Bipolar disorders examples

BZ is undeniably psychotomimetic, but only in the broad sense that it causes a true loss of contact with reality. It also lacks most of the distinguishing features of the natural psychoses. Schizophrenia, for example, rarely produces visual hallucinations. BZ, on the other hand, seldom produces well-organized delusions (as may occur with LSD). BZ does not produce persistent social withdrawal, as seen in chronic schizophrenia, nor does it create the annoying overfriendliness of the manic phase of bipolar disorder. 

One of the major limitations in studies of the genetics of behavioural disorders in children arises from the overlap with other conditions. For example, nearly 50% of the patients with ADHD also have co-morbid conduct disorders. In addition, a subtype of the disorder may exist in those children in which the disorder persists into adulthood. An additional problem arises from the overlap between ADHD and bipolar disorder this has been estimated to be as high as 16%. 

A great many physical and mental disorders develop because of a malfunction in the nervous system. Some examples are Alzheimer s disease, schizophrenia, Parkinson s disease, Huntington s chorea, and bipolar disorder. Most of the effects produced by recreational drugs, such as alcohol, heroin, and cocaine, are also a result of changes in the way the nervous system functions. Today, scientists have a reasonably good understanding of the way in which the nervous system operates and how many types of chemicals affect this operation. 

A potential limitation of most of the controlled studies discussed above relates to the numerous exclusion criteria used for patient selection. For example, in order to find homogenous samples, major depression, bipolar disorder, Tourette s disorder, psychosis (clomipramine, fluvoxamine and fluoxetine trials), primary psychiatric disorder other than OCD (clomipramine and sertraline trials), and attention deficit/hyperactivity disorder (ADHD), autism, or other developmental disorders (clomipramine and fluoxetine trials) were excluded. Thus it remains unknown how well these controlled studies will generalize to more naturalistic clinical populations that are highly comorbid and where exclusion criteria are not applied. 

Given the available data, it is extremely important that clinicians evaluate patients with major depression for features of psychosis, because the failure to do so may result in inadequate treatment for the patient. A practical problem encountered by clinicians, however, is the subtlety of delusions. For example, it is not unusual in geriatric depression for patients to present with a somatic preoccupation that borders on delusional. These so-called near delusions may put the patient into the arena of psychotic depression. Some evidence exists that patients with depression with near delusions may respond more favorably to combinations of antidepressants and antipsychotics or ECT. Once the presence of both major depression and psychosis is determined, other psychotic disorders including bipolar disorder and schizophrenic spectrum illness must also be ruled out because this may influence long-term treatment decisions. 

Virtually all anticonvulsants are or have been of interest for the treatment of bipolar disorder. However, the importance of controlled data cannot be understated. For example, gabapentin, an anticonvulsant that initially received much attention as a potential mood stabilizer, was compared with placebo and did not appear to stabilize mood (Frye et al. 2000 Pande et al. 2000). Similar negative results were seen with topiramate in placebo-controlled trials for the treatment of mania. Although these medications might be useful adjuncts in some patients, given the currently expanded pharmacopoeia of medications with positive controlled trial data in bipolar disorder, we do not recommend the primary use of agents that have only case reports as an evidence base or controlled studies with predominantly negative results. 

Specific factors to consider are both psychiatric and physical contraindications. For example, bupropion is contraindicated in a depressed patient with a history of seizures due to the increased risk of recurrence while on this agent. Conversely, it may be an appropriate choice for a bipolar disorder with intermittent depressive episodes that is otherwise under good control with standard mood stabilizers. This consideration is based on the limited data suggesting that bupropion is less likely to induce a manic switch in comparison with standard heterocyclic antidepressants. Another example is the avoidance of benzodiazepines for the treatment of panic disorder in a patient with a history of alcohol or sedative-hypnotic abuse due to the increased risk of misuse or dependency. In this situation, a selective serotonin reuptake inhibitor (SSRI) may be more appropriate. 

Older persons account for one-third of all suicides in the United States even though this group represents only 12% of the population ( 36). Suicide is even more often related to major depression in the elderly than in younger individuals in whom other causes such as substance abuse, bipolar disorder, schizophrenia, and personality disorders often play a major role. In fact, suicide rates are highest in older white men relative to any other segment of the population. For example, white men older than 85 years age commit suicide 30 times as frequently as black women. 

Paradoxically, ECT is equally useful in both the acute manic and depressive phases of bipolar disorder, constituting the only truly bimodal therapy presently available. For example, in their literature review, Mukherjee et al. ( 51) found that ECT was associated with marked clinical improvement or remission in 80% of patients undergoing treatment for an acute manic episode. This is not the case for lithium, valproate, or CBZ, which, at best, have relatively weak acute antidepressant effects. Drug therapies may also induce a switch from a depressed to a manic phase, whereas ECT can control both phases of the illness. 

It appears that a number of complications await the recovering bipolar patient after an episode of mania. For example, Lucas et al. ( 44) reported on a retrospective linear discriminant analysis of 100 manic episodes (1981 to 1985) during the recovery phase and found that the incidence of subsequent depression was 30% in the first month. Many episodes were transient, however, and did not necessarily require treatment. This phenomenon could be successfully predicted in 81% of cases in which there is a premorbid history of cyclothymia with either a personal or a family history of depression. The highly significant association between family history and postmanic depression again supports the hypothesis of a genetic basis for bipolar disorder. 

Because CBZ and valproate have been used for many years to treat seizure disorders in children and adolescents, more systematic knowledge about their clinical pharmacology in this age group is available than there is about lithium. However, pediatric patients with epilepsy are often on concomitant therapy with other anticonvulsants. That fact complicates attempts to extrapolate from this experience to the use of CBZ or valproate as monotherapy for childhood or adolescent bipolar disorder. For example, the risk of serious and potentially fatal hepatotoxicity with valproate occurs almost exclusively in children younger than age 10 years (usually 2 years or younger) who are on multiple anticonvulsants for congenital seizure disorders. How or whether this risk translates to children or adolescents who are on monotherapy with valproate for bipolar disorder is unknown. Nonetheless, clinicians need to be aware of this possible risk and take the following steps to increase the likelihood of early detection in case this problem arises ... 

There is a modest link to mood disorders, but it is weak in magnitude and somewhat inconsistent. For example, some studies suggest that BPD often exists in families with other members who have bipolar disorder (220). 

Answers to these questions are just beginning to evolve (Tables 5—5 through 5 — 10). For example, the incidence of depression is about 5% of the population, whereas the incidence of bipolar disorder is about 1%. Thus, up to 15 million individuals are currently suffering from depression and another 2 to 3 million from bipolar disorders in the United States. Unfortunately, only about one-third of individuals with depression are in treatment, not only because of underrecognition by health care providers but also because individuals often conceive of their depression as a type of moral deficiency, which is shameful and should be hidden. Individuals often feel as if they could get better if they just pulled themselves up by the bootstraps ... 

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