Bipolar Affective Disorder and Epilepsy

By: Jeanette Wong

What is bipolar affective disorder?

Bipolar affective disorder (BPAD), more commonly known as bipolar disorder or manic depression, is characterised by severe mood changes ranging from disabling highs (mania) to lows (depression) (Bipolar Disorders Clinic); (CMHA Durham, 2018). Furthermore, researchers have uncovered shared biochemical and pathophysiological underpinnings between BPAD and epilepsy (Gutierrez, 2017); (Insel et al., 2018). For instance, the kindling paradigm, where brain cells become sensitised over more manic episodes resulting in higher manic episode frequency, has also been applied to understand seizure frequency (Mazza et al., 2007); (Purse, 2020). Additionally, changes in second-messenger systems and genetic expressions in individuals with BPAD have been similarly observed in individuals experiencing epileptic seizures (Mazza et al., 2007). Moreover, an imbalance of ANK3 (protein-coding gene) may cause BPAD and severe epilepsy (Gutierrez, 2017). Yet, the causes behind BPAD as common comorbidity associated with epilepsy haven’t been fully understood (Barry). Hence, more research needs to uncover the link between the two.

History of Bipolar affective disorder

There has been a link between mood disorders and epilepsy for over 2000 years (Barry). Though approximately only 1-2% of the American population is diagnosed with BPAD (UNC School of Medicine, 2018), multiple studies have shown that mood disorders, including BPAD, remain one of the most comorbid conditions in epileptic individuals (UNC School of Medicine, 2018); (Insel et al., 2018). Moreover, the prevalence of bipolar symptoms in epilepsy compared to other chronic health conditions is higher, with approximately 50% of epileptic individuals experiencing bipolar symptoms diagnosed with BPAD (Vivoweill Cornell Medical College). This illness often begins in adolescence and continues through an individual’s life, with 80% of individuals experiencing manic episodes and 15% ending their lives in suicide (Bipolar Disorders Clinic). As such, understanding BPAD remains as essential as ever.

Causes of bipolar affective disorder

Despite decades of research, the exact cause of BPAD is relatively unknown. However, the predicted leading causes of this condition boil down to genetic makeups, biological differences, and unintended side effects of antiepileptic medication (Mayo Foundation for Medical Education and Research, 2021). First, individuals are ten times more likely to get BPAD if they have first-degree relatives that have BPAD (Mayo Foundation for Medical Education and Research, 2021); ​​(RISD Health and Wellness, 2019). Next, biological differences such as abnormal neurotransmitter activities and chemical imbalance in the brain may cause symptoms of BPAD. For example, when an individual’s noradrenaline levels rise above the standard threshold, manic episodes may occur. If noradrenaline levels fall too low, an individual might fall into a depressive state (NHS). Finally, anticonvulsant medication could lead to depressive symptoms seen in BPAD (Mazza et al., 2007). One example is phenobarbital; a barbiturate used to treat and prevent epileptic seizures (Mazza et al., 2007). Since the causes of BPAD have yet to be fully discovered, spotting the signs and symptoms of BPAD is crucial.

Signs and symptoms of bipolar affective disorder

Individuals with BPAD often experience manic episodes followed by depressive states (CMHA Durham, 2018). However, the extent and number of manic episodes vary across individuals (CMHA Durham, 2018). This is differentiated into:

• Bipolar I disorder — Manic episodes last at least 1 week, or symptom severity requires immediate medical attention. Depressive episodes that last 2 weeks accompany this. Manic and depressive episodes can overlap ​​(RISD Health and Wellness, 2019).
• Bipolar II disorder — A pattern of depressive and hypomanic episodes that do not last as long as Bipolar I disorder ​​(RISD Health and Wellness, 2019).
• Cyclothymia — Depressive and manic episodes happen on a smaller scale, similar to when having your period (Mayo Foundation for Medical Education and Research, 2021).

Additionally, signs and symptoms of manic episodes and depressive states include (NHS):

• Manic episode (NHS):
  • Feel high, elated, irritable, jumpy and overly touchy.
  • Decreased need for rest and sleep.
  • Loss of appetite.
  • Fast-paced speech and lack of focus on one topic.
  • Mind and thoughts racing.
  • Poor judgement and makes risky decisions the individual is unlikely to do.
  • High sense of ego and empowerment.
• Depressive episode (NHS):
  • Feel down, sad, helpless, empty and worried.
  • Feel restless and anxious, causing trouble in sleeping, or sleeping for long hours.
  • Increased appetite and sudden weight gain.
  • Forgetfulness, talking unnaturally slowly, unable to put thoughts into words.
  • Trouble focusing on tasks.
  • Disinterested in activities and sense of helplessness in completing tasks.
  • Inability to experience pleasure (anhedonia).
  • Suicidal thoughts and acts.

