Bipolar Disorder (manic depression)

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Bipolar Disorder (manic depression)

Postby doug » Mon May 23, 2005 4:07 am

Bipolar Disorder
A detailed booklet that describes symptoms, causes, and treatments, with information on getting help and coping. 2001

Bipolar Disorder
What Are the Symptoms of Bipolar Disorder?
What Is the Course of Bipolar Disorder?
Can Children and Adolescents Have Bipolar Disorder?
What Causes Bipolar Disorder?
How Is Bipolar Disorder Treated?
Do Other Illnesses Co-occur with Bipolar Disorder?
How Can Individuals and Families Get Help for Bipolar Disorder?
What About Clinical Studies for Bipolar Disorder?
For More Information
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.
More than 2 million American adults,1 or about 1 percent of the population age 18 and older in any given year,2 have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.
"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide."
"I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do."
Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6.
(Reprinted with permission from Alfred A. Knopf, a division of Random House, Inc.)
What Are the Symptoms of Bipolar Disorder?
Bipolar disorder causes dramatic mood swingsâ€"from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.
Signs and symptoms of mania (or a manic episode) include:
Increased energy, activity, and restlessness
Excessively "high," overly good, euphoric mood
Extreme irritability
Racing thoughts and talking very fast, jumping from one idea to another
Distractibility, can't concentrate well
Little sleep needed
Unrealistic beliefs in one's abilities and powers
Poor judgment
Spending sprees
A lasting period of behavior that is different from usual
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
Provocative, intrusive, or aggressive behavior
Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present.
Signs and symptoms of depression (or a depressive episode) include:
Lasting sad, anxious, or empty mood
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in activities once enjoyed, including sex
Decreased energy, a feeling of fatigue or of being "slowed down"
Difficulty concentrating, remembering, making decisions
Restlessness or irritability
Sleeping too much, or can't sleep
Change in appetite and/or unintended weight loss or gain
Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.
A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.
Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.
It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.
Bipolar disorder may appear to be a problem other than mental illnessâ€"for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.
Diagnosis of Bipolar Disorder
Like other mental illnesses, bipolar disorder cannot yet be identified physiologicallyâ€"for example, through a blood test or a brain scan. Therefore, a diagnosis of bipolar disorder is made on the basis of symptoms, course of illness, and, when available, family history. The diagnostic criteria for bipolar disorder are described in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV).3
Descriptions offered by people with bipolar disorder give valuable insights into the various mood states associated with the illness:
Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?
Hypomania: At first when I'm high, it's tremendous… ideas are fast… like shooting stars you follow until brighter ones appear…. All shyness disappears, the right words and gestures are suddenly there… uninteresting people, things become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria… you can do anything… but, somewhere this changes.
Mania: The fast ideas become too fast and there are far too many… overwhelming confusion replaces clarity… you stop keeping up with itâ€"memory goes. Infectious humor ceases to amuse. Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable, and trapped.
Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings include:
talking about feeling suicidal or wanting to die
feeling hopeless, that nothing will ever change or get better
feeling helpless, that nothing one does makes any difference
feeling like a burden to family and friends
abusing alcohol or drugs
putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one's death)
writing a suicide note
putting oneself in harm's way, or in situations where there is a danger of being killed
If you are feeling suicidal or know someone who is:
call a doctor, emergency room, or 911 right away to get immediate help
make sure you, or the suicidal person, are not left alone
make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm
While some suicide attempts are carefully planned over time, others are impulsive acts that have not been well thought out; thus, the final point in the box above may be a valuable long-term strategy for people with bipolar disorder. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. With proper treatment, suicidal feelings can be overcome.
What Is the Course of Bipolar Disorder?
Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.4
The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.
People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated (see belowâ€""How Is Bipolar Disorder Treated?"). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared.5 But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.
Can Children and Adolescents Have Bipolar Disorder?
Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.
Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day.6 Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.
Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.
For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.
What Causes Bipolar Disorder?
Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorderâ€"rather, many factors act together to produce the illness.
Because bipolar disorder tends to run in families, researchers have been searching for specific genesâ€"the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and growâ€"passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.7
In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.8 It appears likely that many different genes act together, and in combination with other factors of the person or the person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.
Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses.9,10 New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.
How Is Bipolar Disorder Treated?
Most people with bipolar disorderâ€"even those with the most severe formsâ€"can achieve substantial stabilization of their mood swings and related symptoms with proper treatment.11,12,13 Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.
In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.
Medications for bipolar disorder are prescribed by psychiatristsâ€"medical doctors (M.D.) with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.
Medications known as "mood stabilizers" usually are prescribed to help control bipolar disorder.11 Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.
Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.
Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine (Tegretol®), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.
Newer anticonvulsant medications, including lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate (Topamax®), are being studied to determine how well they work in stabilizing mood cycles.
Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.
Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20.14 Therefore, young female patients taking valproate should be monitored carefully by a physician.
Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant.15 Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.
Treatment of Bipolar Depression
Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication.16 Therefore, "mood-stabilizing" medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.
Atypical antipsychotic medications, including clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), and ziprasidone (Geodon®), are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants.17 Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval.18 Olanzapine may also help relieve psychotic depression.19
If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam (Klonopin®) or lorazepam (Ativan®) may be helpful to promote better sleep. However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Other types of sedative medications, such as zolpidem (Ambien®), are sometimes used instead.
Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.
Be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions.
To reduce the chance of relapse or of developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.
Thyroid Function
People with bipolar disorder often have abnormal thyroid gland function.5 Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.
People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Also, lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.
Medication Side Effects
Before starting a new medication for bipolar disorder, always talk with your psychiatrist and/or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremor, reduced sexual drive or performance, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects you notice during treatment. He or she may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist's guidance.
Psychosocial Treatments
As an addition to medication, psychosocial treatmentsâ€"including certain forms of psychotherapy (or "talk" therapy)â€"are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas.13 A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.
Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.
Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.
Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psychoeducation also may be helpful for family members.
Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms.
Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.
Other Treatments
In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.20
Herbal or natural supplements, such as St. John's wort (Hypericum perforatum), have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's wort can reduce the effectiveness of certain medications.21 In addition, like prescription antidepressants, St. John's wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.22
Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.23
A Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come and go, it is important to understand that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.
Do Other Illnesses Co-occur with Bipolar Disorder?
Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders.24 Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.
Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder.25,26 Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment. For more information on anxiety disorders, contact NIMH (see below).
How Can Individuals and Families Get Help for Bipolar Disorder?
Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease. Other mental health professionals, such as psychologists, psychiatric social workers, and psychiatric nurses, can assist in providing the person and family with additional approaches to treatment.
Help can be found at:
Universityâ€"or medical schoolâ€"affiliated programs
Hospital departments of psychiatry
Private psychiatric offices and clinics
Health maintenance organizations (HMOs)
Offices of family physicians, internists, and pediatricians
Public community mental health centers
People with bipolar disorder may need help to get help.
Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral to a mental health professional.
Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.
In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
Family members of someone with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.
Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations. For contact information, see the "For More Information" section at the back of this booklet.
What About Clinical Studies for Bipolar Disorder?
Some people with bipolar disorder receive medication and/or psychosocial therapy by volunteering to participate in clinical studies (clinical trials). Clinical studies involve the scientific investigation of illness and treatment of illness in humans. Clinical studies in mental health can yield information about the efficacy of a medication or a combination of treatments, the usefulness of a behavioral intervention or type of psychotherapy, the reliability of a diagnostic procedure, or the success of a prevention method. Clinical studies also guide scientists in learning how illness develops, progresses, lessens, and affects both mind and body. Millions of Americans diagnosed with mental illness lead healthy, productive lives because of information discovered through clinical studies. These studies are not always right for everyone, however. It is important for each individual to consider carefully the possible risks and benefits of a clinical study before making a decision to participate.
In recent years, NIMH has introduced a new generation of "real-world" clinical studies. They are called "real-world" studies for several reasons. Unlike traditional clinical trials, they offer multiple different treatments and treatment combinations. In addition, they aim to include large numbers of people with mental disorders living in communities throughout the U.S. and receiving treatment across a wide variety of settings. Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies. The main goal of the real-world studies is to improve treatment strategies and outcomes for all people with these disorders. In addition to measuring improvement in illness symptoms, the studies will evaluate how treatments influence other important, real-world issues such as quality of life, ability to work, and social functioning. They also will assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans.
The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is seeking participants for the largest-ever, "real-world" study of treatments for bipolar disorder. To learn more about STEP-BD or other clinical studies, see the Clinical Trials page on the NIMH Web site, visit the National Library of Medicine's clinical trials database, or contact NIMH.
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Postby doug » Mon May 23, 2005 4:11 am

