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Nana searching
Concerned Parent
Posts: 52
(5/31/01 4:53 pm)
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Interesting article a friend sent to me.
Hi Tammi,
You may have already seen this, but I thought I would send it along. A friend sent it to me and I could not open it because he has a mac and I have a pc. Hope I am not violating any copyright laws. If I am just delete it please.
Nana
Harvard Mental Health Letter
May 2001
Bipolar Disorder - Part II
In the first part we described the symptoms of bipolar disorder, its variant
forms, the role of heredity, and the most common drug treatments. Here, we
go on to discuss brain function in bipolar disorder, the uses of
psychotherapy, and the future of research.
Most of what we know about the biology of mood swings is derivedfrom brain
scans, autopsies, and research on the effects and mechanisms of
antidepressant and mood stabilizing drugs. Depression is associated with low
activity in the brain as a whole and especially in the frontal cortex, the
seat of planning and decision-making. At the same time, it activatesthe
amygdala, a region where memories of emotionally significant eventsare
maintained and learned stress responses are generated. Some structural brain
scans suggest that bipolar illness is associated with atrophy in the frontal
cortex and the hippocampus (a center of memory consolidation), and one study
has found enlargement of the amygdala. Mania is associated with increased
blood flow and energy consumption in the cerebral cortex. But the results of
brain scans and autopsies are often inconsistent or ambiguous, and subtle
abnormalities are uncovered only when scientists compare many brains and
compute averages. Because they have not found anything that clearly
distinguishes bipolar disorder from other brain diseases and malfunctions,
brain imaging cannot be used to make the diagnosis.
More is known about how mood is influenced by the chemicaltransmission of
brain signals. In some of the most important brain systems that regulate
mood, arousal, and energy, the monoamine transmitter norepinephrine,
dopamine, and serotonin are used to pass signals between neurons. Any of
these systems can be overactive or sluggish or function erratically. All the
standard drugs used to treat depression and mania significantly affect
transmission by norepinephrine, serotonin, or both. Some recentfindings
suggest that people with bipolar disorder have an unusually high
concentration of neurons that synthesize and release monoamines.
Antidepressant drugs act chiefly at the junctions between neurons, promoting
the transmission of monoamines and subtly modifying the balance of activity
among monoamine transmitter systems. Mood stabilizers apparently alter the
process of signal transduction - the changes that occur inside neurons when a
monoamine transmitter docks at a receptor on its surface. By way of
substances called second and third messengers, master switches (regulatory
genes) are turned on and activate genes that manufacture the proteins needed
by neurons, including receptors and enzymes that catalyze the production of
neurotransmitters. Mood stabilizers seem to intervene in this process and
readjust it. Lithium, for example, may be reducing the activity of an enzyme
needed to manufacture the second messenger inositol triphosphate. Valproate
and omega-3 fatty acids may alter signal transduction at different stages of
the process. These genetically regulated changes in the structure and
functioning of neurons are slow and complex. When a mood stabilizer or
antidepressant is introduced, it takes weeks to establish a new equilibrium,
and its therapeutic effects are not felt until then.
Mood and the related body and brain functions can be disturbed in many places
within the pathways using monoamine transmitters, as well as the thyroid and
adrenal hormone systems, which regulate the body's energy consumption and
responses to stress. Neurotransmitter and hormone systems are intricately
interlinked within the brain; each neuron has receptors for many
neurotransmitters and contains many second messengers. All of our brain cells
contain all of our genes, and more than one gene is required to manufacture
each brain protein. Because of individual genetic variations in the nature,
order, and timing of all these processes, no drug affects all people alike.
We don't know precisely which actions of mood stabilizers are therapeutically
effective, and even if we did know, the causes of bipolar disorder might
remain in doubt.
