Bipolar disorder: characteristics, symptoms, and treatment approaches

Bipolar Disorder Symptoms

Bipolar disorder has been studied for more than a decade after remaining undiagnosed in children and adolescents for many years. Much literature such as that by Pavuluri, Birmaher, and Naylor (2005b), and Kowatch and Debello (2006) is available on diagnostic issues pertaining to paediatric bipolar disorder. In addition, many cases studies have also been published on the topic such as those by DuVaI (2005) and Hamrin and Bailey (2001). This article will discuss the current available literature on the bipolar disorder diagnostic issues with specific focus on psychopharmacological treatments and its management for treating this disorder. This paper will not be focusing on psychosocial interventions related to paediatric bipolar disorder.

Severe disturbances in the functioning of children as well as their families are one of the symptoms of paediatric bipolar disorder. Children with this illness mostly struggle in their academic and interpersonal lives. This causes them to be at risk for legal difficulties, substance abuse, frequent hospitalisations or clinic visitatiosn and suicidal tendencies. According to Mohr (2001), almost 20% of the patients of bipolar disorder reported that they had started to feel the symptoms before they turned 19 years old. In addition, Kogan et al. (2004) provides further evidence that in the study of the first 1,000 patients of adult bipolar disorder registered in the National Institute of Mental Health Systematic Treatment Enhancement Program for Bipolar Disorder found that 37.6% patients experienced the symptoms at an early age i.e. 13-18 years while the 27.7% patients experienced the symptoms during the prepubertal years i.e. under 13 years. Such findings provide evidence that the psychiatric nurse practitioners have a duty not only recognise but to treat child bipolar disorder.

Paediatric bipolar disorder consists of numerous features similar to adult bipolar disorder which makes the former a complex mood disorder. This illness occurs in about 1 to 1.5% of the total paediatric population (Kashani et al., 1987; Lewinsohn, Klein, & seeley, 1995) whereas when the psychiatric clinical environment is discussed, the occurrence rate is between 17% - 30% of the total paediatric population (Youngstrom & Duax, 2005). The occurrence of symptoms varies from children to adults. For instance, in adults the grandiosity results in behaviours such as inflated self-esteem, excessive spending and inappropriate dressing, whereas in children the same grandiosity results in behaviours such as bossiness, argumentativeness, superiority attitude, giddiness such as being stronger or smarter than everyone and such. In such patients, the symptoms of rage, aggression, affective storms are commonly seen. However, according to Biederman et al. (1996), aggression is seen to be impulsive and reactive making it less organised. In addition, the paediatric patients are mostly described as being destructive, out-of-control with severe impairment in academic and social settings (Geller, Cooper, et al., 1998). Children and adults also differ in euthymia. For instance, children may not show clear symptom-free episodes of euthymia unlike adults who demonstrate symptoms of syndromal and subsyndromal depression and mania. In addition, children are seen to demonstrate frequent polarity switch in comparison to adults (Birmaher et al., 2006; Geller, Tillman Craney, & Bolhofner, 2004).

Other symptoms the practitioners should look for are low sleeping needs, increased talkativeness, distractibility, emotional over-reactions, racing thoughts and ideas, increase in energy, pressured speech, high involvement in risky or pleasurable activities and increase in goal-directed activities because all these activities can have severe consequences (American Psychiatric Association, 2000). In a study by Wozniak et al. (1995), it was determined that the paediatric bipolar disorder has features that are related to high depression rates, positive history of family mania, psychosis and low global functioning. The illness prevailing in patients before the age of 17 is characterised by frequent mood switches, history of physical, sexual or verbal abuse, and worsening of the illness (Suppes et al. 2001).

Bipolar Disorder Etiology

Genetics

Parents with a bipolar disorder having a child had a 2.7 times higher risk ratio for instigating a fourfold higher risk psychiatric disorder as compared to parents without any history of bipolar disorder (Chang, Steiner, & Ketter, 2000).

In addition, the early bipolar disorder symptoms are related to those children who show higher risk for genetic disorder load (Neuman, Geller, Rice, & Todd, 1997). In a study by Potash and DePaulo (2000), monozygotic twins with bipolar disorder were observed who reported a 60% concordance rate.

Neuroanatomy

The affective circuitry that consists of amygdalae, orbitofrontal cortex, cingulated gyrus, dorsolateral prefrontal cortex and the limbic system are all concerned with bipolar disorder. In a study of 20 adolescents who had bipolar disorder and 20 youngsters without any disorders were evaluated using magnetic resonance images (Dickstein et.al. 2005). The results produced revealed that the children with bipolar disorder had aged reductions in their left dorsolateral prefrontal cortex and amygdale whereas no differences in the hippocampal volumes were observed. This contrasts the study of Frazier et al. (2005) who observed small hippocampal volume in 43 patients with bipolar disorder.

Different researches have also found low amygdale volumes when high resolution MRIs in 20 bipolar disorder and 18 healthy youths are observed (Blumberg et al., 2005; Chang et al., 2005). The results of MRI in 20 bipolar disorder youths showed a consistent reduction in the volume of gray matter in right and left amygdale. In addition, the subjects treated with lithium or valproic acid showed more volumes of gray matter in the amygdale compared to patients without any medication (Chang et al., 2005). The amygdale function in the paediatric bipolar disorder patients was evaluated by Rich et al. (2006).

