Bipolar Disorder
UNDERSTAND AND PREVENT BIPOLAR DISORDER
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.”
(46) Bipolar Disorder
WHAT IS BIPOLAR DISORDER? (Video)
Bipolar disorder and sex: It's time to talk about this emotional minefield
What are the similarities and differences between borderline personality disorder and bipolar disorder?
The distinction between bipolar disorder and borderline personality disorder is one of the most hotly studied and debated issues today in terms of research and clinical care. The greatest debate occurs regarding the bipolar spectrum disorders, although bipolar I disorder shares some elements with borderline personality disorder as well. The two extreme arguments range from negating bipolar II/bipolar NOS disorders that overlap with borderline personality disorder to negating borderline personality disorder, with the arguments from most clinicians and researchers falling somewhere in between. Although bipolar II is a relatively new disorder and was not operationalized until the publication of DSM-IV in 1994, this debate has been ongoing since the criteria for borderline personality disorder were first established in 1980 with the publication of DSM-III. Borderline personality disorder is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, as well as marked impulsivity. Symptoms begin by early adulthood and include:
• Frantic efforts to avoid real or imagined abandonment
• Extremes of idealization and devaluation of interpersonal relationships
• Markedly and persistent unstable self-image or sense of self
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
• Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
• Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• Transient, stress-related paranoia or severe dissociative symptoms
The symptoms noted in bold are similar to those that occur during a hypomanic or manic episode, which is where the overlap in diagnosis can occur. The other criteria, however, are more distinct and characterize or are associated with the long-standing troubled interpersonal relationships.
The history of the term borderline personality is an interesting one. Originally the term was used to describe patients whose symptoms traversed the border between “neurosis” and psychosis. The individuals were considered “pseudoneurotic schizophrenics” because their general ability to adapt was profoundly impaired although superficially they appeared unremarkable.
Borderline patients can in fact become transiently psychotic in the midst of one of their rages, but later such patients were characterized instead as having emotionally unstable personalities. In 1975 the psychiatrist Otto Kernberg conceptualized borderline personality disorder as a diagnosis associated with particular primitive defense mechanisms, of which splitting was one? The criterion regarding patients’ tendency to over idealize or devalue another person is an example of splitting, in which they have difficulty integrating the good and bad in people and thus “split” the person into either all good or all bad. Personality traits are thought to be different from symptoms associated with mood disorders in that they are a reflection of enduring patterns of perceiving, relating to, and thinking about the environment relative to oneself and are exhibited in a wide range of contexts. These traits are generally first recognized in adolescence and endure throughout adult life.
A recent study examining the affective instability common to both borderline personality and bipolar II disorder patients found clear differences between the types of affects associated with the two disorders. Borderline personality disorder was associated with greater mood lability in terms of anger, anxiety, and depression/ anxiety oscillation, while bipolar II disorder was associated with greater mood lability in terms of depression, elation, and depression/elation oscillation. In fact, the study also showed that labile anger alone was sufficient to predict (with 72% accuracy) the diagnosis of borderline personality disorder versus another personality disorder. This finding is surprising, given the fact that bipolar II disorder is considered to be more often associated with irritability than bipolar I disorder, which is more associated with euphoria or elation. Additionally, another clear distinction exists in the underlying sense of self between the two disorders.
Patients with borderline personality disorder suffer from feelings of emptiness with strong fears of abandonment-feelings that are always present even when the mood is generally stable. Bipolar patients, on the other hand, have a generally stable sense of self when their moods are stabilized.
Leaving aside the validity of such a reconceptualization of the two diagnostic categories, whether or not there is utility to this approach is the more important question.
After all, the ultimate goal of establishing diagnostic accuracy is for the purposes of treatment. With the newer antipsychotic medications that are now approved for bipolar disorder, the utilization of pharmacological interventions for treating a condition that was once thought to be solely amenable to long-term psychotherapy offers new hope for these patients. Keep in mind, however, that such medications are neither diagnostic nor symptom specific and therefore a positive response does not ensure diagnostic validity. Increasing research in this area has demonstrated some modest success in stabilization of borderline personality symptoms with combinations of mood stabilizers and/or antipsychotics. The emphasis on psychotherapy, however, continues to be the primary mode of treatment for patients with borderline personality disorder. The most utilized and validated psychotherapeutic technique for borderline personality disorder is dialectical behavior therapy, designed and studied by Dr. Marsha Linehan. This technique focuses on behaviors and less so on feelings except with respect to how they link directly to self-injury. Studies in Europe have demonstrated a decrease in both suicidal and self-destructive behaviors, though effect on mood is less certain.
Terms:
Affect - feeling or emotion, especially as manifested by facial expression or body language.
