Bipolar Response

A reader posted a question on our Facebook site asking about the difference between bipolar I disorder and bipolar II disorder. I have not yet gotten to that point in the series but I will answer briefly as well as I can.

What I have been talking about so far is what we call bipolar I disorder which has previously been called manic - depressive illness. Bipolar II disorder is a cycling mood disorder in which there are episodes of depression, including chronic depression with episodes of what we refer to as hypomania or "under mania". These are periods in which there are manic like symptoms but not of the severity of full blown mania and not resulting in so many life destructive events. Most people with bipolar II disorder spend the majority of their time in depression.

I hope this helps answer the question and we will discuss this more in detail on a later post.

Bipolar Disorder Part 4

This is the fourth in a series of didactic posts on bipolar disorder. I want to talk a bit about medication treatment as it is an essential component of treatment For patients making informed decisions about these medications requires education as many of the medications that we use to treat this disorder have significant adverse side effects, can be toxic, and can have long term negative effects on different organ systems. I call it the bipolar medication dilemma as there are no easy answers, there is no one size fits all treatment, and decisions need to be made on an individual basis taking into account health risks and other health conditions that a patient may have. It is a true dilemma as these medications that I will talk about have a lot of problems and yet without medication an untreated course of bipolar disorder is a disaster. So for now we have to use them. I would like readers to keep that in mind when I discuss all the potential negative effects.

There are four goals in medication treatment of bipolar disorder. We need to treat mania without causing depression, treat depression without causing mania, prevent depression, and prevent mania. It is unusual for one medication to carry out all four of these tasks so combination medication is the rule, rather than the exception which increases the potential for medication side effects. There are three different types of medication which have clearly shown effectiveness; lithium, anti epileptic drugs used to treat seizure disorders, and the second generation anti psychotic medications. I will talk about lithium to day and cover the others later.

Lithium remains the "gold standard " for treatment of bipolar disorder. No medication has been shown to more effective than lithium which we have had available to use since the mid 70's. Lithium is not a drug. It is a basic element which binds to other molecules to become a salt just as the sodium we use for table salt does. Usually the lithium we use comes in the form of lithium carbonate. The mechanism of action is unknown. It effectively treats mania and does work to prevent mania and depression but by itself is not a good antidepressant. We have more medications available to treat mania than we do bipolar depression. There is a narrow range between therapeutic levels and toxic levels so lithium blood levels do need to be obtained. Toxic lithium levels can result in kidney failure which is not always reversible. Lithium can cause diabetes insipidus which is the inability of the distal tubules in the kidney to reabsorb fluid resulting in excessive urination. Fortunately this can be treated strangely enough by adding a diuretic. Lithium also interferes with the release of thyroid hormone leading to hypothyroidism so thyroid levels need to be monitored. The most worrisome effect though is the evidence that long term lithium use (30 years or more) results in some kidney damage and impaired kidney function. We are now beginning to see this since we have had lithium available now for 35 years. No one really knows whether or not this will result in progressive renal failure or not. Some common day to day side effects are nausea, tremor, development of acne and weight gain.

So you can see that lithium has a lot of problems but I want to state again that it is very effective. It to me is still a "miracle" in that it can stabilize a disorder that otherwise would result in chronic mental illness and difficulty or inability to live in the community. I do not like to use lithium though for milder cases of bipolar disorder but for the more serious cases with the most complications or to use lithium when other treatments are not effective. I will talk about some of the other medication treatments in my next post.

Thought for the day

"Live a life worthy of the calling to which you have been called".

St. Paul

Bipolar Disorder Part 3

I have been talking about bipolar disorder the past two days and want to look at what it takes for effective treatment. There are three main things that must be done to prevent relapses and avoid the devastating consequences of both the mania and depression. The first is adequate medication. The second is avoidance of alcohol and drugs, and the third is management of stress and anxiety. Chances of full and long lasting recovery are slim if one of these things are left out of treatment.

First is adequate medication. Unlike non bipolar depression bipolar disorder cannot be treated with cognitive behavioral and other psychosocial treatments alone. Medications are required and need to be taken lifelong. Bipolar disorder is a progressive disease with deterioration over time if left untreated. There are problems though with the medications that are available to treat bipolar disorder. Many have significant side effects and are associated with long term health risks. I will discuss the bipolar medication dilemma tomorrow.

