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    Bipolar Part

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    270 chapter? Bipolar and Related Disorders 7.4 List and distinguish between different types of bipolar disorders. a dicaee aue peer eariers ore dating _,__ for iniplar laorders bythe presence of mate or hypo- (Psat episodes wich ae neni aay preceded lowe by pero of depression. A person who experiences “armtnc place has a markedly elevated euphois and DX capatlvemod, often ntrrpied by Sashondt bunts st oink stably orc velence parc when Pacts ersec rs ccratong wll nerinic vee ote fered see pea o eesti exeleser ies “aii involve milder versions of th sme symptoms. Alnough Wert the symptoms listed are the same for manic and hypo- Tani elses theres uch es impairment in hypoma tia hegalapon ica eed ‘, Ad, eo ae cthymic Disorder Dem Gelleste yee Some people experience cyclical mood changes oo i severe than normal, but less severe than the mood rig acs nips ure Cyt der ere o th pent expen of Typommie SpE Ren {2 years iss ess serious version see mansion yo mood and behavior changes, psychotic features, and Pee aime oog ties sor Somptane ct tum ar fit me eerste essentially the o son may Become especially because of increased physical ai mental energy. There _may be significant periods between episodes in which the person with eyclothymia functions in a relatively adaptive BGeseaen ‘of eyelothymia, tere must be at lest (2-year san during which there are numerous peri- ‘ods with Typomanic and depressed symptoms (1 year for ‘adolescents and children), and the symptoms must cause clinically significant distress or paiement in funetoning (although not as severe as in bipolar disorder) Individuals ‘with eyelothymia are at greatly increased risk of later developing fll blown bipolar I or I disorder (Goodwin & Jamison, 2007) In the depressed phase of cyclothymic disorder, a per son's symptoms are very similar to what is seen in persis- ‘The individual's mood is dejected, and he or she exper ‘ences a distinc loss of interest or pleasure in customary, activities and pastimes. In addition, the person may show other symptoms such as ow energy, feelings of inadequacy, social “Ea warsas™ brooding: peep a eee tent depressive disorder but without the duration cHteion— [ypooken— faee alo The following cae illustrates cyelothymia, — A Cyclothymic Chef Kevin i 35-yem-0 chet wha le sokng teatment atthe 992 fen ofboth fe employer and gtiend. His prosantng problem i that "forthe past 10. yrs hao boon Navi exer us and lonns prety serous mood svings> Ken says tat he knows that sme fi enployes fart im es “DJ and Mr ye beh his back, ands employer angi have said hat hoy ever know "whch Kaw they are gor to soo. He describes Ns tnood swings a8 petods of ups and downs. Tho “yp at 9 to day dung whch bo is happy, il of energy ae reat, often expanding ns menu, reting new ashes, arc experiencing "a deep [ove of le and evering init” The "downs" last a ite bit longo, maybe 5 to 7 dye anc cing those pis ho fas down, leks ‘nergy, has ta realy push hinse o get rio werk and prepare is ‘menu, ands oe sotated—yeling at his cooks, occastraly 0 oud hat customers can hear hm T pate of ups and dawns as started to hve a negative mosct on his work, ands puting & we ow at Bipolar Disorders (I and II) Recurrent cycles of mania and melancholia were recog nized as early asthe sixth century; however, it wasn’t until 77? 22 {op that Kl mode the om nance aiprege described the disorder as a series of attacks of elsion and e deprespin, with periods of relative normality in between. Toda¥’we call this illness bipolar disorder, although the term ‘manic-depresson is still commonly used as well Bipolar I disorder is distinguished from MDD by the presence of mania (See Table 72 fora summary). A mixed, erisds ie charcteszed by ermpoms of bot tithe intsmised or allernating rapily even a Seu abe eitta ame 4 recent reve of 18 studi fund that approx) 28 percent of ipoac patients experience mixed tate at east some ofthe time, Moreover many patients ina mane fode have some