Defense mechanisms - a set of unconscious methods to protect one’s personality from unpleasant thoughts and realities that may cause anxiety.
Splitting - a defense mechanism that serves to separate opposing affective or emotional states, such as in overidealizing a person one day and devaluing the same person the next. The ability for the ego to hold more than one representation of an object is impaired.
Is there an overlap between ADHD and bipolar disorder?
Attention-deficit hyperactivity disorder (ADHD) is a condition distinct from bipolar disorder, but the differentiation of mania from ADHD can be difficult.
There are similarities in symptoms, particularly in the differential diagnosis of children and adolescents. It has been argued that ADHD is misdiagnosed in some young people who actually have bipolar disorder, although a high number of youth with bipolar disorder also have ADHD. The coexistence of the two conditions may be related to the age of onset of bipolar disorder, as adults with a reported history of comorbid ADHD tend to have the onset of bipolar disorder before age 19. Studies of rates of ADHD in the children of bipolar adults have found higher rates than in control subjects.
Both disorders share many characteristics such as impulsivity, inattention, hyperactivity, high physical energy, mood swings, frequent coexistence of conduct disorder and oppositional-defiant disorder, and learning problems. Family history in both conditions often has the presence of mood disorders. Elevated mood and grandiosity are the symptoms best able to distinguish between pediatric bipolar disorder and ADHD.
Also, with bipolar disorder, hyperactivity may be more episodic. Irritability, hyperactivity, accelerated speech, and distractibility are frequent in both childhood onset bipolar disorder and ADHD and are not useful in differentiating between the two disorders. The response or lack of response to stimulant medications is not diagnostically helpful, but classification of the diagnosis is important as stimulants can promote mania in a bipolar individual if not on a mood stabilizer first (as with antidepressants).
(47) Bipolar Disorder
Bipolar disorder + affairs: how often does this occur?
Bipolar, Adultery and ‘Fool Husbands.’
Bipolar Disorder in Children and Teens
Do children get bipolar disorder?
Bipolar disorder was once thought to occur only rarely in youth, with the peak age of onset in the early thirties. However, approximately 20% of all bipolar patients have their first episode during adolescence, with a peak age of onset between 15 and 19 years of age. Rates of bipolar disorder in children, once considered extremely low, are now thought to be closer to rates in adults, although due to questions of diagnostic reliability, true rates are not known. It is known that 20% to 30% of youth with major depression go on to develop bipolar disorder. The DSM-IV-TR criteria for bipolar disorder are not believed to adequately describe the symptoms present in childhood, which is why the disorder is often missed in the younger age groups.
Depression as well was once believed to be rare in children, but symptoms of major depression are now known to occur. Rates of mood disorders in general in children have been rising over the past half-century for unclear reasons. Bipolar illness in childhood is more likely to affect the offspring of parents with bipolar disorder. While manic symptoms are the same in children as described for adults, the duration criteria are believed to be too long for diagnosis in children. The mood shifts between mania, depression, and euthymia can occur several times within a day. In addition, children with mania are more likely to be irritable than elated. Older bipolar adolescents are more likely to have presentations similar to adults. In children, it may be difficult to distinguish bipolar disorder from attention-deficit hyperactivity disorder, oppositional-defiant disorder, conduct disorder, developmental disorders, or anxiety disorders. Although there remains debate and controversy over the diagnosis of mania in children, it is increasingly recognized that there are children with severe affective dysregulation manifested by severe tantrums, destructiveness, and aggression that may in fact be early bipolar disorder. In fact, childhood onset mania is often considered more chronic rather than episodic, most likely with a mixed (with depression) presentation and psychotic features more common. Early-onset substance abuse may signal bipolar disorder as well.
How is childhood bipolar disorder different from adult bipolar disorder?
Childhood bipolar disorder is not given specific diagnostic criteria in the DSM-IV-TR because the criteria for bipolar disorder are considered applicable to all age groups. The younger the age of onset, however, the less the disorder looks as described in the DSM. Prepubertal-onset bipolar disorder tends to be a nonspecific, chronic, rapid-cycling mixed manic state. For adolescent onset, the presentation of mania is more closely matched to the adult presentation. It is more likely, however, that depression precedes mania in an adolescent.
The onset of bipolar disorder in patients with a history of ADHD is often between 11 and 12 years of age. Many children who develop bipolar disorder develop a depressive disorder first. Of youth with major depression, up to a third go on to develop mania/bipolar disorder.
