Editorial  |   June 2004
Editor's Message
Author Notes
Article Information
Editorial   |   June 2004
Editor's Message
The Journal of the American Osteopathic Association, June 2004, Vol. 104, S1-S2. doi:
The Journal of the American Osteopathic Association, June 2004, Vol. 104, S1-S2. doi:
Why have a JAOA supplement address bipolar disorder? This disorder is a prevalent mental illness that affects between 1%1 and 3%2 of the population and can present at any stage of the life cycle. It often goes unrecognized or is confused with other psychiatric disorders, and when accurately diagnosed, bipolar disorder is responsive to treatment. When not treated, however, bipolar disorder can be a lethal disease, lethality resulting from successful suicide attempts. 
What we now call bipolar disorder was described in medical antiquity. It first appeared in the modern medical literature in the late 1890s. In 1898, the German psychiatrist Emil Kraepelin3 conceptualized a condition he labeled manic-depressive insanity, later to be called manic-depressive disorder. This disorder included episodes of depressed mood along with separate and distinct periods of mania and psychosis. During the past 100 years, and particularly the past 25 years, significant advances have been made in our understanding of the etiology, clinical presentation, course of illness, and treatment of patients with bipolar disorder. 
Despite these exciting discoveries, the clinical presentation of bipolar disorder remains complex and challenging for physicians treating affected patients. As the cover of this supplement so nicely depicts, patients with this disorder often report experiencing a roller coaster ride of emotional states. In addition to the classic symptoms of mania, patients will retrospectively report feeling that every decision they made was unquestionably the correct one. The euphoria they experience can quickly turn to agitation and aggression when attempts to provide structure are attempted. Irritable and hostile mood swings are a common occurrence in these patients. 
Distractibility may be misdiagnosed as attention deficit/hyperactivity disorder or anxiety; however, these conditions are often comorbid. Full-blown, classic bipolar disorder is extremely rare before puberty but can be seen. Difficulty with sleep, short-temper, frequent arguments with parents and teachers, and labile mood states are common initial presentations. A positive family history for bipolar disorder or substance abuse is another frequent finding. Although much of the existing research is focused on the manic or hypomanic presentation, the depressive component of the illness is more prevalent in all age groups. 
In geriatric patients, the increased incidence of comorbid neurologic disorders poses special challenges for diagnosis and treatment. Right-sided cerebrovascular pathologic lesions involving the orbito frontal cortex should be evaluated in patients presenting with late-life mania with no previous history of bipolar disease. Although decreased sleep time without feeling tired is a cardinal symptom of bipolar disorder, understanding the decreased sleep needs of the elderly is important in establishing an accurate diagnosis. Regardless of age, patients who report becomining worse—especially overactivated—while taking antidepressant medications should undergo workup for possible bipolar disorder. All clinicians working with patients with substance abuse disorders should consider bipolar disorder as a potential co-occurring disorder. All that is labile (mood state) is not necessarily bipolar disorder. Including this consideration in the differential diagnostic workup is warranted and will ultimately improve clinical outcomes through more effective treatment interventions. 
Given the high rate of occurrence of comorbidity with other forms of psychopathologic conditions, the important issue is to query patients and their families about labile mood symptoms, sleep problems, and substance use, and then consider the diagnosis of bipolar disorder in the differential diagnosis. In addition to this supplement and the excellent review by Frederick T. Lewis, DO, interested physicians may enjoy reading the new peer-reviewed journal Clinical Approaches in Bipolar Disorders, edited by Gary S. Sachs, MD, of Harvard Medical School in Boston, Mass. Serving with Sachs is an editorial board of the finest bipolar researchers in the world. 
 Dr Baron is a professor and the chair of the Department of Psychiatry and Behavioral Science at Temple University School of Medicine in Philadelphia, Pa.
Hirschfeld RMA. Prevalence and impact of bipolar disorder. Bipolar Disorder: 2003 Literature Year-In Review. May2004 (1): 4-6.
Hirschfeld RM, Calabrese JR, Weissman MM, Reed M, Davies MA, Frye MA, et al. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003;64:53-59.
Kraepelin E. Zur Diagnose und Prognose der Dementia Praecox. Lecture in Heidelberg, Germany, on November 27, 1898. Cited in: Kohl F. The beginning of Emil Kraepelin's classification of psychoses. A historical-methodological reflection on the occasion of the 100th anniversary of his “Heidelberg Address” 27 November 1898 on “nosologic dichotomy” of endogenous psychoses [German]. Psychiatr Prax. 1999;26(3):105-111.