symptom of deposed mood, anxiety Table 7.2 Distinguishing Between Bipolar | ‘and Bipolar I Disorder e oH .o [MDD foes eugene ee te same: oceans ar polos t san 1S eee sal "Gant tapos orecien sah fe ec tray ‘eprestie gen, he dapross otpoer Isso i an. Bipolar + Parson exprences prods of rypomana, buts orher ymeters ‘aebon etresels faa oon mania + Pron expences proof press mood tat mest te cite formar espress, fate plo te Ee Geter. ae, ay ats manic epitore > + dap moodt frsices [guile [Suludaly sous J guilt, and su al thoughts, even if th enough to qualify as a mixed episode. People whose first cpisdde of mania fsa mined episode have a worse long- term outcome than those originally presenting with a epressive or a manic episode (Baldessarini et al, 2010; Dodd et al, 2010) If a person shows only manie symptoms, it is never theless assumed thata bipolar disorder exists and thata depressive episode will eventually occur. Although some researchers have noted the probable existence ofa unipolar type of manic disorder (.e, “pure mania”; Kessler et al, 1997; Solomon et al, 2003), cites of this diagnosis argue ‘hat such patients usually have bipolar relatives and may well have had mild depressions that went unrecognized (Goodin & Jamison, 2007; Winokur & Tsvang, 1996) ‘The following cate illustrates both phases of bipolar I disorder, ped Up and Out of Control Timi a 25,year-oX student ane aspiing poet, per, and mus ‘dan. He was just acmited to a paychiaiic hospital nan apparent mane epizode, Although ha has hac aft table We in wich he es wah is tien, Tess, takes cles at he local community ‘colege, and works ata cote shop in town, his behavior Mas become nereasingy erat, More spoccaly is glrond reports that Tm has appeared obo rey spod up the past month, taking ‘astarthan Ua, expressing Some prety erandlose ase. "m gang to start ard isha Prd Inposty ths year set un arneting wth Kanye Wee to discus ining wh im’ and"am Tupac rai ‘camate). Tessa reports ha hngs have goon much woree dur Ing tha past 2 weeks, dug nich Tin soope st 102 hour per right and ecende the et fh tne nthe evenings making musi, smoling marjuana, and bujlg expensive tans onine to has ‘maxed 01 her cre cards buying mutple qutars,tumtabes, a ‘ow rigor and a five-star tip to Pars). Sho aso reports that Tim deappeared forthe pest 4 day ekeping eceland work as all, on to etu home ts moring saying that ne nas been v Ing with another woman hejust met. Testa says that ts all very ‘ute character for Tim. Sie she has known him he has had per ‘ds of prety severe doprossion during whic he becomes extremely ‘id, sons playing or making music, sleeps most of he day, and bare leaves the house. Hower, she has nove sen him e0 sped Up and out of conto and he has become a completely dierent arson hese past ow weeks, DSM-5 also identifies a distinct form of bipolar dis- ‘order called bipolar II disorder, in which the person IL = No mao. ak ov ‘© +\Mbb Br 72 &E (MW wremor 628) (6 tolS2 Coo) jak $0 S2UeAR 00 — Mina Mood Disorders and Suicide 274 does not experience full-blown manic (oF mixed) epi. sodes buthas experienced clear- s)mP~ toms, research clearly ind __sodosin people witapipolar disorder Freee rnin unipolas dire and, not surprisingly ey See ae more TOTS impairment (Kessler etal 2007) iisdiagnoses are unfortunate because ere are Some hat diferent treatments of choice for unipola ael AP Tevscpreaions Moreover jhere is evidence TSI 7S antidepressant d 6 what is thous " pola depression may actualy Prelate E> ually have as-yet ted sodes in patients who ac bipol fr thus worsening, the coarse of the illness Gaemi etal, 2003; Whybrow 1997) lentes that major depressive epi “Urpalar Bipolar wok UP , oppose Dd ue Eis tye. People with ipl dtrtr ef rom more ep at ern thr ies ado persons wh PO EEaa Lith ne epienestentobesomewhat g 3-4 months, Angst & Sellar, 2000: percent of per BD (OLY axtere Solomon eta, 200). As many a8 5 t0 10 Sons with biplar dione experince a lest four epi Sis ier marco depressive) every yet a ptters ona rapid pling In fact those who go Hvongh oe ater cycling usualy experience