Second is avoidance of alcohol and drugs. Unfortunately over 50% of individuals with bipolar disorder have an alcohol or other substance abuse problem. There tends to be a continuous negative cycle in which the alcoholism worsens the disorder and the disorder reduces chances of long term abstinence. Except for non adherence to medication alcohol abuse and dependence are the number one reason for failure of adequate treatment or so called treatment resistance. I cannot overemphasize this. Bipolar disorder cannot be stabilized in the presence of an active substance abuse problem and co-occurring treatment is required.

The third main pillar of treatment is management of stress and anxiety. High levels of stress can trigger either manic or depressed episodes as well as times of interpersonal conflict. Persistent insomnia which often accompanies stress can trigger manic episodes. Regular sleep, good diet, and exercise are helpful in this regard.

Thought for the day

"God is our refuge and strength, an ever present help in times of trouble"

The Psalmist

Bipolar Disorder Part 2

This is the second part of a series on bipolar disorder which is a common mood disorder affecting about 1% of the population. I indicated that the hallmark of this disorder is episodes of mania that are not due to substance abuse or medical problems. So what exactly is mania?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision(DSM-IV-R) defines mania as follows;

Manic episodes are characterized by at least one week of profound mood disturbance characterized by elation, irritability, or expansiveness that causes significant impairment in occupational or social functioning or represents a danger to self or others that has at least three of the following symptoms;

Grandiosity
Diminished need for sleep
Excessive talking or pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal directed activity at home, at work, or sexually
Excessive pleasurable activities, often with painful consequences

This definition I suppose is ok but it doesn't capture the essence of mania which includes significant impairments in appearance, mood, thought content, perceptions, self destructiveness, aggression and judgment and insight so I will try to describe common changes we see in these areas.

Appearance - we see hyperactivity, hypervigilance, restlessness, excessive energy and activity. Thinking and talking are very fast, the person will often interrupt or talk over everyone else, will have no sense of social boundaries and be behaviorally intrusive. Attire may be very disorganized or very bright, colorful, or garish and they frequently attract attention because of the way they dress. Being with a manic person makes you want to find the "off button".

Mood - we see a tendency to be inappropriate in terms of being elated, jubilant, or euphoric or a high degree of easy annoyance or irritability that seems totally out of proportion to what is actually happening.

Thought content - We see expansive and overly optimistic thinking, inappropriate self confidence or grandiosity, high distractibilty, quickly shifting from one thought to another and, can be very hard for one to follow their train of thought. Often there are thoughts that the manic person has of being special or having some sort of special knowledge and these can become very delusional. There is an apparent need to excitedly tell others about this specialness or the grandiose insights.

Perceptions - We often see overt delusions which reflect perceptions of power, prestige, self worth, or glory and will sometimes move to extreme paranoia or hallucinations.

Self destructiveness - there can be suicidality although most suicide attempts in bipolar disorder occur in the depressed phase of the illness.

Aggression - we see at times aggression and combativeness, demandingness, and acting out of the grandiose belief that others need to obey their commands or wishes with anger and irritability when someone doesn't obey.

Judgment and Insight - It is the impaired judgment that really differentiates mania from normal "highs". Patients with mania have generally no insight. They rarely see anything wrong with themselves and resist efforts at treatment not seeing any need for it. Serious mistakes are frequently made in regard to finances, marriage and relationships, and occupation, refusing to listen to any one's advice often with devastating consequences.

This is a rather long post but I wanted to describe what mania is really like and I don't think the DSM-IV-TR really describes what goes on in mania.

I will discuss tomorrow some options for treatment. Again I welcome any questions or comments.

Thought for the day

Without treatment bipolar disorder can be a devastating disease.

Bipolar Disorder

From time to time I do a series of teaching posts dealing with a particular psychiatric disorder. I encourage any readers to post any comments and questions as we go along and I hope that I can be of use to someone who is interested in knowing more about a particular topic. I have decided to focus for a short time on bipolar disorder which is a common psychiatric problem and one of the most severe, persistent, and often disabling disorders that we treat.

