Bipolar affective disorder is an endogenous mental disorder manifested in the form of maniacal, depressive, and mixed states, in the course of which a patient experiences a fast change of the symptoms of mania (hypomania) or simultaneous symptoms of depression and mania. These states represent disease episodes or phases, which periodically substitute each other, directly or through the slight intervals of mental health (intermission and interphases), without or almost without the decrease in the mental functions, even in case of a large number of the experienced phases and any duration of the disease (Merikangas et al., 2011, p. 242). The purpose of this paper is to review the bipolar disorder and describe the current perspectives of its diagnosing as well as the psychosocial consequences of the disease.
The diagnostics of the bipolar disorder (BD) is rather difficult. This is caused by the polymorphism of the category of bipolarity, the high level of the comorbid characteristic of this pathology, and also the specifics of the diagnostic approaches reflected in the DSM-5 classification (Goodwin, et al., 2016, p. 2). According to Regier, Kuhl & Kupfer (2013), bipolar disorders are separated from the depressive frustration and compose a separate category called “Bipolar disorders and related disorders”. In the DSM-5, there is an accurate definition of mania and the specifying indicators for the mixed episodes. It allows lowering the disorder threshold (Regier, Kuhl & Kupfer, 2013, p. 95).
The features of the diagnostic criteria of the DSM-5 do not promote the improvement of the BD diagnostics. The possibilities of the BD diagnostics are significantly narrowed. This results in untimely or incorrect diagnosing or inadequate antidepressant therapy. Moreover, it promotes the aggravation of the disease and manifestation of its serious social consequences. The criteria presented in the DSM-5 allow diagnosing the BD in the presence of two episodes of the mood disorders, one of which is maniacal, hypo-maniacal, or mixed. In the DSM-5, the diagnostic criteria of BD I and II are more accurately defined. At the same time, BD I is diagnosed in the presence of one maniacal or mixed episode; in this case, big depressive episodes are typical but not obligatory (Regier, Kuhl & Kupfer, 2013, p. 95). The criteria of BD II in the DSM-5 are represented by one big depressive episode at the absence of the maniacal episodes.
Theoretical Models and Etiological Approaches
A BD can arise at any age, but the age more vulnerable to the disease often composes 20-30 years. The concurrency rates of the disorder are much lower than those of the unipolar one, risk of BD fluctuating from 0,4% to 1,6% (Goodwin, et al., 2016, p. 2). There exist biological and psychosocial causes of the BD. The biological approach represents genetic factors of a polygenic character. The researches indicate that one of the main reasons for the bipolar disorder is the disbalance between the neurotransmitters of serotonin, dopamine, and noradrenaline and biochemical factors (Mason, Brown & Croakin, 2016, p. 2). The shortage of these neurotransmitters results in severe mental disorders, such as reality distortion, asocial behavior, or illogical cognition as well insomnia, changes in food behavior, etc. (Merikangas et al., 2011, p. 245). During the mania episodes, the amounts of dopamine and noradrenaline considerably increase. Another biological factor, composing the cornerstone of the BD development, includes the violation of the correct functioning of such systems as “hypothalamus-pituitary-adrenal”, ‘hypophysis-hypothalamus-thyroid gland”, and their biorhythms (Webb, et al., 2014, p. E809).
According to Mason, Brown & Croakin (2016), the psychosocial reasons, including the maniacal and depressive disorders, compose the manifestation of the protective forces of an organism in connection with a stressful situation. In this situation, the behavioral theory can be applied. There are attempts to escape from reality and isolating the traumatic event. There is also a transition from mania to depression at the time of the disintegration of the defensive functions of mania while the transformation of depression into mania protects the feeling of own inferiority. The maniacal and depressive phases are aggravated by the experienced stress at the early stages of the BD (Mason, Brown & Croakin, 2016, p. 3).