There is one partial explanation of the effects of mood stabilizers that does
not depend on knowing exactly what happens in the interior of neurons but is
based on an assumption about how mood is affected by stress. Most people,
most of the time, adjust to internal and external stress without experiencing
depression or elation more than momentarily. But if the stress is too great
or the adjustment mechanism is faulty, equilibrium cannot be restored, and
the abnormal mood persists or becomes worse. Major depression or bipolar
disorder may begin when a faulty mechanism is stressed, but there is evidence
that after several cycles of depression and mania, external influences become
less important and the mood cycle takes on a life of its own - possibly
because of lasting changes that make neurons hypersensitive to minor
disturbances. This development is sometimes compared to kindling, the process
by which epileptic seizures irritate their focus - the spot in the brain
where they originate - and increase the likelihood of further seizures. All
the mood stabilizers (and ECT) inhibit kindling, and they may prevent
repeated mood swings by a similar mechanism.
Psychosocial treatment
Our biological understanding of bipolar disorder is still sketchy, and
biological treatments solve only one part of the problem. No combination of
drugs is sufficient to cope with the emotional and social consequences -
alcohol and drug addiction, suicide attempts, the devastating effects on
marriage, family life, and employment, and the problems that result from
reckless, violent, or psychotic behavior. People with bipolar disorder have
to be educated about the nature of their illness and persuaded that they need
to take mood stabilizers. They must learn to recognize signs of relapse, cope
with anger and shame, and correct bad habits acquired because of the illness.
They may need treatment for associated personality disorders or
alcohol and drug problems. If they plan to have children, they may want
genetic counseling. For all these purposes, a relationship with a trusted
psychotherapist or participation in a therapy group may be useful.
Cognitive-behavior therapy helps patients acquire social and problem-solving
skills, correct their thinking, and monitor their behavior. They can use
charts to track their mood fluctuations and learn what causes disturbances.
To avoid impulsive actions inspired by mania, they can adopt a system of
behavioral planning - promising to consult designated friends or relatives
and to wait a day or two before initiating new projects. Interpersonal
therapy can help them cope with losses, fears of abandonment, social
transitions such as a divorce or a job change, and conflicts about duties and
expectations in daily life.
Mania is often provoked by sleep loss and other disruptions of daily
biological and social rhythms and routines. A technique called social rhythm
therapy is designed to help patients cope with these situations. Patients
and therapists chart the patient's routines - regular times for eating,
sleeping, social contact, medication, reading, watching television,and so on
- and try to identify and neutralize the sources of disruption.
Therapeutic groups are sometimes highly effective for bipolar patients. The
group constitutes a mutual support system, correcting individuals'
misconceptions about the illness. They feel less isolated and preoccupied
with their own troubles as they see that others have similar problems. They
may become more hopeful as they see others begin to recover. Other members
stir feelings that may provide insight into personal relationships. In
controlled studies, group therapy has been found effective in reducing
hospitalization and failed marriages among people with bipolar disorder.
There is no evidence that upbringing or family conflict is a cause of bipolar
disorder, but the choices families make can ease or aggravate the symptoms
and mitigate or exacerbate their consequences. Families suffer greatly from
manic delusions, irritability, recklessness, indiscretions, and infidelities.
Living with a seriously depressed person is often equally difficult. Family
members need to help the patient while coping with the effect of the illness
on their own lives. Including the family is also a convenient way to get
patients to participate in planning their own treatment. Families can be
informed about the nature of the illness and shown how to respond to signs of
relapse and threats of suicide. They learn how to foresee emergencies and
encourage the patient to persist with treatment. They can make rulesfor manic
patients and help them test the reality of their hopes and the plausibility
of their projects. A collaborative care or treatment plan can be arranged,
committing the patient and the family in advance to certain ways of solving
problems and handling crises. Behavioral family management may also help the
family avoid hostility, rejection, or overinvolvement by distinguishing
symptoms of the disorder from the patient's personality traits.
An essential function of psychotherapy or behavior therapy is convincing
patients of the need to take their drugs. They may want to stop because of
uncomfortable side effects or because they miss their manic highs. They may
be concerned about gaining weight or feeling lethargic and uncreative. Under
the influence of depression or mania, they may decide that the drug is
useless or that they are cured and no longer need it. Sometimes they think it
is safe to quit because the symptoms do not return immediately. Advice,
warnings, and moral support from a therapist can be decisive for a patient
who is reluctant to take drugs. Even in a crisis, hospitalization can often
be avoided with the help of family support, telephone calls, and frequent
visits to a therapist. But sometimes patients must be hospitalized, usually
because of rapid mood cycling, mixed mania, physical illness, uncontrolled
drinking, or a serious risk of suicide or violence. Today, hospital stays
rarely last more than a few weeks.