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23Stoll AL, Severus WE, Freeman MP, Rueter S, Zboyan HA, Diamond E, Cress KK, Marangell LB. Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-controlled trial. Archives of General Psychiatry, 1999; 56(5): 407-12.
24Strakowski SM, DelBello MP. The co-occurrence of bipolar and substance use disorders. Clinical Psychology Review, 2000; 20(2): 191-206.
25Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher FC, Vidaver R, Auciello P, Foy DW. Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 1998; 66(3): 493-9.
26Strakowski SM, Sax KW, McElroy SL, Keck PE Jr, Hawkins JM, West SA. Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization. Journal of Clinical Psychiatry, 1998; 59(9): 465-71.
This publication, written by Melissa Spearing of NIMH, is a revision and update of an earlier version by Mary Lynn Hendrix. Scientific information and review were provided by NIMH Director Steven E. Hyman, M.D., and NIMH staff members Matthew V. Rudorfer, M.D., and Jane L. Pearson, Ph.D. Editorial assistance was provided by Clarissa K. Wittenberg, Margaret Strock, and Lisa D. Alberts of NIMH.
All material in this publication is in the public domain and may be copied or reproduced without permission of the Institute. Citation of the source is appreciated.
NIH Publication No. 3679
Printed 2002
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Postby doug » Mon Jun 26, 2006 12:31 pm