Studies have shown that observation of five behavioral symptoms in children/early adolescents aid in correctly diagnosing childhood bipolar disorder. Manic symptoms that do not overlap with ADHD are elation, grandiosity, flight of ideas/racing thoughts, a decreased need for sleep, and hypersexuality (in the absence of sexual abuse or overstimulation). As opposed to adults, however, children with mania seldom experience euphoric mood; the most common mood disturbance is severe irritability with “affective storms” (prolonged and aggressive temper outbursts). In between outbursts, these children are described as persistently irritable or angry. Manic children do often have a decreased need for sleep-they can function well on less sleep than normal. Due to their aggressiveness, these children frequently receive a diagnosis of conduct disorder. Aggressive symptoms often result in the psychiatric hospitalization of manic children.
What are the risks for suicide in children and adolescents?
Suicide is a very real risk for depressed youth. Suicide is the third leading cause of death in teenagers. One in five people with bipolar disorder commit suicide. A study by the Centers for Disease Control and Prevention of high school students indicated that nearly 20% of teens had seriously considered suicide and that more than 1 in 12 had made a suicide attempt in the previous year. Male teens are more likely to kill themselves, while more females attempt suicide. The majority of teen suicides are with guns. Children also can have suicidal ideation but are less apt to make attempts the younger they are.
Risk factors for suicide include:
• Previous suicide attempts
• Depression
• Alcohol or substance abuse
• Family history of psychiatric illness
• Stressful circumstances
• Access to guns
• Exposure to other teens who have committed suicide Stressful life events tend to be higher in children and adolescents who attempt suicide and may include loss of family members due to death or separation, physical or sexual abuse, frequent arguing in the home, or witnessing violence. Youth who are grappling with their sexual identity are particularly at high risk for suicide.
Suicidal youth tend to have poor social adjustment and are lacking adequate social supports. Bipolar youth are at increased risk due to higher rates of mixed mania and depression along with poor impulse control.
Some depressed adolescents engage in self-injurious behavior of cutting themselves without the specific intention of killing themselves, a symptom that is more typical in persons who experience a chronic emptiness and “emotional numbness.” The pain from cutting is described as a relief because the physical pain detracts from the emotional pain. Such behaviors are a sign that help is needed and is typically seen in depression when occurring in adolescence, but it is also a feature in some personality disorders in adults. While those who engage in self-injurious behaviors don’t necessarily intend to kill themselves, “accidental death” is a risk as well as the development of permanent scarring. Often the cutting behavior is transient, occurring during particularly stressful periods (e.g., loss of relationship) and dissipates with the development of better coping skills and improved impulse control.
(48) Bipolar Disorder
My Experience With Mania, Bipolar Disorder
What is the treatment approach for children and adolescents?
The treatment of children and adolescents must first begin with a comprehensive evaluation by a qualified practitioner. Find a treatment provider who has experience with this population or better yet has specialty training with this population. The evaluation tends to encompass more areas of query than do adult evaluations, with full developmental history and family history obtained, and school functioning assessed and contrasted with home functioning. As in adults, other conditions must be considered and ruled out before diagnosing a mood disorder. Once bipolar disorder has been diagnosed, a treatment plan should address the following needs:
• Individual
• Medical
• Family
• School
• Legal
Individual needs can be addressed with psychotherapy.
Cognitive-behavioral and interpersonal therapy approaches have been studied and found effective in adolescent depression. Children and adolescents can benefit from other psychotherapeutic approaches as well. Group therapy should be considered if there are concerns about social development. In addition to individual psychotherapy, work with children and adolescents often needs some level of family work, either with the parents or including siblings as well? Because a child is a member of a family system, the dynamics between the child and others may need to be addressed in ways that individual work cannot. Problems with behavior may require enhancement of parenting skills. Psycho education of family members too may be needed to help them understand the patient’s illness.
Medically, a decision is to be made regarding the use of somatic treatments for bipolar disorder in a child or adolescent, such as a mood stabilizer. Due to the severity of untreated bipolar disorder, a medication will likely be recommended in addition to therapy. All children and adolescents should have medical clearance through the pediatrician to rule out any underlying medical conditions.
Baseline laboratory studies will be needed. Educational needs are also assessed in children and adolescents. A child with bipolar disorder needs and is entitled to accommodations in school. Bipolar disorder and the medications used to treat it can affect a child’s school attendance, alertness and concentration, motivation, and energy available for learning. Functioning can vary greatly at different times throughout the school year. Recurrence of depressive and manic episodes can cause academic delays and may be associated with comorbid learning disabilities. A board of education assessment will determine the most appropriate educational setting. The educational needs of a particular child with bipolar disorder vary depending on the frequency, severity, and duration of episodes of illness. Most states mandate that appropriate educational services be made available to minors with emotional and/or behavioral problems, which may consist of smaller classroom settings, non-public school placement, day treatment programs, or even residential treatment settings.