Bipolar disorder used to be referred to as manic depressive illness. It has been described in medical literature as far back as Hippocrates in ancient Greece. It is common, affecting approximately 1% of the population with men and women being equally affected. There have been no race or ethnicity correlations. Bipolar disorder appears to be an equal opportunity disorder. It is chronic, persistent, and associated with a variety of complications including suicide attempts and suicide, child or spousal abuse or other violent behavior, school failure, occupational failure, divorce, and alcoholism and drug addictions. Untreated it tends to worsen over a person's life. It is considered the most severe mental illness after schizophrenia and often associated with lifelong disability. Over 50% of those affected will develop alcoholism and 11% will die by suicide. It's onset is usually in late adolescence or early adulthood although it can present later in some people. It is strongly genetically linked. First degree relatives of someone with bipolar disorder are 7 times more likely than the general population to have bipolar disorder.

So what exactly is bipolar disorder and what are the features of this problem? The hallmark of bipolar disorder is episodes of mania. Bipolar disorder is diagnosed in anyone with a manic episode that is not induced by drugs or alcohol or a medical disorder, whether or not there are episodes of depression. More commonly though the person will suffer from both depressed episodes as well as mania and the majority of the time the patient will be in the depressed phase of the illness. So if mania is the hallmark what exactly is mania? It is much more than an elevated mood but affects appearance, mood, thought content, perceptions, anger or aggression, judgment, and insight Usually impairments in orientation and memory are not present.

I will discuss tomorrow what these multiple changes are.

Thought for the day

"No power of hell or scheme of man can ever pluck me from His hand".

The Newsboys

Attention Deficit Hyperactivity Disorder Girls Complications

We have known for a long time that Attention Deficit Hyperactivity Disorder (ADHD) in boys has been associated with increased risk of several psychiatric problems in young adulthood but a recent study published in the American Journal of Psychiatry shows for the first time thst the same applies to girls with ADHD.

The study was a very good one in that it that it was a prospective longitudinal study that used a full follow-up assessment after an average of 11 years after enrollment in the study. There were 96 girls with ADHD who were compared to 91 girls without ADHD. 92% of the girls with ADHD had received medication treatment sometime in the intervening 11 years with 42% receiving treatment in the year preceeding the follow-up.

The researchers found that girls with ADHD had almost a seven times higher risk for developing depression or antisocial disorders, and over twice the risk of developing substance abuse problems, anxiety disorders or eating disorders. There are probably many reasons why this is the case such as general impulsivity and risk taking behavior. The rates of depression were high. Whether this represents genetic factors or the chronic demoralization that comes from problems in school,problems with peers, and problems within the families or some combination of factors.

It is discouraging to see that girls with ADHD have as many psychiatric problems in young adulthood as do boys. Hopefully some information will become available to see if early treatment can prevent these complications but for now we don't know.

Thought for the day

"From my first cry to my final breath God holds my destiny".

The Newsboys

Post Traumatic Stress Disorder Morphine

The New York Times reported Wednesday about an article that appeared in the New England Journal of Medicine talking about post traumatic stress disorder and morphine. I do not get the New England Journal so I haven't seen the article itself yet but I want to make a few comments about what was reported.

A record review study of 696 servicemen and women who were wounded in Iraq between 2004 and 2006 noted that those who received prompt treatment with morphine had roughly half the chance of developing post traumatic stress symptoms (PTSD) within the first two years following the injury. Out of the 696 wounded 243 developed
PTSD which in itself is an alarming figure but those that received morphine within generally two hours after the injury fared better than those who did not.

Why does morphine help? My guess is that it works by inhibiting the excessive firing of the amygdala under stress. The amygdala is a group of cells in the front portion of both temporal lobes and as far as we know is responsible for the overall emotional tone we associate with events. It is also known as the "fear center" of the brain. The amygdala is next to and highly linked with the hippocampus which is responsible for encoding memories. Our current understanding then is that an event that gets encoded as a memory by the hippocampus will be encoded with a greater strength as well as with a connection to fear if the amygdala is highly active during the event.