Myrick making family struggle public
Representative to speak about mental illness in effort to end its stigma
In January 2005, Rep. Sue Myrick changed committee assignments, taking a seat on the House panel that deals with health.

Her reason?

She wanted a stage, she told me at the time, to bring national attention to an issue that had affected her family -- and millions of others'.

The issue: Mental illness.

Specifically, the stigma of mental illness, and how it keeps people from getting treatment.

The Charlotte Republican wasn't ready then to go public with her own granddaughter's bout with bipolar disorder.

But she is now.

On Wednesday, Myrick will take her family's struggle public when she chairs a hearing on "Dispelling Myths and Promoting Recovery Through Awareness and Treatment."

In her opening remarks, Myrick is expected to talk about her granddaughter, who's now 27 and living in Charlotte.

Her granddaughter will not attend the hearing, but Myrick's office said she is OK with making her situation public.

"For more than a decade now, Rep. Myrick has watched her granddaughter struggle with bipolar disorder, and, as a result, drug addiction," said a release from Myrick's office. "She has worked to get her granddaughter help, but it has been a daily battle for her and her family."

Myrick, a breast cancer survivor, likens the stigma of mental illness today with the stigma that used to keep cancer victims silent -- for fear of seeming weak or even losing their job.

"Today, people with brain disease face the same problems in society," Myrick said in the release. "The public doesn't realize that diseases affecting one's brain can be just as destructive and life-threatening as cancer, diabetes, and other chronic illnesses ... I hope that these hearings will educate the public on brain disease and change their perception. I hope it will also empower people who have these challenges to step out of the shadows and get treatment."

Myrick and her panel will hear from experts about advances in treatment.

Also testifying: TV soap star Maurice Benard of ABC's "General Hospital, who will talk about his own bipolar disorder.

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Postby doug » Sun Mar 23, 2008 1:49 pm

Experts troubled by at-home tests for bipolar
Many such products sold online with almost no government oversight
The Associated Press
SAN DIEGO - Dr. John Kelsoe has spent his career trying to identify the biological roots of bipolar disorder. In December, he announced he had discovered several gene mutations closely tied to the disease, also known as manic depression.

Then Kelsoe, a prominent psychiatric geneticist at the University of California, San Diego, did something provocative for the buttoned-down world of academic medical research: He began selling bipolar genetic tests straight to the public over the Internet last month for $399.

His company, La Jolla-based Psynomics, joins a legion of startups racing to exploit the boom in research connecting genetic variations to a host of health conditions. More than 1,000 at-home gene tests have burst onto the market in the past few years.

The proliferation of these tests troubles many public health officials, medical ethicists and doctors. The tests receive almost no government oversight, even though many of them are being sold as tools for making serious medical decisions.

Health experts worry that many of these products are built on thin data and are preying on individuals’ deepest anxieties.

“People are always rushing to the market on the basis of one or two studies,” said Dr. Muin Khoury, director of the National Office of Public Health Genomics at the Centers for Disease Control and Prevention. “We have very little evidence that telling people their genetic information is going to make any difference.”

Tests have become available claiming to help predict and diagnose everything from serious illnesses like cancer and Alzheimer’s to athletic ability and a person’s ideal diet. Psynomics’ offering is one of the first psychiatric gene tests on the market.

Findings far from complete
Kelsoe, 52, acknowledges that bipolar disorder probably results from a combination of genetic factors and life experiences, and that the presence of these gene variations does not at all mean that someone will, in fact, develop the disease. He admits, too, that his findings about the genetic basis of the illness are far from complete.

But he said his test is a vital starting point toward moving away from the notoriously tricky practice of diagnosing bipolar disorder based purely on a person’s behavior.

“The goal of this is to try and help doctors make an accurate diagnosis more quickly so the patient can be treated appropriately,” Kelsoe said. “Anything is going to help, even if it just helps a little bit.”

Bipolar sufferers experience intense mood swings as they cycle between manic, sometimes delusional highs and depressive lows that can lead to suicide if untreated. The disease is often misdiagnosed as other forms of depression, which delays treatment and can result in the prescribing of antidepressants that make some patients’ symptoms worse.