Looking ahead
Despite everyone's best efforts, difficulties may remain. Neither drugs nor
psychotherapy can always prevent mood swings. The symptoms can fluctuate so
much that it may be difficult to tell whether a patient is responding to
treatment or simply passing through a different stage of the cycle.
Treatment may also be complicated by other illnesses, including alcoholism,
drug abuse, and anxiety disorders. Most troubling of all, recovery in the
symptomatic sense does not necessarily mean functional or social recovery or
a satisfying life. In one recent study, 50% of patient hospitalized with
mania or mixed depression and mania were found to have recovered
symptomatically after a year - they were no longer clearly manic or depressed
- but only about 25% had a reasonably satisfactory job and family life.
Another study found that four years after hospitalization, only about
one-third were making a living on their own. (An important qualification is
that today only the most severely ill patients with bipolar disorder are
hospitalized; the majority, who never have to see the inside of a psychiatric
ward, are more likely to make a nearly full recovery.) In new, large
controlled studies of bipolar disorder that are now beginning, researchers
hope to determine systematically which drug combinations and psychotherapies
are effective for which patients under which circumstances. More research is
also needed on the nature of mixed states, bipolar disorder in children and
adolescents, and the relationship between mood changes and personality
traits. Neuroscience, molecular genetics, and the study of biological rhythms
may provide a better understanding of the causes of mood swings and suggest
new treatments. Progress in fighting bipolar disorder depends on this
combination of social, psychological, and biological approaches, with an
emphasis not only on relieving symptoms but also on improving the quality of
life.
For further information and referrals, consult:
National Alliance for the Mentally Ill (NAMI), Colonial Place Three, 201
Wilson Boulevard, Suite 300, Arlington, VA 22201-3042; (800) 950-6264,
www.nami.org.
National Depressive and Manic-Depressive Association (DMDA), 730 North
Franklin Street, Suite 501, Chicago, IL 60610-7204; (800) 826-3632,
www.ndmda.org.
National Institute of Mental Health, 6001 Executive Boulevard, Bethesda, MD
20892-9663; (301) 443-4513, www.nimh.nih.gov.
For Further Reading
Goldberg, J. and Harrow, M. eds. Bipolar Disorders: Clinical Course and
Outcome. American Psychiatric Press, 1999.
Goodwin, F. and Jamison, K. Manic-Depressive Illness. Oxford University
Press, 1990.
Miklowitz, D. Bipolar Disorder: A Family-Focused Treatment Approach.
Guilford, 1997.
Mondimore, F. Bipolar Disorder: A Guide for Patients and Families. Johns
Hopkins University Press, 1999.
Sachs, G. et al. Medical Treatment of Bipolar Disorder 2000: The Expert
Consensus Guideline Series. Postgraduate Medicine Special Reports. New York:
McGraw-Hill, April 2000.
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Rochelle23
Moderator
Posts: 211
(6/1/01 6:22 am)
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Re: Interesting article a friend sent to me.
Great article Nana. Thanks.  Rochelle
"...Well, now that we have seen each other," said the Unicorn, "If you believe in me, I'll believe in you." from Through the Looking Glass by Lewis Carroll
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Peanut WA
Administrator
Posts: 517
(6/2/01 10:18 am)
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Re: Interesting article a friend sent to me.
Thanks Nana! I'll move this one to the archives in a couple of weeks. Think I'm gonna be adding another forum for articles/studies to put things like this in.
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alogan3
Concerned Parent
Posts: 239
(6/5/01 5:45 am)
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Re: Interesting article a friend sent to me.
What a great article!!
So essentially this is saying we need cognitive therapy to learn appropriate responses, standard therapy to cope with the chaos and a therapeutic group.
That makes perfect sense to me!
I know the family stuff already! 
Dyl is mixed, mod with psychotic features. He has become so manipulative that only God knows whats real or not anymore.
Thank You Nana!!
HUGS,
Andrea
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