHAEL RAMIREZ, and BARRY A. RITZLER Impact off childhood deceives one off the clinical race bipolar disorder. Br. J. Psychiatry, Feb 2005; 186:121 - 125.
Jari Tiihonen, Jari Haukka, Markus Henriksson, Mary Canon, Tuula Kieseppä, Ilmo Laaksonen, Juhani Sinivuo, and Jouko Lönnqvist. Premorbid Intellectual Functioning in Bipolar Disorder and Schizophrenia: Results From has Cohort Study Male Conscripts off. Am J Psychiatry, Oct. 2005; 162:1904 - 1910.
Hilary P. Blumberg, Andrés Martin, Joan Kaufman, Hoi-Chung Leung, Pawel Skudlarski, Cheryl Lacadie, Robert K. Fulbright, John C. Gore, Refusals S. Charney, John H. Krystal, and Bradley S. Peterson. Frontostriatal Abnormalities in Teenagers With Bipolar Disorder: Preliminary Observations From Functional MRI. Am J Psychiatry, Jul 2003; 160:1345 - 1347.
Raymond F. Deicken, Mary P. Pegues, Susan Anzalone, Robert Feiwell, and Brian Soher. Lower Concentration off Hippocampal N-Acetylaspartate in Family Bipolar I Disorder. Am J Psychiatry, May 2003; 160:873 - 882.
Tsung-Ung W. Woo, John P. Walsh, and Francine Mr. Benes. Density off Glutamic Acid Decarboxylase 67 Messenger RNA-Containing Neurons That Express train the N-Methyl-D-Aspartate Receptor Subunit NR2A in the Anterior Cingulate Cortex in Schizophrenia and Bipolar Disorder. Arch Gen Psychiatry, Jul 2004; 61:649 - 657.
Neil P. Mills, Melissa P. DelBello, Caleb Mr. Adler, and Stephen Mr. Strakowski. MRI Analysis off Cerebellar Vermal Abnormalities in Bipolar Disorder. Am J Psychiatry, Aug 2005; 162:1530 - 1533.
Stephen Mr. Strakowski, Melissa P. DelBello, Molly E. Zimmermann, Glen E. Getz, Neil P. Mills, Jennifer Ret, Paula Shear, and Caleb Mr. Adler. Ventricular and Structural Periventricular Volumes in First- Versus Multiple-Episode Bipolar Disorder. Am J Psychiatry, Nov. 2002; 159:1841 - 1847.
Simona Noaghiul and Joseph R. Hibbeln. Cross-country race-national Comparisons off Seafood Consumption and Spleens off Bipolar Disorders. Am J Psychiatry, DEC 2003; 160:2222 - 2227.

Treatment

The basic salary consists of one or more thymorégulateurs: salts of Lithium, Anticonvulsivant S, Lamotrigine which vary according to the types. The Antidépresseur S should be prescribed only very punctually (risk of turn maniac or anxious reaction), the Neuroleptique S of the same for the mania (risk of depressive turn): that is unfortunately not yet the practice in France. The therapies known as of support, psychoéducative, interpersonal, even TCC help. There is generally no cure and the treatment is generally with life.

The Psychanalyse is not indicated during a depressive episode or maniac, but can be interesting at certain subjects between the episodes.

At present, in certain cases of bipolarity, one calls upon the lamotrigine (also used as anti-epileptic) while the interest for low dose of aripiprazole often gives very good performances: the last studies in the United States indicate an improvement of the blood formulation of the patients (glycemia/cholesterol) compared to what is observed with the olanzapine (zyprexa).

For the treatment pharmacological of the bipolar depressions, the regulation of antidepressants in monothérapie incontestably worsens the forecast of the bipolar disorder by inducing mixed turns maniacs, episodes, fast cycles, and by supporting resistance to the treatment. It is thus advisable initially to optimize the thymoregulator treatment by carrying out blood proportionings and by as well as possible adjusting the therapeutic rates towards the recommended higher limits, provided that does not induce undesirable effects. The recourse so necessary, in the second time, to a second thymoregulator treatment will aim at finding the normothymy while protecting the patient against a risk from destabilization of mood. The antidepressants in the bipolar depression are generally justified only in the event of depressions of severe intensity and in partnership with a thymoregulator.