To take the test, patients receive by mail a plastic cup that they spit into, seal and send back to Psynomics. The company analyzes DNA in the saliva.

Psynomics will send patients’ test results only to their doctors to avoid the risk of self-diagnosis.

The report that accompanies those results instructs doctors that a positive test means patients are two to three times more likely to have bipolar disorder. But the studies from which those figures come also show the gene variations themselves are rare even among those with bipolar.

The report also points out that for now, the test is valid only for whites of Northern European ancestry who show some behavioral symptoms and have at least one other bipolar family member.

Patients taking Psynomics’ bipolar test may feel branded by a positive result, even if they are not ultimately diagnosed with the disorder, said Hank Greely, a professor of law and genetics with the Stanford Center for Biomedical Ethics. Or they may feel false hope from a negative result, despite the company’s disclaimers.

Spur poor decisions?
Likewise, doctors have little training beyond what companies tell them when it comes to applying the test results. “They may make a foolish decision that backfires to put you on meds,” Greely said. “Or they may make a decision that backfires not to put you on meds.”

Unlike many tests for other conditions on the market, Psynomics does not claim its bipolar test can predict a person’s risk of developing the disorder later in life. It is meant to be used as a purely diagnostic tool for patients already showing symptoms.

That is an important distinction that makes the Psynomics test more responsible than others that promise a glimpse into the genetic crystal ball, according to Dr. Greg Feero, head of genomic health care at the National Human Genome Research Institute.

“Now you’re talking about an individual who has symptoms or signs that already put them in a very different risk category than someone who has no symptoms or signs,” Feero said.

Among hundreds of families Kelsoe has studied, one of the gene variations in the Psynomics test showed up in 1 percent of those unaffected by the disorder versus 3 percent who are affected. The other variation appeared in 7 percent of those without bipolar compared to 15 percent who have the disease.

Many other genes interacting with a patient’s environment contribute to the development of bipolar disorder, Kelsoe and other researchers believe, meaning no single genetic variation ultimately causes the disease. Researchers in Kelsoe’s lab are working to track down more genes.

“Why are we starting before it’s finished? You’ve got to start somewhere,” Kelsoe said. “Even if we knew everything about the genes, which we certainly don’t, it’s never going to be 100 percent predictive.”

Psynomics has sold only a few tests so far but is projecting sales of 1,800 tests in 2008 and 30,000 in the next five years.

In coming months, at least two other startups led by genetic researchers are set to release their own psychiatric genetic tests. One test claims to predict the risk of developing schizophrenia. The other is designed to forecast the likelihood that some medications for major depression could heighten suicidal thoughts in patients.

The American Psychiatric Association has yet to create an official policy on genetic testing. A fact sheet issued by the Federal Trade Commission advises consumers to be wary of assertions made by at-home genetic testing companies.

The Food and Drug Administration does not evaluate the tests for accuracy, though a panel is working on a set of standards for the growing industry.

For now, worry persists that with the proliferation of tests, there is too little understanding of what to do with the results, or what they mean.

“We just don’t know how people will use the information,” said Dr. Jinger Hoop, a professor of psychiatric genetics and medical ethics at the Medical College of Wisconsin in Milwaukee. “We don’t know whether it will be helpful to them in the long run.”

© 2008 The Associated Press. All rights reserved.
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Postby doug » Fri Apr 04, 2008 8:32 am

Published on Wednesday, April 02, 2008
The treatment of depression
By Thomas J. Harbin
Fayetteville, NC
A March 18 Observer editorial described the tragic suicide of Army Pfc. Jason Scheuerman. Your writer was justifiably disturbed that this soldier evidently did not receive comprehensive and effective treatment for his depression. All people — soldiers and civilians — deserve to be treated for their psychological problems and to have caring and competent professional help.

It is unfortunate that your writer did not seem to understand the realities regarding where depressed people can obtain that help. In particular, your writer stated, “It was a psychologist, not a doctor, who, instead of evaluating Scheuerman’s mental and emotional state, concluded that he was ‘capable’ of feigning mental illness.”

Your writer went on to state, “The point is that the for-the-record diagnosis of a major mood disorder should, like the course of treatment, come from an M.D. — if not from a psychiatrist …” There are several important misunderstandings in those statements.

First, doctoral-level psychologists are doctors. They attend five to eight years of graduate training in the diagnosis and treatment of psychological problems. This is typically followed by two years of intensive postdoctoral training and a year of supervised practice before they are granted full licensure. Both by training and by law, psychologists are expertly capable of diagnosing and treating depression and suicidal tendencies.

Second, research data are virtually unanimous in demonstrating that psychological treatment of depression is equally effective as medical treatment. But what is more important are the findings that the combination of psychological and medical treatment is more effective than either alone. This strongly indicates that collaboration between medical and psychological professionals is the most effective approach.

