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1.Introduction

This course is about a mood disorder that is so commonly discussed in the media of late-bipolar disorder. Although this disorder is not as common as depression, the number of bipolar disorder diagnoses appears to be rising, mainly because of new research and consideration of symptoms that do not meet the full criteria for bipolar but do have many similar symptoms that cause significant impairment.

 

Such symptomatology may comprise other bipolar categories that are considered part of the “bipolar disorder spectrum.” Of course, as occurs with any expansion or new development of existing ideas, the psychiatric community is divided in regard to what constitutes true bipolar illness. In this course we present the data and evidence at hand, although active research continues on the subject as the DSM-V committee works toward refining diagnostic criteria for the future.

Historically, the diagnosis has been through many changes. Emil Kraeplin first described bipolar disorder, also known as manic-depressive disorder, in the early twentieth century. Prior to that, the condition was characterized as cyclic psychosis. The term was prompted, in large part, by the curious phenomena that some patients with a psychotic illness recovered fully and then relapsed in a cyclic nature, while others appeared to deteriorate slowly over time.

Physicians were puzzled by this difference, and Kraeplin, through careful observations, determined that it was not so much a psychotic disorder as it was a mood disorder. Despite this reclassification, American psychiatry lagged behind its European counterparts in making this fundamental distinction. It was not until the late 1970s and early 1980s that the distinction in America was complete, partly because of the reintroduction of lithium into the American pharmacopoeia and partly because of the work of two American psychiatric researchers, Harrison Pope and Joseph Lipinsky, that distinguishing between schizophrenia and manic depression became more than just an academic curiosity.

This distinction now had real treatment implications, as the treatment of schizophrenia required lifelong antipsychotic medication while manic-depressive disorder could be managed more safely and effectively with lithium alone.

When Dr. Herrick was in training in the mid to late 1980s, the emphasis in making a diagnosis was on not mistaking manic depression for schizophrenia. Since the late 1990s, however, manic-depressive disorder has been called bipolar disorder and is solidly ensconced as a mood disorder, with little to no concern that clinicians will misdiagnose it as schizophrenia.

The concern nowadays is the possibility of mistaking the disorder for unipolar depression and other psychiatric conditions such as personality disorders or drug and alcohol abuse.

Why did the change of emphasis occur?

The answer is long and complicated. In brief we offer several reasons: Psychiatry understands and characterization of bipolar disorder has changed. For example, bipolar disorder and childhood bipolar disorder did not “exist” in the 1980s.

The explosion of psychiatric medications into the marketplace has exposed more patients to medications that had both positive and negative effects on their moods, allowing for a broadening of psychiatry’s understanding of mood disorders and how they could be pharmacologically “manipulated.” For example, the SSRIs, because of their relative ease of use and tolerability, have been used more widely than their counterparts, the tricyclics.

The growing numbers of patients asking for and receiving these medications was followed by greater numbers of persons being unwittingly switched into manic or hippomanic episodes, thereby leading to a change of views within the profession about the nature of mood disorders. In  addition, the atypical antipsychotics, also because of their relative safety and ease of use, were found to help patients with “mood swings” that did not respond to SSRIs and who were otherwise not viewed to warrant treatment with traditional mood stabilizers. Because of larger cultural changes in a variety of areas affecting psychiatry, the importance in distinguishing between these other psychiatric disorders is more complete. These changes occurred in deinstitutionalization, commitment laws, and, most notably, destigmatization of certain psychiatric conditions. Having the likes of Jane Pauley and Brooke Shields talk openly about their own struggles with mental illness has gone far toward people accepting the idea that these are real diseases in need of medical care. Deinstitutionalization and commitment laws have changed the types of patients hospitalized in psychiatric settings. Commitment laws now emphasize dangerousness rather than the presence of psychiatric symptoms. Increasing numbers of patients are being admitted primarily with impulsive aggression, whether it is directed toward themselves or others, rather than merely because they are depressed or psychotic. Many of these patients have underlying personality disorders and substance abuse disorders.

This has radically changed the focus of psychiatric care from treating psychotic illness to treating explosive moods and behavior. A greater degree of overlap now exists between bipolar disorder and impulsive aggression than between bipolar disorder and schizophrenia, which has become increasingly an ambulatory condition managed primarily in the community.

Each of these changes, whether it is the number of medications available, new scientific understanding, broadening of the classification of the disorder, commitment laws, or destigmatization, has led to larger numbers of patients being diagnosed with bipolar disorder, as well as greater interest in understanding what the condition is and how it is best treated.

Hopefully, this course will address the myriad questions you may have about this most curious condition and its dizzying array of presentations - and more dizzying numbers of medications used in treating it.

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