Legal needs of a child also have to be considered in the evaluation process. As the child is a minor, a parent or guardian will make the final decision regarding the treatment intervention. Older adolescents do, however, have some say about their treatment. In particular, it is best if they are in agreement to a medication because they cannot be forced to take a medication against their will. Other legal issues to consider are custody issues and need for family court involvement or state involvement.
What are the risks of treating my teenager with psychotropic medication?
In years past, it was often presumed that medications worked in young people the same as in adults. Clinical trials rarely included persons under the age of 18. Prior to the development of SSRIs, children and adolescents were rarely treated with antidepressants. The tricyclics and monoamine oxidase inhibitors that were available had potentially harmful side effect profiles that outweighed the benefit of the treatment. This was in part because clinical studies in persons under 18 did not demonstrate antidepressants to be more effective than placebo. When SSRIs entered the market, however, because of their better safety profile, prescriptions for antidepressants in children and adolescents increased dramatically. There was clearly a need for safe, effective treatments, because in adults untreated depression has serious adverse outcomes. In recent years, studies of SSRIs have been conducted in children and adolescent populations, with efficacy demonstrated in some. One observation from SSRI studies (that was also noted in the early studies using tricyclics) was the presence of a relatively high placebo response rate. Adolescents may benefit from the supportive contact with the treatment provider and thus “respond” to the placebo. Talk therapy is clearly a necessary part of treating depression in children and adolescents, even if on medication.
In the treatment of bipolar disorder, medication use is more complicated due to the potential need for more than one medication. In addition, except for the use of Sarafem (fluoxetine) for major depression, no medication indicated for a mood disorder (depression or bipolar) in adults has such an indication for use in children or adolescents. Some antidepressants, for example, while effective in adults have data that do not support their efficacy in children and adolescents.
Although the FDA has not provided indications for use of medications in youth with bipolar disorder, because of the significant risks of no medication intervention, it is standard practice to treat the condition with medications that have demonstrated efficacy in adults. Many medications have some level of research evidence in literature supporting their use in childhood bipolar disorder, but their use is considered “off-label.” Monitoring of medication therapy must be done very closely.
In the case of using various mood stabilizers other than antidepressants, choices become more difficult due to the increased severity of side effects in contrast to SSRI antidepressants. Children and adolescents appear to be more sensitive to the side effect of weight gain, for example, which can significantly hamper compliance as well as contribute to physical health problems. Lithium has been studied in children for a variety of conditions. Adverse effects are similar as in adults, with careful monitoring of kidney and thyroid function required. Regular blood level monitoring is necessary as well because of the narrow range between effective blood level and toxic blood level. Studies in patients with epilepsy have shown that Depakote (valproate) may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who begin taking the medication before age 20 (Question 79). Therefore, young female patients taking Depakote (valproate) should be monitored carefully by a physician.
There have been recent concerns about the risk for increased suicidal thinking in children and adolescents prescribed SSRIs. Warnings are now included in the labeling of all antidepressants that there can be a risk of suicidality, and close monitoring is recommended. It is not clear, however, if such effects are specific to certain SSRIs. A recent analysis by the FDA of all the studies of newer antidepressants showed a rate of suicidal behaviors in 3% to 4% of children and adolescents with depression who took an antidepressant and a rate of 1% to 2% of those taking a placebo (inactive pill). Of note, there were no deaths by suicide in any of the studies. Also, there was no difference in the rate of suicidal behavior for those being treated with an antidepressant for an anxiety disorder. The results of the analysis have prompted the FDA to require a warning on all antidepressants regarding the risk of increased suicidal behavior (thoughts or actions) when used in children and adolescents. While this can be disconcerting for any parent, it is important to keep in mind that the risk for suicide in untreated depression is approximately 15%.. The necessity for close monitoring is important because of this. As in adults, depression is a condition that is associated with suicidality. Whether on an antidepressant or not, patients need to be closely monitored for the onset of such symptoms or worsening of existing symptoms. Keeping the data in mind, contrary to fears of increased suicidal tendencies, data from around the world actually document that the suicide rate among teenagers has dropped concordant with increased prescribing of SSRIs for depression.
I have been hearing about polycystic ovaries.What is that and should I be concerned if I take Depakote (valproate)?