Whether the provider is a psychologist or a physician, it is unfortunately not possible to know with certainty which depressed patients will or will not attempt suicide. The real tragedy is that Scheuerman took his life. Blaming that tragedy on the fact that he was evaluated by a psychologist instead of a medical doctor misses the point.

All soldiers deserve to have their mental health problems addressed professionally. The optimum treatment will involve medicine, psychology, counseling, social work, and other disciplines working in cooperation with the patient’s needs as the most important focus.

Thomas J. Harbin, Ph.D., is a licensed psychologist, practicing in Fayetteville.

Copyright 2008 - The Fayetteville Observer
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Postby doug » Wed May 21, 2008 10:31 am

From Wikipedia, the free encyclopedia

Brain: Amygdala

Location of the amygdala in the human brain

Subdivision of the amygdala
Latin corpus amygdaloideum
Gray's subject #189 835
NeuroNames hier-219
MeSH Amygdala
Dorlands/Elsevier c_56/12260351
This article is about part of the human brain. For the comic book character, see Amygdala (comics).

Human brain viewed from the underside, with the front of the brain at the top. Amygdalae are shown in dark red.The amygdalae (Latin, also corpus amygdaloideum, singular amygdala, from Greek αμυγδαλή, amygdalē, 'almond', 'tonsil')[1] are almond-shaped groups of neurons located deep within the medial temporal lobes of the brain in complex vertebrates, including humans.[2] Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.[3]

1 Anatomical subdivisions
1.1 Connections
2 Emotional learning
3 Memory modulation
4 Neuropsychological correlates of amygdala activity
5 See also
6 References
7 External links

Anatomical subdivisions
The regions described as amygdalae encompass several nuclei with distinct functional traits. Among these nuclei are the basolateral complex, the centromedial nucleus and the cortical nucleus. The basolateral complex can be further subdivided into the lateral, the basal and the accessory basal nuclei. [3][4]

The amygdalae send impulses to the hypothalamus for important activation of the sympathetic nervous system, to the reticular nucleus for increased reflexes, to the nuclei of the trigeminal nerve and facial nerve for facial expressions of fear, and to the ventral tegmental area, locus coeruleus, and laterodorsal tegmental nucleus for activation of dopamine, norepinephrine and epinephrine.[4]

Coronal section of brain through intermediate mass of third ventricle.The cortical nucleus is involved in the sense of smell and pheromone-processing. It receives input from the olfactory bulb and olfactory cortex. The lateral amygdalae, which send impulses to the rest of the basolateral complexes and to the centromedial nuclei, receive input from the sensory systems. The centromedial nuclei are the main outputs for the basolateral complexes, and are involved in emotional arousal in rats and cats.[4][5]

Emotional learning
In complex vertebrates, including humans, the amygdalae perform primary roles in the formation and storage of memories associated with emotional events. Research indicates that, during fear conditioning, sensory stimuli reach the basolateral complexes of the amygdalae, particularly the lateral nuclei, where they form associations with memories of the stimuli. The association between stimuli and the aversive events they predict may be mediated by long-term potentiation, a lingering potential for affected synapses to react more readily.[3]

Memories of emotional experiences imprinted in reactions of synapses in the lateral nuclei elicit fear behavior through connections with the central nucleus of the amygdalae. The central nuclei are involved in the genesis of many fear responses, including freezing (immobility), tachycardia (rapid heartbeat), increased respiration, and stress-hormone release. Damage to the amygdalae impairs both the acquisition and expression of Pavlovian fear conditioning, a form of classical conditioning of emotional responses.[3]

The amygdalae are also involved in appetitive (positive) conditioning. It seems that distinct neurons respond to positive and negative stimuli, but there is no clustering of these distinct neurons into clear anatomical nuclei.[6]

Different nuclei within the amygdala have different functions in appetitive conditioning.[7]

Memory modulation
The amygdalae also are involved in the modulation of memory consolidation. Following any learning event, the long-term memory for the event is not instantaneously formed. Rather, information regarding the event is slowly assimilated into long-term storage over time (the duration of long-term memory storage can be life-long), a process referred to as memory consolidation, until it reaches a relatively permanent state.

During the consolidation period, the memory can be modulated. In particular, it appears that emotional arousal following the learning event influences the strength of the subsequent memory for that event. Greater emotional arousal following a learning event enhances a person's retention of that event. Experiments have shown [1] that administration of stress hormones to mice immediately after they learn something enhances their retention when they are tested two days later.

