BiPolar Disorders: Clinical Strategies and Treatment Outcomes
BiPolar Disorders: Clinical Strategies and Treatment Outcomes
Bipolar as a term is being used so broadly that it is beginning to lose some of its meaning. It is, I think, often used as a default diagnosisespecially in children and adolescents. We dont know whats going on so we call it bipolar if there is mood instability, meltdowns, rages, or if the symptoms respond to a medication that is used to treat bipolar category symptoms.
So, the first clinical issue is what exactly is being treated? Diagnoses tend to be reductionistic. In other words, they are used as categorical labels instead of being recognized as a somewhat limited tool for communication between clinicians. They also tend to separate patients out into us and them. I am bipolar becomes an identity rather than a description of certain behaviors/emotions that are only part of a much greater whole that we call a person. It reminds me of Alcoholics Anonymous where someone stands up and says, Hi, Im Chuck. Im an alcoholic. Now I know that this is necessary, but I always want to ask, So, what does that mean? because viewing behavior in the whole context of the persons life helps me understand who someone is much more.
When I was rotating through different services in medical school, we tended to refer to patients as, the gallbladder in room 12 or the M.I. (myocardial infarction) in the emergency room. While you can get away with this more in surgery or internal medicine, this tendency to objectify patients has more treatment implications in mental health than in the other medical specialties because the treatment protocols/algorithms are much more unpredictable in terms of responses. Treatment has to be tailored to the individual. Added to that is the use of the clinicians personality as a diagnostic/ therapeutic tool.
That being said, it is still important to understand the diagnostic categories that are applied to this disorder. They are: Bipolar Type I, Bipolar Type II and cyclothymia. To complicate matters, there are other subtypes such as rapid cycling and mixed states.
Many times, there are concurrent diagnoses such as borderline personality disorder or conduct disorders in adolescents. There are patients who have a completely atypical presentation with mood instability being the primary symptom. However, they do not clearly fit into any diagnostic concept.
The most well known diagnosis is also called manic-depressive. This is Bipolar Type I.
In this form, highs alternate with periods of depression. Highs can be indistinguishable from the psychosis of schizophrenia when an individual is at the extreme end of the spectrum. Consequently, individuals can experience auditory hallucinations, paranoia, bizarre delusions, etc. After treatment, it usually becomes more apparent whether it is or is not schizophrenia, since true schizophrenia shows residual impairment in many areas.
Alternatively, with bipolar disorder, the pattern is somewhat predictable in that there are recognizable highs with grandiosity, heightened sexual impulses, little to no need for sleep, excessive spending and poor judgment, which is not clearly recognized by the individual. Individuals with this kind of bipolar disorder are often seen in hospitals, as their impairment is unmistakable. What I see more of in an outpatient setting is the other types of bipolar disorder.
Bipolar Type II is characterized by elevated states with little need for sleep, creativity, impulsiveness, heightened sexuality and poor judgment, but without the clear impairment that comes with a psychotic state. I treated one patient who had essentially been in a hypomanic state for ten years and only came for treatment when a depression finally materialized in his mid- 40s. Elevated states can be hard to identify because they can be mild and others may mistake this for doing well, especially if someone is coming out of a depression.
Unfortunately for individuals with this profile, an antidepressant may have a counterproductive impact. These individuals may come out of the depression, pass through normal and then go into an elevated state. The hypomanic symptoms arent caused by the antidepressants, but they are triggered and aggravated by them.
Cyclothymia refers to the cycling of highs and lows that do not seem as severe as what you find in Bipolar Type I or II. There is some discussion regarding whether this should be considered a personality characteristics or a true form of bipolar illness. After many years of clinical experience, I think this is definitely a form of bipolar illness. Unfortunately, it isnt recognized or treated as often as it should be because it isnt as dramatic in its presentation. However, it is very frustrating to the individual who experiences its consequences. Fortunately, it responds well to treatment.
I think that two of the most miserable states individuals with any type of bipolar disorder can experience are rapid cycling and mixed cycling. Rapid cycling refers to changes in mood many times throughout the day. One minute youre up and the next youre down. Mixed cycling refers to feeling up and down simultaneously. This results in a jarring juxtaposition of agitation/anxiety being experienced at the same time as deep depression. Both remain difficult to treat.
To add to the complexity of the bipolar spectrum, there is another symptom complex that often accompanies AD/HD and OCD. It is characterized by meltdowns, mood swings, time-limited angry episodes, over-reactivity and unpredictability. These episodes can be accompanied by physical acting out. Individuals frequently dont remember much of the episode after it is over. Although this syndrome is most often identified in children and adolescents, it is readily diagnosable in adults with proper attention and clinical experience.
Understandably, it carries the diagnosis of bipolar disorder because it responds to the same class of medications. It seems to me, however, that it is being used as a default diagnosis. The prognosis for individuals in this category seems to be much better and I have seen many younger patients make it to adulthood with resolution of symptoms and certainly without developing a classic bipolar presentation of any kind. Did early intervention prevent full-blown development of the disorder?
Personally I dont think so because adults who have never been treated before have the same symptoms and also respond to the same medications. What seems most likely to me is that there are several disorders or subtypes of disorders and our conceptual framework is not broad enough yet to identify these separately.
So, what is the good news? First, we are now able to image brain structure as well as brain function. We are also much more sophisticated diagnostically. This means that we are much better at identifying what brain abnormalities are driving particular symptoms and which diagnoses produce similar symptoms, but require different treatments.
Consequently, we can look more closely at how the brain spends energy and where problems might occur. We can compare our clinical findings with what we see in PET (positron emission tomography) scans, FMRI (functional magnetic resonance imaging and SPECT (single photon emission computerized tomography).
Education is broadly available. In addition to local support groups and national organizations, the Internet has substantial old_resources from general information to support groups to online chat rooms where individuals can actually discuss their symptoms/concerns with similar people. This helps normalize the experience and offers opportunities to learn what strategies have been helpful to others. It is much more socially acceptable these days to admit your diagnosis and seek treatment.
There are now many different medications available. We understand a fair amount about what works and why. Different combinations and more choices mean that medical treatment can be tailored to the individual. If one medication doesnt work, there is probably another or a combination of two or more that will. The newer classes of medications have better side effect profiles and therefore compliance is better.
From my standpoint, the single most important part of treatment is the relationship with the provider or treatment team. Due to the nature of this particular set of disorders, it is often very difficult for the individual to see him/herself realistically as the mood elevates. An individual needs feedback from someone he/she trusts and who is familiar with his/her patterns. He/she needs to be followed regularly. An ongoing, timely relationship allows for confrontation and adjustment of medications before the episode gets to the point of requiring hospitalization or does serious damage to employment or family relationships.
WARNING! A sleep disturbance is often the herald of a manic episode and requires rapid intervention. Having a close relationship with the patient and family often means catching the episode before it escalates. I have several patients and their families who will call me immediately if sleep becomes a problem, even if there are no other active symptoms. Take help from telephone counseling.
The take away message is that the future holds much promise in diagnosis and treatment. We are on the cutting edge of technology that allows us to look at the living brain and gain a much more basic understanding of all psychiatric disorders. Tracing these disorders to the level of the genome will eventually provide for correction, if not elimination, of many of these neurologic/psychiatric disorders that have plagued us for so many years. Until then, we need to fine tune our clinical skills and continue to trust in the Lord for guidance and direction.
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