Family and Friends of Individuals with Bipolar Disorder

Family and friends may be able to provide more accurate information about the patient’s mental condition than the patient themselves.  While they may not know what the patient is feeling, they can give an account of the patient’s behavior from day to day.  In addition, co-workers, instructors, and individuals who frequently come into contact with the individual may provide significant details pertaining to his or her condition. 

If it is confirmed that a patient has family members with a mental disorder, especially immediate family members with bipolar disorder, than the chances of inheritance are great.  Sometimes a genetic link may be the most significant clue of a full-blown or impending case of bipolar disorder.  If a patient has a parent with bipolar disorder and presents with symptoms of depression, then special attention should be given. Bipolar I disorder often begins with depression, so even if mania has not yet arisen, the individual should be carefully monitored for signs of extremely elevated or irritable moods.

 

Bipolar disorder is a difficult disorder to both diagnosis and to live with.  Family members are often affected as much as the patient.  Children with a bipolar parent may live in constant fear of their parent’s extreme mood swings and bear the major blunt of the disorder.  Many times a child may feel it is his or her fault when a parent is depressed or that he or she did something to cause the parent to become angry.  Spouses have it no easier.  The destructive behavior manic patients often engage in may have serious consequences, not just for themselves, but to their relationship as well.  A manic individual may desire sexual intercourse constantly or engage in dangerous sexual practices.  A family may go bankrupt due to a manic induced spending spree. A manic individual may be extremely volatile and have violent outbursts over the most insignificant things. 

 

When a patient comes off of a manic high, the situation is no better.  Depression is almost inevitable, and the consequences of their manic episodes often arise, causing an even deeper form of depression.  Considering how frequent suicide is in patients with bipolar disorder, families may live in a constant state of worry.  If an individual does commit suicide, family members often blame themselves as well.  Family members of individuals with bipolar disorder often experience mental disorders, even when there is no genetic link. The stress and anxiety of trying to take care of, and live with, a bipolar individual is great.  A clinician should not only assess a patient with bipolar disorder, but the family members as well.    

Description of Bipolar Disorder

Bipolar disorder, which was once termed manic-depressive disorder, is a mood disorder that affects around one percent of the population.  Unlike major depressive disorder, the prevalence of bipolar disorder is the same in men and women.  However, men are more likely to suffer from manic episodes and women from depressed episodes.  When women do experience mania, they are more liable to experience mixed episodes and rapid-cycling. Five to fifteen percent of individuals with bipolar disorder experience rapid-cycling, or having four or more manic episodes in a year (Sadock, 2003).

Two irregular mental states, depression and mania, are the hallmarks of the syndrome. A mixed episode, which meets the criteria for mania and major depression, may also occur.  The symptoms of depression displayed in bipolar disorder are consistent with that of major depressive disorder, including a depressed mood, weight loss or decreased appetite, fatigue, insomnia or hypersomnia, feelings of worthlessness or guilt, psychomotor agitation or retardation, a diminished ability to think, recurrent thoughts of death, and diminished pleasure in activities (Sadock, 2003).

 

Mania is defined as an abnormally elevated, irritable, or expansive mood lasting for a period of a week or longer (if untreated, three months on average) that causes marked impaired functioning. The normal onset is rapid- a few hours or days, but the state may evolve over a few weeks (Sadock, 2003). Symptoms include distractibility, a flight of ideas, a decreased need for sleep, increased talkativeness, inflated self-esteem, an increase in goal-directed activity or psychomotor agitation, and an excessive involvement in possibly detrimental, pleasurable activities (2003).  In severe cases of mania, psychotic features may be present, including delusions or hallucinations.  Patients with mania, especially those with psychotic features, may need hospitalization to keep from harming themselves or others. 

Patients with hypomania, a less severe form of mania, experience similar symptoms to those with mania, but do not have impaired functioning.  Episodes only have to last for four days or more rather than a week, hospitalization is not necessary, and psychotic features are not present (Sadock, 2003).  Even so, symptoms are noticeable by others and individuals in a hypomanic state have an unmistakable heightened level of functioning.

 

There are two main categories of bipolar disorder, Bipolar I and Bipolar II disorder.  To be diagnosed as having Bipolar I, a patient must have experienced at least one manic mood and one episode of major depression or a mixed episode. Bipolar I normally commences with depression; and the earlier the onset, the poorer the prognosis (Sadock, 2003).  Fortunately, around seven percent of individuals with Bipolar I disorder do not have a recurrence of symptoms. However, around a third of patients have persistent symptoms and social decline (2003). The criteria for Bipolar II disorder consists of at least one major depressive episode and hypomanic episode, without any periods of mania or mixed episodes.  Unlike Bipolar I disorder which may have permanent remittance however infrequent, Bipolar II disorder is a chronic, long-term disease. 