The amygdalae, especially the basolateral nuclei, are involved in mediating the effects of emotional arousal on the strength of the memory for the event, as shown by many laboratories including that of James McGaugh. These laboratories have trained animals on a variety of learning tasks and found that drugs injected into the amygdala after training affect the animals' subsequent retention of the task. These tasks include basic classical conditioning tasks such as inhibitory avoidance, where a rat learns to associate a mild footshock with a particular compartment of an apparatus, and more complex tasks such as spatial or cued water maze, where a rat learns to swim to a platform to escape the water. If a drug that activates the amygdalae is injected into the amygdalae, the animals had better memory for the training in the task.[8] If a drug that inactivates the amygdalae is injected, the animals had impaired memory for the task.

Despite the importance of the amygdalae in modulating memory consolidation, however, learning can occur without it, though such learning appears to be impaired, as in fear conditioning impairments following amygdalar damage.[9]

Evidence from work with humans indicates that the amygdala plays a similar role. Amygdala activity at the time of encoding information correlates with retention for that information. However, this correlation depends on the relative "emotionalness" of the information. More emotionally-arousing information increases amygdalar activity, and that activity correlates with retention.[citation needed]

Neuropsychological correlates of amygdala activity
Early research on primates provided explanations as to the functions of the amygdala, as well as a basis for further research. As early as 1888, rhesus monkeys with a lesioned temporal cortex (including the amygdala) were observed to have significant social and emotional deficits.[10] Heinrich Klüver and Paul Bucy later expanded upon this same observation by showing that large lesions to the anterior temporal lobe produced noticeable changes, including overreaction to all objects, hypoemotionality, loss of fear, hypersexuality, and hyperorality, a condition in which inappropriate objects are placed in the mouth. Some monkeys also displayed an inability to recognize familiar objects and would approach animate and inanimate objects indiscriminately, exhibiting a loss of fear towards the experimenters. This behavioral disorder was later named Klüver-Bucy syndrome accordingly.[11] Later studies served to focus on the amygdala specifically, as the temporal cortex encompasses a broad set of brain structures, making it difficult to find which ones specifically may have correlated with certain symptoms. Monkey mothers who had amygdala damage showed a reduction in maternal behaviors towards their infants, often physically abusing or neglecting them.[12] In 1981, researchers found that selective radio frequency lesions of the whole amygdala caused Klüver-Bucy Syndrome.[13]

With advances in neuroimaging technology such as MRI, neuroscientists have made significant findings concerning the amygdala in the human brain. Consensus of data shows the amygdala has a substantial role in mental states, and is related to many psychological disorders. In a 2003 study, subjects with Borderline Personality Disorder showed significantly greater left amygdala activity than normal control subjects. Some borderline patients even had difficulties classifying neutral faces or saw them as threatening.[14] In 2006, researchers observed hyperactivity in the amygdala when patients were shown threatening faces or confronted with frightening situations. Patients with more severe social phobia showed a correlation with increased response in the amygdala.[15] Similarly, depressed patients showed exaggerated left amygdala activity when interpreting emotions for all faces, and especially for fearful faces. Interestingly, this hyperactivity was normalized when patients went on antidepressants.[16] By contrast, the amygdala has been observed to relate differently in people with Bipolar Disorder. A 2003 study found that adult and adolescent bipolar patients tended to have considerably smaller amygdala volumes and somewhat smaller hippocampal volumes.[17] Many studies have focused on the connections between the amygdala and autism.[18]

Studies in 2004 and 2006 showed that normal subjects exposed to images of frightened faces or faces of people from another race will show increased activity of the amygdala, even if that exposure is subliminal.[19][20]

Recent research suggests that parasites, in particular toxoplasma, form cysts in the brain, often taking up residence in the amygdala. This may provide clues as to how specific parasites manipulate behavior and may contribute to the development of disorders, including paranoia.[21]