Forces Shaping the Development of the Bipolar Disorder
The history of different mood frustrations extends back over two thousand years. Mason, Brown & Croakin (2016) state that the concepts “melancholy” and “mania” as medical terms were first encountered in Hippocrates’s books of the 5th century BC. In 1896, Emil Kraepelin offered the concept “maniac-depressive psychosis” (MDP) (p.3). It included the description of the polar syndromes of the mood frustration – mania and depression, the course of frustration with the alternation of aggravations and remissions, and the favorable forecast in comparison to schizophrenia. Kraepelin’s concept remained dominant in the world psychiatry throughout the 20th century. The first important milestone in the understanding of the BD heterogeneity included the monopolar depression (recurrent) and the bipolar (maniac-depressive) disorder (Mason, Brown & Croakin, 2016, p. 4). The distinctions between the monopolar and bipolar forms of the mood frustration concern both clinical manifestations and the features of the active and supporting therapy. The identification of the two types of the disorder became the second important stage in the diagnostics of the bipolar disorder. According to Mason, Brown & Croakin (2016), the diagnosis of BD replaced the maniacal depressive psychosis in the American classification of the DSM-III in 1980. BD as a diagnosis was included into the approved ICD-10-CM WHO in 1994 (p. 3).
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Symptoms Observed by the Therapist
Mixed affective episodes of the BD include a triad of symptoms, including mood, activity, and mentality, and the states when one of the components of the triad is opposite to the peak of the episode. According to the NIH (2008), they include agitated and disturbing depressions, on the one hand, and the slowed-down, unproductive, and dysphoric manias, on the other hand. The mixed affective episodes are followed by earlier and frequent hospitalization (NIH, 2008, p.2). Patients with such states, including the fast change of the depressive and maniacal phases, are difficult to diagnose and often resistant to therapy.
Despite the main value of mania for the diagnostics of the BD, the symptomatic patients experience three times more (for type I BD) and 39 times more (for type II BD) depressive manifestations than the maniacal ones. Within the frameworks of depression, there is a high level of the psychomotor block, emotional liability, hyperphagia, an increase in body weight, and hypersomnia. Such depressions are close to the atypical ones in accordance with the DSM-5, including irritability, even without mood decrease, especially in teenagers and senior people (Mason, Brown & Croakin, 2016, p. 4). At the periods of depression, they are combined with the depressive cognition (self-accusation).
The patients suffering from BD experience psychotic symptoms. Such patients have a chronic social dysfunction and a high risk of recurrence and suicide (NIH, 2008, p.6). The problem of the diagnostics of BD patients includes the separation from schizophrenia, especially if a patient is checked up only at the peak of the disease development. The expressed nonsense, the broken-off speech, and strong excitement can conceal the main mood frustration and lead to the wrong treatment.
The Impact of Diagnostic Labels
The harm caused by the bipolar depressions exceeds the harm caused by manias, as patients spend more time in a depression, experiencing more disorders in the professional, social, and family life as well as test a high risk of suicide during and after depression. According to the calculations of the National Institute of Health (2008), the BD occupies the 6th place among the reasons of disability. Unemployment can reach 57% within the first six months and 75% after two years of the disease. Bipolar patients are often criminalized, making, for example, up to 10% of the prisoner population, including the patients with a risky behavior (p.7-8). The consequences of the BD include frequent changes of work, moves, stains, bankruptcies, hypersexuality, and the risk of infectioning with sexual and incurable infections.
The accompanying somatic diseases compose the problem significant for the forecast of the BD. For example, according to Goodwin et al. (2016), obesity is met at 21-32% of patients while 31% have the risk to be overweighed. The arterial hypertension composes 35%, diabetes – around 11-17%, hyperlipidemia – 23%, etc. (Goodwin, et al., 2016, p. 3). Also, the somatic diseases that accompany the BD contribute to the deterioration of the patients’ life and its expectancy. During the course of the disease, the BD patients lose, on average, 9 years of life expectancy. Besides, the somatic diseases decrease the working capacity of BD patients by 14 years (Webb, et al., 2014, p. E811).
In most cases, these consequences are connected with the untimely diagnosing of the disease within the first 10 years of its development. Patients do not visit a doctor for a long time. Often, it is connected with the fact that the increase in mood or irritability is not perceived by patients and their families as a disease but rather as stress or a bad temper (Mason, Brown & Croakin, 2016, p. 19). Thus, the therapeutic impact of the BD treatment is damaged due to the diagnostic labels imposed on the patients. The diagnostic tools should be used in a soft unintrusive form in a form of advice.
In conclusion, bipolar disorder is characterized by the change of two phases, maniacal and depressive, followed by an intermission. Quite often, one of the phases dominates in the disease; its symptoms are more manifested. Modern researches revealed significant consequences of the BD hypodiagnostics and its wrong therapy, such as the increased mortality rates, social, psychological, and professional disorders, and health problems. It is necessary to eliminate the diagnostic labeling of BD patients for the effective treatment of the disease.
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