Polycystic ovary syndrome, also known as PCOS, is a syndrome that includes a cluster of signs and symptoms usually associated with having polycystic ovaries. A polycystic ovary is defined by having at least ten ovarian cysts. Not all women with polycystic ovaries develop PCOS and not all women with PCOS have polycystic ovaries. The signs and symptoms may include polycystic ovaries, menstrual cycle irregularities (both frequency and flow), excessive body and facial hair (hirsutism), female-patterned baldness, and skin problems, including acne. All of these signs and symptoms stem from hormonal imbalances, which include an overproduction of testosterone. Additionally, truncal obesity and metabolic syndrome may accompany the signs and symptoms described above. The prevalence of PCOS varies depending upon the researchers’ definition but ranges anywhere from 4% to 18%. PCOS does appear to occur more often in women with epilepsy than others, with rates between 13% and 25%. It also appears to occur more frequently in women with bipolar disorder, though in frequencies less than in those with epilepsy. Menstrual irregularities have been shown to approach 50% in women with bipolar disorder independent of treatment. One explanation as to why women with either epilepsy or bipolar disorder may have more frequent menstrual irregularities, as well as PCOS, may have to do with the brain’s poor regulation of the endocrine system secondary to seizures or manic-depressive cycles.
Not only is it believed that these conditions may cause PCOS, it may be the case that PCOS worsens these conditions through the hormonal imbalance PCOS causes. The question of whether or not PCOS is caused by anticonvulsant medications, especially valproic acid, has been hotly debated, though current research suggests that valproic acid does increase the chance of developing it. This research has suffered from the fact that few, if any, longitudinal studies following women over a long course of therapy have been done. That being said, the increased risk is particularly evident in young teenage women. The mechanism by which Depakote (valproate) may increase risk is poorly understood but may be attributed to a number of factors.
Depakote (valproate) appears to affect hormone levels independently, which may in turn contribute to PCOS. Depakote (valproate) is not enzyme inducing and therefore will not reduce hormones that promote PCOS as other anticonvulsants will do, such as Equetro (carbamazepine), phenytoin, and Lamictal (lamotrigine). In fact, the latter two anticonvulsants appear to reverse PCOS in women who develop it while on Depakote (valproate). Finally, Depakote (valproate) causes weight gain, which is associated with higher circulating levels of insulin and male hormones, both being linked to PCOS. It is difficult to determine diagnostically whether or not one has PCOS as there are different definitions of the syndrome and no one test can clinch the diagnosis. As a result it remains a diagnosis of exclusion. The simplest approach in management of PCOS is to treat the symptoms empirically.
That is, if there is a strong possibility it is developing or has developed; switching medication is the first line of treatment.
Terms:
Somatic - referring to the body.
Somatic therapy - refers to all treatments that have direct physiological effects, such as medication and ECT.
Somatic complaints - refer to all physical complaints that refer to the body, such as aches and pains.
(49) Bipolar Disorder
Spending Sprees in Bipolar Disorder
Mental Capacity and Mental Illness Factsheet
I have recently been diagnosed with bipolar disorder. What are the risks my children will inherit it?
The lifelong prevalence worldwide is anywhere from 0.3 to 1.6% for bipolar I disorder and larger for bipolar II disorder, with rates adding an additional 0.5 to 4% to the total number, depending on the epidemiological study. Thus, regardless of one’s background, this is the risk for the development of the disorder. Now, supposing you have the diagnosis of bipolar disorder, how much greater is the risk to your child? We know that bipolar disorder, especially bipolar I disorder, has a major genetic component, with evidence coming from several studies. First-degree relatives-that is, immediate family members who share 50% of your genes (siblings and children)-are around seven times more likely to develop bipolar I disorder than the general population. Additionally, the offspring of a parent suffering from bipolar disorder have a 50% chance of having another psychiatric disorder, independent of their chances of having bipolar disorder. Identical twin studies demonstrate a concordance rate of 33% to 90%, depending on the study. That is, if you have bipolar disorder, the likelihood of your identical twin having the disorder is between 33% and 90%. For nonidentical twins, the concordance rate is between 15% and 20%. For first-degree relatives-that is, brothers and sisters who are not twins or children of parents who suffer from the disorder-the concordance rate is between 5% and 10%. Adoption studies demonstrate that the risks of developing bipolar disorder follow those of the biological parent and not the adoptive parent.
Schizophrenic, schizoaffective, and manic syndromes appear to share genetic risk factors, suggesting that bipolar disorder is more akin to a psychotic disorder than a mood disorder.
The fact that there is not 100% concordance between identical twins demonstrates, however, that environmental influences still have a role in the development of the disorder. Environmental effects can mean anything non-genetic, from local chemical environmental effects on the gene, to more global biological effects like fetal exposure to some as yet unidentified substance, to what are more commonly thought of as environmental factors such as family and social circumstances. If a patient has negative family and social circumstances, environment is considered more of a trigger than an actual cause, and any genetic vulnerability may be either protected by a stable environment or, more typically, provoked or precipitated by an unstable environment. Putting together genetic and environmental factors as contributors to the onset of bipolar disorder means that with a family history, an individual has a higher relative risk than anyone in the general population for developing bipolar disorder.