many Ore rarer epicodes a year. People who develop rapid Gpaling ae slightly more likely to eae) tohaves ‘notory of more episodes (especially more manic oF hYPo- episod), wo have an erie average age of onset aa ete more suicide attempts (Coryell ta 2008; Kupka etal, 2005; Nierenberg etal, 2010)- Rapid eycling rtain kinds of anti- is sometimes precipitated by tains TT a seats (Coodorin & Jason, 2007; Kizeh ARS FEET Fortunately, for about 50 percent of cases, rapid alngsa temporary phenomenon and gradual st: ‘ars thin about 2 vars (Corel et a 1935 2003) Sr he probabilities of fll recovery” from bipo- tar doprder are ciscouraging even with the widespread war anod:stabilizing medications such as ihium with Tents with bxpoRe tisorder ir lives in episodes (Angst & pady in which Uy eprsoae fone review est spend about 20 percent ofthe Sellaro, 2000). One 20-year Pi ver 200 patients were followes Found that 24 percent had relapsed W recovery; 77 percent had had at least rete yonts of recovery andl 82 percent had Tl eee Yeats (Coryell ly 1995). Another resPerh® srospective st xl for an average of 17 Years sithin 6 months of me new episode psed 1146 bipotae patients found hat they experienced aay eee oe aul subeyndromal) on an average of Freer ene weeks daring the D-year folow-yp 1 rng the fllow-up per, depressive symptoms Fore thee times more common than manic or hypomanic ‘Spmptoms Gud etal, 2002; se also Juda et al, 2003) in review + Ditngdsh batwoon th pened phases of + ifeertia between the symtoms othe depressive episodes of ood anc unpol dore ynploms of the hypomanic and Causal Factors in Bipolar Disorders 7S Describe the causal factors influencing the development and maintenance of bipolar disorders ‘Athos of causal factors for bipolar disorder have been pos ited during the past century. However, biological causal factors are clearly dominant, and the role of psychological ‘causal factors has received significantly less attention. The _majority of research has concentrated on bipolar I disorder, ‘which is what we focus on here. Biological Causal Factors ‘Aruumbe of biological factors ate thought to playa enuisal role in the onset of bipolar disorder. These factors include genetic, neurochemical, hormonal, neurophysiological, euroanatomical, and biological shythm influences. GENETICINFLUENCES. There is a greater genetic contri- bution to bipolar 1 disorder than to unipolar disorder. “Appronimatey 8 1 10 percent ofthe fis-degre relatives ofa pron with bipolar liness can be expected to have Ispolar disorder compared to 1 percentin the general pop- “ntion Comin tal, 2013, Wilt McQueen, 2010) ‘The firs-degre relatives ofa person with bipolar disorder also are at elevated risk for unipolar major depression, although the reverse is not true (AKiskal& Benazzi, 2005, GGoostin & Jamison, 2007, ‘Although family studies cannot by themselves estab- lish a genetic basi forthe disorder, results from twin stud- ies dating back to the 1950s also point to a genetic basis because the concordance rates for these disorders are much Iigher for identical than for fraternal twins. The average concordance rates about 60 percent for mono twine and only about 12 percent for dizygotic twins (Kelsoe, 1997), This and other studies su ep cesta aes ea 80 10 90 percent ofthe variance in the liability to develop polar I disorder (Goodwin é Jamison, 2007; ipol der (Goodwin & Jamison, 2007; MeGuifin 213 tal, 2008). This ie higher than heritability estimates for unipolar disorder or any of the other major adult peychisg- tic disorders, including sehizophenia Torrey eta, 1994), Efforts to locate the chromosomal ste) ofthe imp cated gene oF genes inthis gene ic transmission of bipolar disorder suggest that it is polygenic (Willewt te McQhecn, 2010). Although a great deal of research has been diestes at identifying candidate genes through linkage analyte nd association studies no consistent support yet exis any specific mode of genetic transmission of bipolar digge der (Potash & DePaulo, 2000; Teuang etal, 200, Another wrinkle inthe star identified by recent studies