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.
Two Poles
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.
Genetic Virus
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.
Comorbid
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.
Brain Disorder
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.
Psychiatric Interview
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).
Medicamentose
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.reference:
http://olahraga.kompasiana.com/bola/2013/10/17/sikap-chauvinisme-supporter-bola-indonesia-602204.html
Ellin Virliana (10410118)
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