Bipolar disorder/ depression

What is bipolar

-              Is a mood disorder

-              Characterised by mood swings are extreme and persistent (mood swing are normal if not persistent)

-              Affects more than 1-2% of the population worldwide

Types of Bipolar

-              Bipolar 1,  this is less common and affects males and females equally. It is characterised by periods of mania which are periods of depression and these may or may not reach threshold for major depression

-              Bipolar 2, this is more common and affects females more than males equally. It is characterised by periods of Hypomania which are periods of major depression

Mania

-              For episodes to be classed as hypomanic or manic episodes in the ICD-11 they must have the following features:

o   Euphoria

o   Irritability

o   Expansive and increased activity or subjective experience of increased energy.

And also serval of the following 7 symptoms:

o   Increased talkativeness or pressured speech

o   Flight of ideas, loads of ideas

o   Increased self-esteem or grandiosity

o   Decreased need of sleep

o   Distractibility

o   Impulsive reckless behaviour

o   Increase in sexual drive, sociability  or goal-directed activity

-              Can include: excessive cleaning, sudden interest in particular craft, excessive spending/ shopping and interferes with daily life however some find it enjoyable.

-              Rapid cycling, this is repeated switching between depression and mania with no ‘normal’ stage between. This does not affect everyone with bipolar, people affected usually experience at least 4 cycles within a year and these can occur monthly, weekly, daily, or hourly.

-              Mixed state, this is when the individual experiences symptoms of both depression and mania at the same time (over-activity with a depressed mood). This can be characterised

o   By the individual being very difficult to cope with

o   Unpredictability

o   Worrying, more likely to act on suicidal thoughts

o   Mixed episodes

Psychological factors  of Bipolar

-              Stressful life events, traumatic life events such as car crash or loss of a loved one may tigger bipolar or affect how long manic phases last (epically if there is a genetic link with other family members being bi-polar).

-              Social support, this is the idea that low social support leads to more relapses and so high expressed emotion families have high rates of relapse due to less support.

Biological explanations

-              Biological & biomarkers of bipolar disorder can be:

o   Genetic and epigenetic changes

o   Structural and functional changes in the brain, and damage in certain neuronal circuits

o   Immune and endocrine system changes

o   Neuronal plasticity impairment

o   Synaptic transmission and signal transduction disturbances (how the cells behave is different).

o   Changes in neurogenesis

-              Genetics shows high heritably rates compared to other conditions.

o   The concordance rate for MZ twins varies depending on the research but ranges from 43% - 72% (so about half the time which is strong genetic link in the development of this condition, however twins tend to be brought up in a similar environment which can also affect the likelihood of you developing schizophrenia).

o   The concordance rate for DZ twins is 6%, this would also be expected to be the same for siblings.

o   If a parent is Bi-polar there is a 10% chance of you also becoming bi-polar.

-              Neuroanatomical differences

o   fMRI studies show an increased  activation in amygdala (this is associated with fear and emotion) and thalamus (is involved in the sense and sensory relay).

o   People with bipolar 1 disorder have abnormities in the structure and function of emotional control networks in the human brain (such as amygdala, thalamus, and limbic system).  And there is also evidence that disruption in early development leads to decreased connectivity between ventral prefrontal networks and the limbic brain region (particularly the amygdala).

o   When using MRI to measure the thickness of the grey matter (edge of the cerebral cortex) of patients with Bi-polar to heathy individuals they found that cortical grey matter was thinner in the frontal (which is involved in high level cognition, reasoning, and planning) , temporal (which is involved in interpreting sound and language and, memory) and parietal regions (which is involved in tactile information such as pressure, touch, and pain). And this can link to some of the symptoms such: inflated self-esteem or grandiosity, decreased need for sleep, more talkative, flight of ideas/ racing thoughts, distractibility, increased activity/ psychomotor agitation, engagement in high risk activity and irritability.

-              Biological treatments

o   Lithium bicarbonate is often a first line treatment as it is a mood stabiliser and can help with rapid cycling. However it can have unpleasant side effects such as motor co-ordination problems, lethargy, cognitive slowing, weight gain and Gastrointestinal issues.

o   In systematic review was shown that Antipsychotics were significantly more effective than mood stabilisers for treating mania, with Haloperidol, Risperidone and Olanzapine being the most potent and Risperidone and Olanzapine being the most effective and most acceptable.

o   Electro convulsive therapy is not a first line treatment but can be used in severely depressed at risk of suicide, it is done under general anaesthetic (to prevent pain) and works by inducing a seizure which then causes changes of blood flow in the Brian and promotes neurogenesis. It can be effective for treating manic episodes, however, can be controversial as it can lead to side effects such as confusion, and occasionally long term cognitive effects on memory.

o   Transcranial magnetic stimulation, is non-invasive and uses intense pulsating magnetic fields delivered around the brain and induce electrical activity in the cortex and this causes the release of neurotransmitters which help you better manage the condition. This has also been shown to be effective in treatment resistant individuals e.g. where drugs haven’t worked.

Conative explanations

-              Beck thought of mania as the mirror image of depression, therefore believing it was caused by positive cognitive triad of self, world, and future, and positive conative distortions. And so have high self-esteem and feel extremely loveable, powerful and like you have unlimited potential. And these ideas that the world is full of possibility and opportunity and promise was termed hyper-positive conative distortions.

o   The Dysfunctional attitudes scale was used to test this in people with bi-polar against people without bi-polar and they found that actually, people with Bi-polar had lower levels of dysfunctional attitudes then the groups with out bi-polar. However when repeated by Scott et al they found that people with Bi-polar did have increased levels of dysfunctional attitudes, specifically in the areas of perfectionism and need for approval which contradicts the previous study.

o   Found that people with unipolar and bipolar showed more similarities than differences in cognitive style, and so when comparing self-esteem ratings and dysfunctional attitudes there was no differences between individuals with Bi-polar and Uni-polar depression. However when looking at the subscale Unipolar had a higher mean levels of negative self-esteem, while  bipolar had higher levels of preference for affiliation (the desire to want to be with other people). And this challenges Becks idea of the positive triad.

o   Also found that when people were in remission from bipolar disorder and so weren’t having any symptoms of mania or depression, that they had higher mean scores for self-esteem and lower for dysfunctional attitudes compared to those not in remission, and this is the opposite to when patients don’t have depression and this further disproves Beck.

-              Treatment

o   CBT and medication was shown to have a positive impact on clinical symptoms, improved treatment adherence (people more likely to continue taking their medication (however could be due to them just being more motivated people and not CBT)), improved quality of life but had not effect on relapse but did reduce rehospitalisation rates.

o   Family focused therapy was developed in the mid 1980s and is especially helpful for people who came from high expressed emotion families as they have increased rates of relapse. And so the therapy involves psychoeducation, which is educating patient and the family about the condition such as the role of stress and genetics and the patients get to contribute as experts about how the condition affects them impacts them. And due to the presence of the therapist the family listen more to the patient and this helps patient to be supported better and also involves communication enhancement training, which involves active listening, praise each other, expressing negative feelings about specific behaviour and problem solving skills related to family conflict.

§  In a systematic review found that patients who had the  family focused therapy and pharmacotherapy had lower rates of relapse and less severe symptoms over 1-2 years compared to those who just had brief psychoeducation or individual psychoeducation and pharmacotherapy.