Known treatments for managing bipolar affective disorder

*Before attempting any treatment or medication changes please consult your physician

Epileptic individuals are more likely to get mood disorders than those without epilepsy. To combat this, more controlled studies on possible treatments have been surfacing over the years since the 2000s (Prueter and Norra, 2005). However, as a caveat, individuals’ reactions to the different treatments may vary and might not be as effective. Hence, it is essential to consult a trusted medical practitioner before attempting these treatments. Nevertheless, below are some known possible treatments for epileptic individuals struggling with their BPAD:

• Antidepressant medication*:
  • Studies show that epileptic individuals’ reactions to antidepressant medication are highly varied. Though some individuals demonstrate a reduction in seizure frequency and induced calmness with prolonged medication use, others face a worsening in their bipolar symptoms and seizure frequency (Cardamone et al., 2013). Some of the listed antidepressants include antidepressants of the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) families (Kanner).

• Anticonvulsant medication*:
  • While anticonvulsant medication helps calm the brain’s neurological activities, prolonged usage may induce undesirable side effects such as nausea, unwanted weight gain, dizziness, and tremors (Bhandari, 2021). Below are some anticonvulsant medication and their reported efficacies (Moreno et al., 2022):
    • Valproate — More efficacious in preventing mania but not depression (Moreno et al., 2022). Used to treat more acute episodes rather than as a preventative treatment (Bhandari, 2021).
    • Carbamazepine (Tegretol) — Similar to oxcarbazepine. More studies are needed to test efficacy (Moreno et al., 2022). But has anticonvulsant and antinociceptive properties (Moreno et al., 2022). Used to treat more acute episodes rather than as a preventative treatment (Bhandari, 2021).
    • Oxcarbazepine — Effective in patients with mild to moderate mania but lacks convincing data on whether it prevents depressive cycles effectively (Grunze et al., 2021).
    • Lamotrigine (Lamictal) — Efficacious in decreasing manic and depressive cycles than lithium and olanzapine. It should not be used in pregnant or breastfeeding women (Moreno et al., 2022). Has more potent antidepressant than antimanic effects (Bhandari, 2021). Used more often to prevent future episodes rather than treat current cycles (Bhandari, 2021).
    • Gabapentine — Could be helpful in the treatment of mania, including cases of poor responses to previous treatments. However, more studies are needed to test clinical efficacy (Moreno et al., 2022).
    • Topiramate — Similar effects to Gabapentine (Moreno et al., 2022).
    • Clonazepam — More efficacious than benzodiazepine counterparts for the treatment of various anxiety disorders and allegedly safer for use (Moreno et al., 2022).

• Behaviour therapies*:
  • Cognitive behavioral therapies may be efficacious in regulating BPAD as they can reduce the impact of seizure triggers and enhance adherence to other epileptic treatments (Markowski and Schachter, 2017).

• Seizure therapies*:
  • Electroconvulsive therapies (ECT), the application of small amounts of electricity to the human brain to generate a mini convulsion when the person is asleep, have been effective in treating depressive disorders and symptoms for decades (Electroconvulsive therapy (ECT) service, 2018). More recently, physicians have also assessed the efficacy of magnetic seizure therapies (MST), deeming them potentially effective in possible treatment for depressive disorders (Grunze et al., 2021). MSTs may also be a better alternative to electrical therapies like ECTs (LaFee, 2021).

• Alternative therapies*:
  • While the most sought-after treatments for BPAD include a combination of medications and cognitive behavioural therapies, alternative therapies exist that help ease and improve individuals’ quality of life (Lehmann and Bhandari, 2020). Studies have shown that mind and body practices such as meditation, acupuncture, and supplement regimens can be beneficial in reducing stress, improving circulation, and regulating breathing, though results are mixed (Lehmann and Bhandari, 2020). Studies have also discovered that supplements such as omega-3-fatty acids and dehydroepiandrosterone are effective in treating mood disorders. However, more research has to be conducted (Qureshia and Al-Bedah, 2013).

In conclusion, while there is no cure for BPAD, specialized therapies and the right combination of medication might help more individuals control their BPAD, increasing their quality of life.

Resources:

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Bipolar Disorders Clinic. (n.d.). What is bipolar disorder? Bipolar Disorders Clinic. Retrieved July 31, 2022, from https://med.stanford.edu/bipolar/bipolar.html

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