Js that different dlsordersscom to share ther yentic ets For instance, some ofthe genetic ae ymorphisms that 6 sceninthase wihbipdlr diorler nestor ee Goth dooners experince paghate free ee depression (pethaps explaining why people with thee e ian et erpetae eee a der Group of te apc ee ei sychlatic Genomics Consortium, 2018), NEUROCHEMICAL FACTORS The easly monoamine Ingpotnesis fr unipolar disorder was extended to Bipsae ori: te bypass oe by defen of seepage een oe haps mania is caused by excesses of these Te/otrancite ters, Thete is good evidence Tor increased mTeSTREp Te sclvty during manic episodes and less consistent er lence for lowered norepinephrine activity luring depres sive eplsodes (Goodwin & Jamison, 2007; Manji Lenen, 2000). However, serotonin activity appears to be lowe both depressive and manie phases, * As noted earlier, norepinephrine, TNe serotonin, and dopamine are all involved in regulating our mood states (Howland & Tac 1995;Soutricket a they Ro trike lof dopamine tne npr fesroeehcnn TD ing hat increned dopaminergic nen aes ys nave hind iomanis Gmaplimeafiseer sity, grandiosity and euphoria (Cousins etal, 2009; Goodwin cf figs ee eee ee _aptimanic In depression there appear to be decreases in ‘oth norepinephrine and dopamine funtioning (Goodwin a ee Rema ee eee [ABNORMALITIES OF HORMONAL REGULATORY y5- Eset eee eee has focused on the HPA axis. Cortisol levels are elevated in ' bipolar depression (as they are in unipolar depression), but fe enone eee (Goodin & mts, 27} Sy oslo iE isle Trowel - oa Bam powia 9 &: e S Se en Oe UCHMral ty er DS ia loon T hor Promograliiy a KOC 4 tp via DAP = hrm. episode show evidence of Othe ents with nce examethasone suppression test (DST) bipolar disorder have shown both silanes toand afer. 274 crap? cou §) disorder who are ina depres neurophysiologica findings érom a about the 4 betaine minis do people erperhnchig Muilpclan ened Eoin palin it ale duetaee Geka corso an the abort even en he snl Foren ae Teen reviews suggest nk 2 aed ar ue fly remitted and asymptomatic for at ther are deficits in etvity inthe prefrontal conten mbipot Cpu g OF" least 4 weeks (Langan & McDonald, 200%; Watson et lar icone 7 pelted renopeychniogianls eet arse sererzting a mani episode, however thir rate of DST dei that people with bipolar daonder show n prose. @eoeee$ bs ng, plating, working memory, shy eo Coeaern & Jamin 207; Mani Leos 200, aTRongh and std tenon oh captive take Cher tay (SSO 004; Malhi, lvanowski, etal, = ts seen in unipolar depres See Langan & McDonald, 2008) Research also has focused 2011, Haldane on abnormalities of the hypothalamic-pituitary-thysoid 2004) This is similar te Suis because abnormalities of thyroid function are fre- sion, as are deficits inthe anterior cingulate cortex (Largan D ~ Gueniascomipanied y.changes in mood. Many Dipolar fe McDonald, 2008). However, structural inaging sudies 4 give Patients have subtle but significant abnormalities in the suggest that certain subcortical structures, inchaling the fanctioning of this axis, and administration of thyraid basal gangh ai 8 » and administration of thyroid basal ganglia and amygdala, are enlarged in bipolar disor. O22 lormone.often makes antidepressant drugs work better er But reduced in size in unipolar depression: The ane 4 (Altshuler et al, 2001; Goodwin & Jamison, 2007). How- decreases in hippocampal volume that are afer observed codes in patients with bipolar disorder (Goodwin & depression (Konarsk etl, 2008), Some studies using fone Jamison, 2007), ed activation in bipolar patients in subcortical bra [), Ntonornsiotocicat AND NEUROANATOMICAL INFLUENCES With PET sans its posible to voualze variations in brain glucose metabolic aes in depresed cantsendere hovel Laon eed A jntmani st alough heisfalcvidencemprt- 204). Overal i iharo dnw m anunos in as 3 manic states Decne ofthe ret fice stung ane erbecuseeresese sey ern oes De OE eric Ree | ee manana Cap UIEC Y evidence fom studies using PET and ole neuroimaging por fr dyereguaion Is otalinticccivetas etek ‘7 techiques show that whatas Blood fow lo