Stressful life events, specific environmental circumstances, or certain psychological processes may serve as a trigger of a manic episode in someone with a genetic predisposition for the disorder.
Is there a link between epilepsy and bipolar disorder?
Questions about a possible link between epilepsy and bipolar disorder naturally arise due to the fact that anticonvulsants also treat bipolar disorder. From a historical standpoint epilepsy was first thought to be a purely mental or psychological disease, although at that time neurologists were the only specialists who treated both neurological as well as psychiatric conditions, and most medical people felt that psychiatric disorders were fundamentally neurological in origin.
Toward the end of the nineteenth century, epilepsy was beginning to be regarded as a distinct phenomenon, and controversy developed as to whether hysteria, a psychological condition, was actually due to epilepsy or to childhood trauma. Jean-Martin Charcot, a prominent neurologist in France, weighed in on the side of epilepsy, though he was most famous for his studies on hysteria utilizing hypnotism. His clinical picture of hypnotism was similar to the clinical picture he had previously developed for epilepsy. He believed that hypnotism demonstrated that hysteria was a form of epilepsy because it presented with the three clinical stages of catalepsy, lethargy, and somnambulism.
Catalepsy is a type of sudden paralysis, and somnambulism is sleepwalking. Another neurologist, Sigmund Freud, who first began developing his theory of hysteria as having roots in childhood, disagreed. Ultimately Freud’s arguments carried the day. Although Freud and Charcot both believed that all mental diseases were brain diseases, Freud’s writings ultimately led to the development of psychotherapy for all mental illnesses and the brief historical abandonment of biological causes of mental illness.
Research has increasingly demonstrated that the incidence of neurobehavioral disorders is higher in patients with epilepsy than in the general population. The link between neurobehavioral disorders and a particular type of epilepsy known as temporal lobe or complex partial seizures is particularly strong. The underlying mechanisms or causes of bipolar disorder share many similarities with epilepsy. As in epilepsy, the more episodes that occur in a bipolar disorder patient early in the course of the disease, the more frequent and severe later episodes will be. This is thought to be due to a well-known phenomenon called kindling. Kindling is defined as seizures provoked by repeated stimulation of the brain that require less and less intensity. In animal studies a particular stimulus that once required great intensity can thus be extremely faint after kindling to provoke the same level of seizure. The seizure threshold is then considerably reduced. Kindling may also explain why the levels of stress that can precipitate a manic episode in a particular individual often become reduced over time.
Additionally, anticonvulsant agents play an important role in the treatment of bipolar disorder. They affect the same neurotransmitter systems thought to play a role in both conditions-namely, the GABA/glutamate neurotransmitter systems. GABA is the brain’s major inhibitory neuron, suppressing or dampening brain activity through nerve cell membrane stabilization. Glutamate is the major excitatory neurotransmitter serving to activate brain activity. Seizures can then occur by relative decreases in GABA or increases in glutamate causing large segments of neurons to fire asynchronously or haphazardly. This leads to not only motor disturbances but sensory and mental disturbances as well.
I have recently been diagnosed with depression, but I have a family history of bipolar disorder. What is my risk of becoming manic if I take antidepressant medication?
Part of a comprehensive mental health evaluation involves a detailed past personal psychiatric history as well as a family psychiatric history. The family psychiatric history is important because many psychiatric conditions have a heritable component and can inform the clinician as to risks for certain conditions. Although bipolar disorder is known to have genetic links, a family history of bipolar disorder does not automatically rule in bipolar disorder in a person presenting with a major depressive episode. In the absence of a personal past psychiatric history of mania or hypomania, bipolar disorder is not diagnosed. That said, bipolar disorder can present with depression first and must always be considered even in the absence of family history of bipolar disorder. The presence of bipolar disorder in the family history increases the risk for the condition in a given individual, and it also increases the risk for mood disorders in general-not only bipolar disorder. In addition, the risk level needs to be kept in perspective. Although there are known heritable conditions that are either dominant or recessive, and present with a very specific risk (e.g., 50% chance of Huntington’s chorea being acquired if one parent is afflicted), the risk for developing bipolar disorder, let alone any mood disorder, cannot be so precisely defined.
In such a situation, the risk of taking antidepressant medication has to be balanced against the risk of not taking it. In the case of moderate to severe depression, the risk of not taking the medication can include suicide, in addition to the consequences of significant functional impairment at work, home, and so forth.