See also
List of regions in the human brain

^ amygdala - Definitions from
^ University of Idaho College of Science (2004). amygdala. Retrieved on 2007-03-15.
^ a b c d Amunts K, Kedo O, Kindler M, Pieperhoff P, Mohlberg H, Shah N, Habel U, Schneider F, Zilles K (2005). "Cytoarchitectonic mapping of the human amygdala, hippocampal region and entorhinal cortex: intersubject variability and probability maps". Anat Embryol (Berl) 210 (5-6): 343-52. PMID 16208455.
^ a b c Ben Best (2004). The Amygdala and the Emotions. Retrieved on 2007-03-15.
^ Michael McDannald, Erin Kerfoot, Michela Gallagher, and Peter C. Holland, John Hopkins University (2005). Amygdala central nucleus function is necessary for learning but not expression of conditioned visual orienting. Retrieved on 2007-03-15.
^ Paton, Joseph; et Al. (25 November 2005). "The primate amygdala represents the positive and negative value of visual stimuli during learning". Nature 439: 865-870. doi:10.1038/nature04490.
^ See recent TINS article by Balleine and Killcross (2006)
^ Ferry B, Roozendaal B, McGaugh J (1999). "Role of norepinephrine in mediating stress hormone regulation of long-term memory storage: a critical involvement of the amygdala". Biol Psychiatry 46 (9): 1140-52. doi:10.1016/S0006-3223(99)00157-2 . PMID 10560021.
^ Killcross S, Robbins T, Everitt B (1997). "Different types of fear-conditioned behaviour mediated by separate nuclei within amygdala". Nature 388 (6640): 377-80. doi:10.1038/41097. PMID 9237754.
^ Brown, S. & Shafer, E. (1888). "An investigation into the functions of the occipital and temporal lobes of the monkey's brain.". Philosophical Transactions of the Royal Society of London: Biological Sciences 179: 303-327.
^ Kluver, H. & Bucy, P. (1939). "Preliminary analysis of function of the temporal lobe in monkeys.". Archives of Neurology 42: 979-1000.
^ Bucher, K., Myersn, R., Southwick, C. (1970). "Anterior temporal cortex and maternal behaviour in monkey.". Neurology 20: 415.
^ Aggleton, JP. & Passingham, RE. (1981). "Syndrome produced by lesions of the amygdala in monkeys (Macaca mulatta).". Journal of Comparative and Physiological Psychology 95: 961-977. doi:10.1037/h0077848.
^ Donegan et al. (2003). "Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation.". Biological Psychiatry 54 (11): 1284-1293. doi:10.1016/S0006-3223(03)00636-X .
^ Studying Brain Activity Could Aid Diagnosis Of Social Phobia. Monash University. January 19, 2006.
^ Sheline et al. (2001). "Increased amygdala response to masked emotional faces in depressed subjects resolves with antidepressant treatment: an fMRI study.". Biological Psychiatry 50 (9): 651-658. doi:10.1016/S0006-3223(01)01263-X .
^ Blumberg et al. (2003). "Amygdala and hippocampal volumes in adolescents and adults with bipolar disorder". Arch Gen Psychiatry 60 (12): 1201-8. doi:10.1001/archpsyc.60.12.1201. PMID 14662552.
^ Schultz RT (2005). "Developmental deficits in social perception in autism: the role of the amygdala and fusiform face area". Int J Dev Neurosci 23 (2–3): 125–41. doi:10.1016/j.ijdevneu.2004.12.012. PMID 15749240.
^ Williams, Leanne M.; Belinda J. Liddell, Andrew H. Kemp, Richard A. Bryant, Russell A. Meares, Anthony S. Peduto, Evian Gordon (2006). "Amygdala-prefrontal dissociation of subliminal and supraliminal fear". Human Brain Mapping 27 (8): 652-661. doi:10.1002/hbm.20208. Retrieved on 2008-01-16.
^ Brain Activity Reflects Complexity Of Responses To Other-race Faces, Science Daily, 14 December 2004
^ Vyas et al. (2007). "Behavioral changes induced by Toxoplasma infection of rodents are highly specific to aversion of cat odors". Proc Natl Acad Sci U S A. 104 (15): 6442-7. doi:10.1073/pnas.0608310104. PMID 17404235.

External links
Look up Amygdala in Wiktionary, the free dictionary
.BrainMaps at UCDavis amygdala

Human brain: Limbic system

Diencephalon Hypothalamus · Mammillary body

Telencephalon: limbic lobe Archicortex: Hippocampal formation (Hippocampus, Alveus of the hippocampus, Subiculum, Perforant path, Fimbria, Dentate gyrus) · Paraterminal gyrus · Supracallosal gyrus
Cingulate gyrus · Parahippocampal gyrus · Uncus

Telencephalon: other Amygdala · Nucleus accumbens · Orbitofrontal cortex
septum: Septum pellucidum, Septal nuclei

[show]v • d • eBrain: telencephalon (cerebrum, cerebral cortex, cerebral hemispheres)

Frontal lobe Precentral gyrus (Primary motor cortex, 4)
Superior frontal gyrus/Frontal eye fields (6, 8, 9), Middle frontal gyrus (46), Inferior frontal gyrus/Broca's area (44-Pars opercularis, 45-Pars triangularis)

Orbitofrontal cortex (10, 11, 12, 47)

Prefrontal cortex, Premotor cortex

Precentral sulcus - Superior frontal sulcus - Inferior frontal sulcus - Olfactory sulcus

Parietal lobe Somatosensory cortex (Primary (1, 2, 3, 43), Secondary (5)), Precuneus (7m) - Parietal operculum
Parietal lobules (Superior (7l), Inferior (40)), Angular gyrus (39)

Intraparietal sulcus, Marginal sulcus

Occipital lobe Primary visual cortex (17), (Cuneus, Lingual gyrus, Lateral occipital gyrus (18, 19))
Calcarine fissure

