Understanding The Bipolar Disorder #2
More complete and detail information about bipolar are obtained from article in Farmacia Magazine Website (http:J/www.maialah-farmacia.com), written by Andra with Prof. dr. Sasanto Wibisono, SpKJ(K) as resource person.
Most symptoms and reasons of this disorder are equal to what have been experienced by Andra.
The following is the descriptions.
“Do not underestimate bipolar disorder!", said by Prof dr Sasanto Wibisono SpKJ(K), Honorable Lecturer of Department of Psychiatry FKUURSCM, as quoted from the daily Pikiran Rakyat on 12 May 2006. He continues, “bipolar disorder can put the mentality into danger if it is not treated well”.
Mental disorder is not only “belonged to” poor countries or developing nations like Indonesia. It begins to be one of four health problems in advanced country. Bipolar disease is one example.
Bipolar disorder incident is not high enough or just ranging between 0.3-1.5%. However, this rate excludes miss-diagnosis cases. Risk of death always follows the bipolar patient. Mortality risk is evident due to high susceptibility to commit suicide. Indeed, suicide risk increases among bipolar patients with less therapy, which counts to 5.5 per 1000 patients. The figure for those with therapy is 1.3 per 1000 patients.
Equal to magnet, bipolar disorder has “two poles”, mania and depression. The word “bipolar” may come from this root. According to Pedoman Penggolongan dan Diagnosis Gangguan Jiwa (PPDGJ) III, this disorder is the repeating episodes that produce a chaos within patient’s feeling and activity.
This disorder is also indicated with the arousal of feeling or the increase of energy and activity (mania or hypomania), and the decrease of feeling or the deprivation of energy and activity (depression).
The unique is a perfect healing between episodes. Mania episode always starts suddenly and lasts for 2 weeks or even 4-5 months, while depression episode can last longer.
First episode begins in any ages either from kids or olds. Many cases occur in youth between 20-30 years old. The earlier the person to experience bipolar is the heavier the disease risk they subject to, either chronic or refraction.
Based on Diagnostic and Statistical Manual (DSM IV, bipolar disorder is differed into 2, which are bipolar I and II. Bipolar Disorder I or classic type is signed with 2 episodes, mania and depression, while Bipolar Disorder II is characterized with hypomania and depression.
Mania episode is assigned into 3 degrees of seriousness, which are hypomania, mania without psychotic symptom, and mania with psychotic symptom.
Hypomania is identified with a woman who struggles with her ovulation period (“estrus”) or a man when he falls in love. A joy feeling, enthusiasm to be self-active, and an increasing sexual arouse are some hypomania symptoms. Degree of hypomania is lighter than mania because these symptoms are not causing social dysfunction.
At mania case, the symptoms are quite heavy because it can mess up almost all works and social activities. Self-dignity jumps too high with too much optimism. The ease toward suspicion and irritation is more evident than elation (happiness). If these symptoms develop high level of suspicion, diagnosis of mania with psychotic symptom is enforced.
In contrast against hypomania / mania, symptom of depression is reverse. Heart stance is depressive, and it is characterized by the absence of interest and enthusiasm, lack of activity, being pessimist, and easily self-blamed.
Depression episode can last minimally for 2 weeks because the diagnosis can only be made after this period. If depression triggers toward the intention of suicide, it means that the patient has been depressive heavily.
Etiology and pato-physiology of bipolar disorder is not easily explained. Virus is once accused as primary cause. It is estimated that virus attacks the brain during fetal phase in the worm or during first year after delivery. However, bipolar disorder manifests truly in the next 15-20 years. The tardiness of this manifestation is obvious because in 15 years old of age, thymus and pineal glands which are important to produce hormone to prevent any psychiatric disorders are decreased their functional to 50 %.
Later, research relates this with genetic involvement. This opinion surfaces when 50% bipolar patients have similar disease background to that in their family. The first descendant of bipolar disorder patient will be risked from having similar disorder for seven times. The risk for twin may be very high, especially for monozygot twin, which can be 40-80 %, while it can be lower for dizygot twin, which can be 10-20 %. Such reduction pattern defies Mendel Law.
Some studies successfully prove the link between bipolar disorder and chromosomes 18 and 12. It is not yet investigated which locus of chromosomes is engaged.
Interestingly from this chromosome study, Down syndrome patients (trisomi 21) have low risk from subjected to bipolar disorder.
Since the invention of agents with success story to relieve bipolar disorder, the author starts to estimate the presence of the relationship between neurotransmitter and bipolar disorder. Neurotransmitter agents are dopamine, serotonin, and noradrenaline.