Such a risk would likely outweigh the risk for becoming manic and thus would warrant an antidepressant trial. This situation would, of course, especially require very close follow-up with a psychiatrist and may warrant that certain safeguards are put in place (e.g., a family member could monitor for signs of mania, with a specific plan for such an occurrence). As with a documented history of mania or hypomania, the psychiatrist may consider use of a mood stabilizer in conjunction with an antidepressant; however, the side effects and risks of taking a mood stabilizer, when in fact it may not be necessary, likely do not outweigh the risk for becoming manic on an antidepressant. Discuss the variables involved with your psychiatrist.
Terms:
Relative risk - a ratio of incidence of a disorder in persons exposed to a risk factor to the incidence of a disorder in persons not exposed to the same risk factor.
Catalepsy - a condition that occurs in a variety of physical and psychological disorders and is characterized by lack of response to external stimuli and by muscular rigidity, so that the limbs remain in whatever position they are placed.
Somnambulism - sleepwalking.
Kindling - changes that occur in the brain as a result of repeated intermittent exposure to a sub threshold electrical or chemical stimulus (such as in seizures) so that there develops a permanent decrease in the threshold of excitability.
(50) Bipolar Disorder
I want to get pregnant but take medication for bipolar disorder. What can I do?
Because bipolar disorder has its average onset in late adolescence and early adulthood, many women with bipolar disorder are faced with decisions about their treatment in the midst of their reproductive years. The best first step is to plan the steps to take before becoming pregnant. You need to familiarize yourself with the data that are available regarding medication use and its potential effect on a fetus. You also need to be aware of the risks associated with stopping medication treatment. First off, know that there is controversy in the literature as to whether or not bipolar disorder improves during pregnancy, but that even if it does for some, it does not for others. Also, it is important to know that there is a high risk for symptom recurrence in the immediate postpartum period.
The risk of use of mood-stabilizing agents during pregnancy appears to be greatest in the first trimester, although there are teratogenic effects that can occur later as well. A review of the literature on various medications was done by Yonkers et al. and noted the following:
Lithium
There is an association with cardiovascular malformations.
Ebstein’s anomaly occurs in 0.1% to 0.2% of the offspring of lithium users in contrast to 0.005% in the general population. While the risk is increased several fold, the absolute risk remains small. Lithium-exposed infants have been found to weigh more than nonexposed infants. In two studies of behavior and development, there were no differences in milestone development or behavior. Exposure to lithium during labor has been associated with “floppy baby syndrome,” so close monitoring of levels is part of routine obstetrical care.
Depakote (valproate)
Use during the first trimester is associated with high rates of neural tube defects of 5% to 9% with the risk being dose related. Craniofacial abnormalities, growth retardation, small head circumference, and heart defects are at a twofold increased risk from the use of anticonvulsants. Depakote (valproate) has neonatal complications associated with it as well such as heart rate decelerations, irritability, jitteriness, feeding problems, and abnormal tone. Some experts recommend Depakote (valproate) be switched to another mood stabilizer before pregnancy. Teratogenic risk is also higher with the use of more than one anticonvulsant agent.
Equetro (carbamazepine)
Craniofacial defects, fingernail hypoplasia, and developmental delay have been found at high rates. Neural tube defects range between 0.5% and 1%. Reduced birth weight and head circumference are associated with Equetro (carbamazepine) use. Equetro (carbamazepine) is not recommended by most experts for use during pregnancy unless there are no other options.
Lamictal (lamotrigine)
In 2004, rates of major malformations appeared to be similar to those in the general population, but new information suggests an increased risk for cleft lip and palate with first trimester exposure.
Typical Antipsychotics
There have been mixed findings on whether there is an increased rate of malformations, with many studies conducted on chlorpromazine. One study on rates between those on chlorpromazine for psychosis and those who were psychotic but not on chlorpromazine showed similar rates of malformations that were higher than in the general population, suggesting that something else about the illness was contributory. Case reports have suggested a link between Haldol (haloperidol) and limb reductions, but larger case series have not supported this. The risk from typical antipsychotics is considered by many experts to be less than the risk from some mood stabilizers, and thus during pregnancy, a switch from a mood stabilizer to an antipsychotic is often made.
Atypical Antipsychotics
There are limited data on the use of atypical antipsychotics in pregnancy. Keeping the data in mind, it is possible to manage both pregnancy and bipolar disorder safely, but again the planning should ideally occur before getting pregnant. With careful planning and monitoring, outcomes can be improved for both mother and offspring. Communication with both psychiatrist and obstetrician are critical.
I found out I am three months pregnant and have been on a mood stabilizer. Is my baby at risk?