There are some problems with this study though that need to be sorted out with further work before we can recommend morphine for non combat traumas. It has been noted that the same benefit of morphine has been seen in children at burn centers. The problems with this post traumatic stress disorder morphine study first of all is that it is a record review, a retrospective study which is never as beneficial as a prospective study. Secondly we may be confusing association with causation. These were men and women injured in combat. It may be that quick and adequate pain control is responsible for the effect on trauma. This makes sense with burned children as well. The trauma could be the pain itself especially as many of the wounded here did not get adequate morphine pain relief until well after two hours of the injury. It was also noted that many of the wounded received anti-anxiety medication as well so it may be length of time to receive help after a combat wound is the determining factor rather that the morphine itself.

I hope to be able to read the New England Journal article itself soon. Some of these issues may be addressed there. It is important that further work be carried out in this area as the symptoms of post traumatic stress disorder can be devastating and disabling and there are many more sorts of trauma than combat injuries and burn injuries.

Thought for the day

Every day is new with possibility.

Cocaine Sudden Death

We have known that cocaine is sometimes associated with sudden cardiac death and occasionally hear about someone in the news who has died that way. We haven't known particulars though such as prevalence, doses of cocaine used, age ranges and other concomitant drug or alcohol use. A recent study from Spain published in the European Heart Journal has provided us with some of this information.

The study from the Institute of Legal Medicine in Seville, Spain is the first study to look at cocaine-related deaths in a systematic way with autopsies and toxicology screens in a series of 600 consecutive sudden death victims. The study showed that 3% of these sudden deaths were cocaine-related with the majority due to cardiac causes.

All the cocaine deaths were males. Myocardial infarction (heart attack) was the most common cause of death although there were strokes as well. Interestingly the serum cocaine concentrations varied widely so any amount of cocaine can be deadly. The demographic findings were that most of the victims were working and died at home on the weekends suggesting that they were "recreational " users rather than chronic cocaine addicts. 81% smoked and 76% had used alcohol along with the cocaine both which decrease coronary arterial blood flow. The most important take home message from this study is that no amount of cocaine is "safe".

In the United States there are approximately 500,000 emergency room visits per year for cocaine related events. We have no idea of the figures of sudden death because we have no way at present of reporting cocaine related sudden death and also because autopsies with toxicology screens are not usually performed but left to the discretion of the pathologist. It would be a good idea for us to develop some standard reporting procedures.

Thought for the day

No amount of cocaine use is safe.

Press Trivializes the Treatment Process and Devalues the Suffering

I read this morning that Casey Johnson, heiress to the Johnson & Johnson fortune, died alone in her Los Angeles apartment after a well-publicized life of drugs and partying. I feel sad to hear yet another story of a celebrity who succumbs to addiction after cycling in and out of a series of boutique rehabs.

If you follow the news the story is familiar. Train wrecks of pop check into posh $100,000-a-month beachfront rehabs, where they demand - and appear to receive - special indulgence. In my mind this kind of press trivializes the treatment process and devalues the suffering that I see every day as a therapist at Cottonwood Tucson. In the morning paper I read of the rich and famous going to treatment to save face and then go to work and treat less famous patients who struggle to save their lives. Too often, the news media leave general public with the notion that treatment doesn't work.

I know better. As an "in the trenches" clinician, I see overwhelming evidence that treatment does in fact work. While miracles can be hard to quantify, the Substance Abuse and Mental Health Administration's National Outcome Measures show that treatment results in improvement in every life domain, including: abstinence from alcohol and other drugs, decreased symptoms of mental disorders and improved functioning in all major areas. The same study reports that those who have completed treatment also have decreased involvement with the justice system and are better able to find and keep safe and stable housing for their families.

That's what miracles sound like when measured in the dry, public sector language of the National Institute on Drug Abuse. For a more personal take on the value of treatment, please consider the words of a grateful mother who recently sent a thank-you note to one of the family therapists at Cottonwood:

"We are still floating. None of us will ever be the same.
Our son is doing great - happy and clean out in
California. He told me the other day that he had gotten
a sponsor. The sound of his laughter has returned to us.
We have gotten a miracle."

I wish you could have had one too, Casey.

Jeffrey C. Friedman, LISAC
Primary Therapist
Cottonwood Tucson