Gen candidates related to neurotransmitter are begun to be researched, such as the encoder gene of monoamine oxidase A (MAOA), tyrosine hydroxilase, catechol-O-methyl-transferase (COMT), and serotonin transporter (5HTT).
Not stopped in this, the author also has new “suspect”, which is a gene which expresses brain derived neurotrophic factor (BDNF). BDNF is neutrophin which plays a role in regulating synapse plasticity, neurogenesis and brain neuron protection. BDNF also involves within mood process. The regulator gene of DNF is located at chromosome 11p13. Three researches look for the relationship between BDNF and bipolar disorder, and the result is positive.
Most bipolar patients not only experience bipolar disorder but also are subjected to other mental disorder (comorbid). Research by Goldstein BI etc, as reported by Am J Psychiatry 2006, has mentioned that of 84 bipolar patients above 65 years old, 38.1 % of them are with alcohol abuse, 15.5 % with dysthymia, 20.5 % with comprehensive anxiety disorder, and 19 % with panic disorder.
Meanwhile, attention deficit hyperactivity disorder (ADHD) can develop into comorbid that mostly found in 90 % children and 30 % teens.
There is a different brain sketch between healthy group and bipolar patient. Through the imaging of magnetic resonance imaging (RR) and positron-emission tomography (PET), nigra substance and blood flow are shown deprived in prefrontal subgenual cortex.
Not only that, Blumberg etc, in Arch Gen Psychiatry 2003, have found small volume these liquids in amygdala and hypocampus. Prefrontal cortex, amygdala and hypocampus are the part of brain involved within emotional response (mood and affection).
Other research shows that the expression of myelin-oligodendrocyte decreases in the brain of bipolar patient. Oligodendrocyte has produced myelin membrane which covers the axon such that it accelerates conduction between nerves. If the oligodencrocyte decreases, it is ensured that communication between nerves will not smooth.
Similar to other mental disorders, the laboratory examination is not too much necessary. Periodic psychiatry interview and physical check up are really adequate to enforce bipolar disorder diagnosis.
First, medical condition shall be assessed to eliminate organic mental disorder (F00-F09). Next, it shall be acknowledged whether mental disorder experienced by patients is due to the use of psychoactive substance (F10-19). Finally, the possibilities of schizophrenia, schizotypal disorder and other suspicion disorder are removed (F20-29).
It has been more than 50 years that lithium is used as a therapy for bipolar disorder. Its effectiveness has been proved in healing 60-80 % patients. “Its efficacy” is highly approved because it can save treatment cost and the number of suicide case.
However, it does not mean that lithium is without limit. From few people who with less response to lithium, there are patients with histories of head injury, serious mania (psychotic symptom), and comorbid. If the use of lithium is suddenly stopped, the patients will relapse fast. Besides, its therapy index is too narrow, and therefore, lithium content in the blood must be strictly monitored.
Kidney disorder can be a contra-indication against the use of lithium because it prevents the elimination such that it may produce toxic rate. In addition, lithium is once reported as damaging kidney in the long term usage. Due to this weakness, lithium is abandoned.
Anti-psychotic starts to be used as anti-mania since 1950s. Anti-psychotic is better than lithium for bipolar patients with psychomotoric agitation. Extra attention shall be given to the planning of long term anti-psychotic, especially for first generation (a typical group), because of the presence of side effects such as extra-pyramidal, neuroleptic malignant syndrome, and tardive dyskinesia.
Valproat is optional if bipolar patient does not respond to lithium. Valproat has shifted the domination of lithium as first line regimen. One advantage of valproat is to give good response to rapid cycler group.
Bipolar patient is classified as rapid cycler if only in 1 year, they have experienced 4 or more mania or depression episodes. Therapeutic effect is achieved if the optimal rate in the blood is precisely 60-90 mg/L. Side effects develop when this rate reaches to 125 mg/L which may include nausea, increased weight, liver disorder, tremor, sedation, and broken hair. The recommended acceleration dose of valproat is loading dose of 30 mg/kg in 2 first days, and continued with 20 mg/kg in the next 7 days.
A strive for an alternative agent is still exerted. One is lamotrigine. Indeed, lamotrigrine is an anti-convulsant which is useful to heal epilepsy. Some random studies with double-blinded conclude that lamotrigine is effective as an acute therapy against bipolar disorder episodes such as depression and rapid cycler. Unfortunately, lamotrigine is not good enough for mania episode.Bipolar disorder must be medicated in continuous fashion without significant break. If so, normal phase will shorten and the relapse can back too often. The shortened normal phase in bipolar disorder case can damage the obedience to the treatment because the patients consider themselves as healed already. Therefore, education can be very important for early treatment to this patient.
Ellin Virliana (10410118)