To read the symptoms of bipolar disorder is one thing; to experience them is a totally different situation.  Imagine being on a roller coaster. When the coaster is sitting still, the patient is stable, but may very well have an impending sense of dread for what is about to happen. Then the roller coaster starts climbing the hill.  One could equate this to the evolution of a manic episode.  Sleep starts to diminish and the mood starts to elevate.  The “rider” no longer has a sense of dread because he or she gets excited, elevated, and feels as if he or she can do anything. Then the ride truly begins.  Thoughts start flowing rapidly and the individual wants everyone to feel what he or she is feeling and has a desperate “need” to talk to anyone who will listen.  Things are truly wonderful and the world is a nice place to live.  However, once the ride goes on for a while, things begin to get confusing.  Everything seems to be rapidly flying past, but things start to make less and less sense.  Words don’t come out as fluently and this sense of elevation starts to become a source of extreme irritation. Everything starts to become exasperating.  Then the ride slowly comes to a stop.  The sense of elevation suddenly ends and the excitement is over.  After such a ride and being able to accomplish so much, what is left?  Every day life seems boring and thoughts are still muddled. The individual no longer wants to be around anyone because he or she has nothing to say.  Words don’t come out right anymore, and no one can understand what they are feeling. The only thing left is death because he or she no longer has anything left to give.  Of course, this is only a simplistic analogy of some of the symptoms patients experience when bipolar, but hopefully it provides a little insight into the disorder.

Concordance Study of Bipolar I Disorder in Twins

 

Studying the concordance, which is the similarity of certain characteristics, in twins is a popular method of determining the role of genetic effects in mental disorders (Carlson 2004). Consistent results in studies of twins with bipolar I disorder have supported the hypothesis that genetic factors are great contributors to mental disorders. Accordingly, a similar study was done using a population-based twin sample in which personal interviews were conducted to formulate diagnoses. This study was approved by the Ministry of Social Affairs and Health, along with the Ethics Committee of the National Public Health Institute (Kieseppä, Partonen, Haukka, Kaprio, & Lönnqvist 2004).

All Finish same-sex twins born between 1940 and 1957 were screened for a diagnosis of bipolar I disorder, either through surveys or in the National Hospital Discharge Register. Thirty-eight pairs were identified and invited to participate via mailed invitations; 68% (or 26 pairs) accepted. Participants had to be diagnosed with either bipolar I or the bipolar type of schizoaffective disorder; individuals with bipolar II disorders did not qualify. Five individuals included in the test were deceased (three due to suicide, one due to alcoholic withdrawal and acute mania, and one unknown); forensic examinations along with medical records and information from the opposite twin were utilized All available medical records were obtained prior to personal interviews. Clinical and demographic characteristics of participants in the study and outside of the study were compared using Fisher’s exact test, the chi-square test, Student’s t test, and the Mann-Whitney rank sum test. These tests helped to affirm that there was a representative population sample of twins (Kieseppä, et al. 2004).

Seven of the 26 pairs were monozygotic (identical) and 19 were dizygotic (fraternal). These statistics are also comparable with the national percentages. The study found that the concordance for bipolar I disorder in monozygotic twins was 43%, while only 6% for dizygotic twins. Once the participants with schizoaffective disorder were included, the percentage of concordant monozygotic twins went up to 50%, where as the dizygotic twins went down to 5%. Three-fourths of identical twins experienced concordance for the broad affective disorder spectrum, along with 11% of dizygotic twins. Zygosity testing was performed by means of autopsy tissue samples, microsatellite markers (used in routine paternity tests), and questionnaires on resemblance and confusability during childhood. Interviewers were unaware of the results while testing; the tests were done only after the final diagnoses. Concordance rates were then recalculated to include zygosity results. Two of six (33%) monozygotic twins and one of thirteen (8%) dizygotic twins were concordant for bipolar I disorder; whereas the concordance rates for bipolar I disorder plus schizoaffective disorder and bipolar type were three of seven (43%) and one of fourteen (7%), respectively (Kieseppä, et al. 2004).

Different models were used to account for other factors that could play a part in bipolar I concordance of twins. The E model, which was based strictly on specific environmental factors, was rejected by the chi-square test. The CE model used both common and specific environmental factors; even though it could not be completely rejected, it fit much worse than the ACE and AE models. The AE model, which was the best fit, included both genetic and specific environmental factors. Environmental risk factors, including problems during pregnancy and delivery and childhood infections, were also ascertained from birth clinics, maternity clinics, and child welfare clinics. No significant differences in concordant or discordant pairs of twins were noted (Kieseppä, et al. 2004).

In summary, the results from this study supported past studies. Bipolar I disorder is slightly concordant in fraternal twins, and extremely concordant in identical twins. Concordance rates rise even farther when twin pairs consisting of one individual having bipolar I disorder and another having a disorder in the broad affective spectrum are included. Environmental factors do seem to a play a part in the concordance discussed above, but can not be the only cause. Problems during pregnancy or birth do not appear to have a significant influence on bipolar I concordance in twins. Though this study was small, it included a significant representation of the entire population and used evidence to support the hypothesis that genetics play a role in mental disorders, especially bipolar I disorder.
References:
1. Carlson, Neil R. (2004). Methods and Strategies of Research. In Physiology of Behavior, 8, 160.
2. Kieseppä, T., Partonen, T., Haukka, J., Kaprio, J. & Lönnqvist, J. (2004). High Concordance of Bipolar I Disorder in a Nationwide Sample of Twins [Electronic version]. The American Journal of Psychiatry, Vol. 161, Iss. 10, 1814-1821.