helaftene viduals wih trees dates omen es ES Aion eel ceecre ee etene) abe ee sin carta ther parts fhe pstonalcortet_ when muchonded technologies! mooetons vetoed (Bermpotl et al, 2010; Goodwin & anion, 2007-Tts (Goodin Jonson, 2) there are siting pattems of brain acy during ania and during depressed and normal moods (s¢ Figure 7,8). SLEEP AND OTHER BIOLOGICAL RUYTHMS There is tees R frowel + Teruporel Aepiovs — considerable evidence regarding disturbances in biological Figure 7.8 Mood Disorders and the Brain even after symptoms have mostly remitted (Harvey, 2008; Bain imaging stuses have ravenied hat people with mood dsorcers Murray & Harvey, 2010), During manic episodes, patents aed rae ana renc peere oia arsed HR, yin bapa csuder tn to sleep vary litle Goeringly amygdala, and hippocampus. 3 by choice, not because of insomnia), and this is the most citi Aorymnon symptom tosis prior to the onset of a manic episode. During depressive episodes. they tend toward hhypersomania (too much sleep). Even between episodes people with bipolar disorder show substantial slep die culties, including, high rates of insomnia (Harvey, 2008; Millar etal, 2004) Bipolar disorder also sometimes shows Gina way unipolar disorder does, “Suggesting disturbances of seasonal biological rhythms, although these may be the result of circadian abnormalities in which the onset ofthe sleep-wake cycle is set ahead of the onset of other circadian thytims. Given the eyelic nature ofbipolar disorder itself this focus on disturbances in iological rhythms holds promise for future integrative theories ofthe biological underpinnings of bipolar disorder. [rrawins- dhe vAJIae (48 Wtrornn) \ pep: bovoands Wye here 60 ~ grow Leadmal Poker ca ad bo) 2 woot stares th aegmener unpre nota gage ea ™ tional magnetic resonance imaging ((MRD also find jy, Gabee 1h bipolar d- “Ths pretty te bee atts with i der scan ees sense and evs ditrbed by, pet day cyl al gue a eset ter biol Haney locks (Goodwin & Jamison, 2007 2010). uray Psychological Causal Factors Although biological factors play a prominent role in the ‘onset of bipolar disorder, psychosocial factors have also ‘been found tobe involved in the etiology ofthe disorder. In particular, stressful ie events, poor social support, and Certain personality traits and cognitive styles have been ‘entfee {important psychological causal factors, ) STRESSFUL LIFE EVENTS. Stressful life events appear to be as important in precipitating bipolar depressive episodes as they are in triggering tnipolar depressive episodes. Both stressful life events during childhood (eg. physical and sexual abuse) and recent lf stressors during adulthood (eg, problems with friends and pass ‘iz, Finarcial pardship) increase the likelihood of ever developing bipolar disorder as well as having recur ‘eneas (Gilman etl, 2015 How might stresful life events operate to increase the chance of relapse? The dathesis-stress model would sug- gest that steal fe events infuence the onset of episodes by activating the underlying vlnerablty. One hypothe ‘aed mechanism is through the destabilizing effects that stresafllifeevents may have on etal biological yt. Although evidence in suppert ofthis ea i tl prelim nary itppens tobe a promising hypothesis, especially for manicepisodes Sender & Alloy 201; Grandin tal, 2008). ‘Goa atisinent ke dong very welln an exam, can sua Increase a manic symptoms JOTHER PSYCHOLOGICAL FACTORS IN BIPOLAR DIs- ORDER Other soci enonnestal varables may alg slit the course of bipbKY deste For example, ne study found that people with bipolar disorder who reported showed more depressive recurrences over a year follow-up, independent of the cffectsofsiressiul life event WHE mo 5, WHI also predicted more” 4 Mood Dscrdrsand Sucide 275 recurrences (Cohen etl, 2004 se also Alloy eta, 2610) Theres lo some evidence hat rsonaliy and cogntin. ‘evables may interact with stressful le event inlets ‘pling he Mahood of elapse For example the person. ality variable ngusaicism has been associated with symone of rein and nana Quilty 20 and two studies have found