In a study, 22 paediatrics with bipolar disorder were compared to 21 paediatrics without bipolar disorder using the MRI tests where the patients were told to label the emotional and non-emotional aspects of faces. Bipolar disorder patients viewed higher hostility in neutral faces and showed higher activity levels in their accumbens, left amygdale, ventral prefrontal cortex and putamen. In another study by Kaur et al. (2005), 16 youngsters with bipolar disorder were compared to 21 healthy subjects for cingulate cortex examination. It was found that the youth with bipolar disorder showed small mean volumes in their left anterior cingulated, and right and left posterior cingulate.

Neurobiology

There is a lot of information on the genetic studies that support bipolar etiology but the pathophysiology of bipolar disorder is not yet very clear (Kapczinski, Frey, & Zannatto, 2004). Research in the areas of protein systems, signal pathways and neurotransmitters is crucial for understanding bipolar etiology.

The role played by monoamines such as serotonin, dopamine and norephinephrine is vital. The prefrontal, limbic and striatal circuitry are highly supplied by the neurotransmitters as revealed in the MRI and mood regulation research. In addition, the pathological process is supported by the psychopharmacological success in the sites of these receptors and pathways (Payne, Quiroz, Gould, Zarate, & Manji, 2004). In addition, the preliminary findings of Dean (2004) suggest that the changes in the binding site may be directly influential on the gamma-amino butyric acid (GABA).

The cyclic adenosine monophosphate (cAMP) also known as a messenger has been studied as a cause for bipolar disorder. In post-mortem studies conducted by Chang, Li and Walsh (2003), low levels of cAMP were found in brain regions in patients with bipolar disorder as compared to healthy patients. The G-protein is the binding agent for serotonin and dopamine to their respective receptor sites. Such monoamines regulate the patient's mood and behavior. Many studies have been conducted that link the G-protein level disturbance in bipolar disorder patients even though their relation is still unclear (Emamghoreishi et al., 2000).

The neurobiologic process is not linear when it is performed in the etiology of bipolar disorders. In addition, to understand the bipolar disorders' pathophysiology more clearly, studies on the neurotransmitter systems related to the nervous system needs to be understood as well as the G-proteins, receptors, signal transduction pathways and cAMP kinases interaction need to be studied (Dean, 2004).

Bipolar Disorder Treatments

When the mood stabilisers are evaluated, it becomes clear that the lithium and divalproex sodium are highly effective in the acute mania treatment. According to Kowatch and Delbello (2005), lithium is effective in children showing signs of classic euphoric mania i.e. does not consist any psychotic symptoms or comorbid ADHD. In comparison, divalproex sodium performed much better in one of the studies (Kowatch et al., 2000), whereas in other four studies the response rate was equal for the two medications (Calabrese et al., 2005; Davanzo et al., 2003; Findling et al., 2005a; Pavuluri, Henry, Carbray, et al., 2004a). When divalproex is used as a monotherapy drug for short-term stabilisation of bipolar disorder, the response rate ranged from 46% to 80%.

In amalgamation with other medicines like antipsychotics, Divalproex sodium is well tolerated and highly effective. In addition to this, the blend of these two generally requires a minor dose of the antipsychotic pills (Singh, Muzina, & Calabrese, 2005). When comparison is done between divalproex sodium and lithium with the Carbamazepine, then due to less effectiveness Carbamazepine has been used in a smaller amount with respect to the side effects of Stevens-Johnson's aplastic anemia which are itchiness and irritation. Besides this, due to the CYP450 drug interactions, carbamazapine in combination with sodium divalproex are not suggested for use in combination (Kowatch & Delbello, 2005). Researchers have said about a reduction in manic or depressed symptoms in studies evaluating monotherapy with lithium (only or in comparison to divalproex sodium at the periods of 20 months, then 14 weeks and finally 6 weeks) that these specific mood stabilizers could not uphold over the longer period of time and a second medication was defensible to get reduction in symptoms in some studies (Calabrese et al. 2005; Findling et al., 2005a and 2005b; Geller, Williams, et al., 1998).

In addition to this, for managing a short-term and severe bipolar disorder in children, the use of risperidone, olanzapine as monotherapy and quetapine is strongly supported by the evidence. The rate of response had been between 53 to 82%. Since some studies are double-blind placebo-controlled and others are retrospective chart reviews or open label, therefore it is not easy to compare head-to head. However, for the treatment of pediaratic bipolar disorder, it is recommended by the research data that atypical antipsychotics can be a fine first-line treatment, mainly in youth facing psychotic symptoms. According to the findings of Findling and colleagues' (2003), youth taking divalproex sodium monotherapy and lithium for psychotic symptoms and bipolar disorder did not get reduction in symptoms. Only a single double-blind randomized study of 28 days has been done with children which compares antipsychotic (seroquel) and a mood stabilizer (divalproex sodium) (DelBello et al., 2006). As examined by the YMRS, both of the drugs were equally good in getting quick immediate stabilization of bipolar symptoms. As far as scores are concerned on the Clinical Global Inventory for Bipolar Disorder, quetapine performed in an effective way, which resulted in quick action, enhanced reduction and response rate in comparison to divalproex sodium.

Much more convincing treatments include combined treatments of a mood stabilizer (divalproex sodium or lithium) and an antipsychotic (quetiapine or risperidone). These treatments give assurance of lasting reduction in the symptoms. It is imperative that clinicians must compare the benefit of drug with the negative effects. With the usage of mood stabilizers and antipsychotics, certain things should be examined carefully such as sedation, gain of weight, metabolic problems that cause diabetics, enhanced lipid and cholesterol levels. In order to prevent enhanced lipid and cholesterol levels and obesity, it is imperative to give education on exercise and nutrition. In spite of these interventions other drug choices should be evaluated for those children who face a five percent gain in body weight.