Acompagnement is also very important, the close relations are often disabled in front of a bipolar person. But their presence is a factor of the success of the improvement of the physical status and psychological of the patient.

Reference: Bipolar disorders: practices, research and prospects work collective to dir: M.LEBOYER 2005
With for the place of the psychoanalysis the following article:
Psychoanalytical Place des treatments in the depressive disorders D.WIDLOCHER
Pharmacological treatment of the bipolar depressions J. Thuile, C.Even, J.D. Guelfi

Evolution of the bipolar disorder

In general:

the cyclicity tends to worsen during time with appearance of short cycles. The fast cyclicity is associated with an early age of beginning, association with an anxious disorder, an abuse substances, antecedents of suicide attempts, the use of the antidepressants and a family antecedent of fast cyclor. (one speaks about bipolar disorder with fast cycle when there is more than 4 episodes maniacs and/or depressive lasting at least two weeks per annum) the fast cycles are particularly associated with the disorder panics and the family antecedents of disorder panics.
the nature of the episodes changes with mixture of symptoms maniacs and depressive: one speaks then about mixed episodes,
average mood tends to becoming increasingly depressive and the patient will present less and less episodes maniacs,
one notes with the evolution a reduction in the cognitive capacities.

This rather pejorative evolution can be stopped by a founded adapted treatment most precociously possible.

Comorbidity

The early diagnosis and the treatment of the bipolar disorder make it possible to avoid the disorders which are often associated to him, one speaks then about disorders comorbides or comorbidity.

It is important and must be taken into account as well as the bipolar disorder. It concerns primarily:

the syndrome of alcohol abuse, also frequent, found especially in the depressive phases. A recent study estimates this risk at 30% for the women and 50% for the men suffering from bipolar disorder. As the syndrome of abuse/dependence to alcohol is much more frequent at the men than among women, the fact of being bipolar, multiplies by 7,5 the risk for a woman to have a diagnosis of abuse/dependence to alcohol for only one multiplicative factor of 2,75 for the men. It is useful to recall that in front of any alcoholism, it is necessary to seek a bipolar disorder and this, especially among women.
the anxious disorders and in particular the disorder panics (20% in study ECA): the prevalence on the whole life of the anxious disorders is of approximately a bipolar patient on two. They are associated in particular with an young age of beginning, a stronger tendency to make suicide attempts.

Lived of the bipolar ones

Frequent others turbid occur at the same time as the bipolar disorder (Comorbidité): Agoraphobia, Claustrophobia, symptoms maniacs at the same time as of the depressive symptoms mixed states , anguishes and anxiety, excessive consumption of alcohol and cannabis. One also often notes a maladjustment of the treatments by the unsuited use of the Neuroleptiques and especially of the Antidépresseurs, absence of Thymorégulateur or regulation of incompatible drugs. The refusal of the treatment or its irregular observance is also a very frequent drift, encouraged by the nostalgia of the phases of (hypo) mania.

The people having undergone several cycles of the disease remain hypersensitive and see their threshold of release of the disorder lowered (theory of the " kindling"). A strict hygiene of life is recommended.

Mortality

It is estimated that 20% of TB I and TB II die by Suicide. The figures concerning the Cyclothymie are not known. Because of the Addiction S various and behavioral problems, it seems that an untreated bipolar person in general has on average a Life expectancy lower by 20 years than the life expectancy present in the population.

The bipolar disorder is primarily a disorder of fluctuation of the Humeur, generally characterized by the depression. The bipolar people can misuse substances, but otherwise they typically do not show the variety of different the Symptôme S.

The Cycle S in the bipolar disorder are theoretically of enough long life.

The bipolar one has long periods of remission during which it goes well.

The phases of the cycle of bipolar do not depend on external factors.

Notes and references of the article

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