It is ideal that planning for conception occur first, for many women pregnancy is not anticipated. Unfortunately, many of the fetal malformations do occur in the first days to weeks after conception and thus by the time pregnancy is discovered, the exposure has often already occurred. Depending upon the medication being taken, once that time period of higher risk has passed, it may no longer be prudent to go off a specific medication. Keep in mind as well that although rates are higher than the general population for various malformations, in some cases the rates with medication exposure are still low. Meetings with both your psychiatrist and obstetrician to go over your options are needed as soon as possible. Prenatal testing for some conditions may be desired to check for abnormalities. Your psychiatrist can work with you to minimize additional risk for the duration of the pregnancy and to determine the best course of treatment postpartum.
Can I take a mood stabilizer or antidepressant while I am nursing?
Data regarding use of many medications during breastfeeding are scarce. The FDA gives a category classification for most medications as to whether they are safe during pregnancy or nursing, but this information is not always reliably based upon available data. Some medications, like benzodiazepines, are known to be present in large quantities in breast milk and thus are presumed to be unsafe. There have been increasing amounts of data as well as interest in the risks versus the benefits of taking bipolar medications while breastfeeding. Typical medications taken for bipolar disorder may include both antidepressants and mood stabilizers, such as anticonvulsants and/or antipsychotics.
All antidepressants are excreted into breast milk. Although differences may exist between antidepressants as to quantities found in breast milk, data are insufficient to make definitive statements about these differences. Both tricyclic antidepressants (TCAs) and SSRIs are generally undetectable in nursing infant blood. Nortriptyline has been the most studied TCA in breastfeeding women. Children exposed to TCAs have been followed through preschool, and no developmental differences have been found compared to children not exposed to TCAs. TCAs, however, are not typically the first-line treatment for depression because of their side effects and are not recommended in bipolar depression. Data are available on the use of Sarafem (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), and Luvox (fluvoxamine), with Zoloft (sertraline) being studied most over the past few years. Although SSRI medications have not usually been detectable in most studies, there have been infrequent reports of detectable serum levels of Zoloft (sertraline), Celexa (citalopram), and Sarafem (fluoxetine) in exposed infants. A case report on paroxetine found no evidence of it in breast milk, thought possibly due to its half-life, but more studies are needed. No adverse developmental or behavioral effects have been detected to date in nursing infants, but there have been no long-term studies. Zoloft (sertraline) is generally considered relatively low-risk, but Sarafem (fluoxetine) may have some level of risk associated with it, possibly due to its long half-life. Three cases of colic have been reported in babies with detectable levels of Sarafem (fluoxetine), and there is some evidence for reduced weight gain after birth. Although for the most part levels of SSRIs are not usually detectable in infant serum, this does not exclude the possibility of the drug having entered the central nervous system. In unipolar depression, the benefits of breastfeeding may outweigh the risks of SSRI exposure alone, and thus staying on medication while nursing is often warranted.
In considering use of other medications for bipolar disorder while nursing, data too are limited. Lithium levels in breast milk are close to half the levels in maternal blood. Infant kidney function is not optimal, which can result in elevated blood levels of lithium. If lithium is taken during breastfeeding, the infant’s blood levels and complete blood count should be monitored closely.
Depakote (valproate) has not been associated with adverse effects in exposed infants or mothers, and the American Academy of Neurology does advocate breastfeeding for mothers on antiseizure medication. Equetro (carbamazepine) levels in breast milk are low. The American Academy of Pediatrics lists both Depakote (valproate) and Equetro (carbamazepine) as compatible with breastfeeding. As for the antipsychotic agents, there had been twenty-eight reports on infant exposure during breastfeeding at the time of the Yonkers et al. review; no adverse events were reported in the majority of cases.
Deciding whether to breastfeed while on bipolar medications is difficult. The risk of going off medication, however, is great. There is a high rate of recurrence of illness during the postpartum period. Lithium has been found to reduce the rate of relapse from 50% to less than 10% in the postpartum period. Although it is desirous of many women to breastfeed, if you absolutely do not want the infant exposed to any medications, the more conservative approach is to remain on medication and not breastfeed, as both depression and mania can be associated with adverse outcomes in an infant. Untreated maternal depression is associated with reduced weight gain in infants. A depressed or manic mother will be less in tune with a baby’s needs, less able to monitor the environment for safety, and less apt to engage in a nonverbal dialogue with the baby. Early attachment is important in a baby’s development, as poor attachment early on confers risks later in life for emotional and behavioral problems.
Terms:
Teratogenic - that which can interfere with normal embryonic development.
Half-life - the time it takes for half of the blood concentration of a medication to be eliminated from the body. Half-life determines as well the time to equilibrium of a drug in the blood and determines the frequency of dosing to achieve that equilibrium.
Attachment - the psychological connection between a child and his or her caretaker. Infants develop attachment behaviors within the first month. Deficits in early attachments can result in problems in later relationships in life.