that neuroticism predicts increases in depressive symptoms i disor unipolar dso ‘Moreover, personality variables and cognitive styles that ate related to goal striving dive and ingentive mot ‘ation have been associated with bipolar disorder (Alloy et 51, 2009), For example, two personally variables asoct- ated with high levels achievement striving and increased sensitivity to rewards in the environment predicted increases in mani Symptoms especially during periods of active goal striving r goal attainment (such as studying for an importan€ exami and then doing very well ini ‘Lozano & Johnson, 2001; Meyer etal, 2001) Another study found that students with aGessinisie aitiDUtOND style ‘who had also experienced rigalive fSpvenis showed an increase in depressive symptoms whether they had bipolar or unipolar disorder. Interestingly, however, the students with bipolar disorder who had a pessimistic attbutional style and experienced negative life events also showed {increases in manic symptoms at other points in ime (Alloy ta, 2010; Reilly-Harrington etal, 1999), \in review ‘Summarize the mao biologics causal factor for bps sac, ', neluding genet, bocharcs, and ther ico acters ‘nat le do peychologial facts, cluding stressful events, seem olay in biped? Sociocultural Factors Affecting Unipolar and Bipolar Disorders 7.6 Explain how cultural factors can influence the expression of mood disorders. Research on the association of sociocultural factors with both unipolar and bipolar mood disorders is discussed. together because much of the research conducted in this area has notmade-lear-cut diagnostic distinctions between, the two types of disorders. Although the prevalence of ‘mood disorders seems to vary considerably among differ ent countries; it has been difficult to provide conclusive evidence for this because of various methodological prob- lems, including widely difering diagnostic practices in dif ferent cultures, and because the symptoms of depression MWokehu) Ben Abe p 276 craper? appear to vary considerably across cultures (Chentsova Dutton & Tsai, 209; Kleinman, 2004), Cross-Cultural Differences in Depressive Symptoms Depression occurs in ll cultures that have been studied However, the for that takes di 2s dos is Prevalence (Chentsova-Dutton & Tsai, 2009; Marella, 198i). For example, in Western culture the “payeholog- symptoms of depression (eg. guilt, worthlessness, Suieldal ldStion) are prominent, whereas they ae not Prominenty reported in non-Western cultures such 38 China nd Japan, where rates of depression are relatively law daca people in now Wester cultures tend 30 ktubit the more ‘physieal” symptoms (eg, sleep star tance; loss of SPReUIE regHt idl, end loos ef acral Interest (Kleinman, 2004; Ryder etal, 2008; Tel & CChentsova-Dutton, 2002) Several posible reasons for these symptom differ: fences stm fom Asan belie inthe unity of the mind and body, a lack of expressiveness about emotions more gener ally and the stigmaatached 0 mental ness in thes cule tures (Chentsova-Dutton & Tsai, 2009). Another reason ‘why gullt and negative thoughts about the self may be common in Wester Dut notin Asian cultures that West em cultures viéw the individual as independent and utonomous’30 when failures cual ‘aemmade. By contrast, in many Asian CUTOTE individuals “are Viewed as inherently interdependent with others. Nev- then aunts Chins Rave incorpo smte Western values over the course of becoming increasingly industrialized and urbanized, rates of depression have risen a gooll deal relative to several decades ago (Dennis, 2004; Zhou et al, 2000). Indeed, one study of adolescents Tnsome cultures the concept of depression as we knw itsimply © ‘docs not exit. For example, Australian aborigines who are “depressed” show none ofthe gult nd elsbnegaton commonly seen in more developed countries. They alo do at show suicidal tendencies but instead are more likely vent her haste onto thers rather than onto thea, 5 Poyetoleyicae oy ( h (aleyy quill, ertiuteasnoe?, sujcrtal aahor) p curt. 400 9

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