Temporal lobe Primary auditory cortex (41, 42), Superior temporal gyrus (38, 22/Wernicke's area), Middle temporal gyrus (21), Inferior temporal gyrus (20)
Fusiform gyrus (37) Medial temporal lobe (Amygdala, Parahippocampal gyrus (27, 28, 34, 35, 36)

Cingulate cortex/gyrus Subgenual area (25), Anterior cingulate (24, 32, 33), Posterior cingulate (23, 31), Retrosplenial cortex (26, 29, 30)
Callosal sulcus

Interlobar sulci/fissures lateral: Central (frontal+parietal), Lateral (frontal+parietal+temporal), Parietoöccipital
medial: Medial longitudinal, Cingulate (frontal+cingulate), Collateral (temporal+occipital)

White matter tracts Commissural fibers - Association fibers
Internal capsule (Anterior limb, Genu, Posterior limb), Corona radiata, External capsule, Lamina terminalis, Extreme capsule, Semioval center

Olfactory tract, Terminal stria

Other Insular cortex

gray: Olfactory bulb, Anterior olfactory nucleus, Basal optic nucleus of Meynert, Substantia innominata, Anterior perforated substance

Corpus striatum - Limbic lobe

Some categorizations are approximations, and some Brodmann areas span gyri.

Retrieved from ""
Categories: Limbic system | Cerebrum | Neuroanatomy

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Postby doug » Wed May 21, 2008 11:09 am

From Wikipedia, the free encyclopedia

This article is an expansion of a section entitled Mania from within the main article Bipolar disorder. For the classical mythological figures named Mania, see Mania (mythology).
For other uses, see Manic (disambiguation).

History · Areas


Industrial &


Manic episode
Classification and external resources
ICD-10 F30
ICD-9 296.0 Single manic episode, 296.4 Most recent episode manic, 296.6 Most recent episode mixed

Mania (from Greek μανία[1] and that from μαίνομαι - mainomai, "to rage, to be furious") is a severe medical condition characterized by extremely elevated mood, energy, unusual thought patterns and sometimes psychosis. There are several possible causes for mania, but it is most often associated with bipolar disorder, where episodes of mania may cyclically alternate with episodes of clinical depression. These cycles may relate to diurnal rhythms and environmental stressors. Mania varies in intensity, from mild mania (known as hypomania) to full-blown mania with psychotic features (hallucinations and delusions).

Manic patients may need to be hospitalized to protect themselves and others. Mania and hypomania have also been associated with creativity and artistic talent.[2]

1 Symptoms
2 Mixed states
3 Hypomania
4 Associated disorders
5 Medical treatment
6 Psychopharmacology
7 Mania and over the counter drugs
8 Personal accounts
9 See also
10 References
11 External links

Symptoms of mania include rapid speech, racing thoughts, decreased need for sleep, hypersexuality, euphoria, impulsiveness, grandiosity, and increased interest in goal-directed activities.[3] Mild forms of mania, known as hypomania, cause little or no impairment, but most people who suffer from prolonged hypomania due to bipolar disorder develop full mania.[citation needed]

Another symptom of mania is racing thoughts during which the sufferer is excessively distracted by unimportant stimuli.[4] This negative experience creates an inability to function and an absentmindedness where the person with mania's thoughts totally preoccupy him or her, making him or her unable to keep track of time or be aware of anything besides the neurological pattern of thoughts.

Manic symptoms include irritability, anger or rage, delusions, hypersensitivity, hypersexuality, hyper-religiosity, hyperactivity, impulsiveness, racing thoughts, talkativeness, pressure to keep talking or rapid speech, and grandiose ideas and plans, decreased need for sleep (e.g. feels rested after 3 or 4 hours of sleep). In manic and less severe hypomanic cases, the afflicted person may engage in out of character behavior such as questionable business transactions, wasteful expenditures of money, risky sexual activity, abnormal social interaction, or highly vocal arguments uncharacteristic of previous behaviors. These behaviors increase stress in personal relationships, problems at work and increases the risk of altercations with law enforcement as well as being at high risk of impulsively taking part in activities potentially harmful to self and others.

Although "severely elevated mood" sounds somewhat desirable and enjoyable, the experience of mania is often quite unpleasant and sometimes disturbing, if not frightening, for the person involved (and those close to them), and may lead to impulsive behavior that may later be regretted. It can also often be complicated by the sufferer's lack of judgment and insight regarding periods of exacerbation of symptoms. Manic patients are frequently grandiose, obsessive, impulsive, irritable, belligerent, and frequently deny anything is wrong with them. Because mania frequently encourages high energy and decreased perception of need or ability to sleep, within a few days of a manic cycle, sleep-deprived psychosis may appear, further complicating the ability to think clearly. Racing thoughts and misperceptions lead to frustration and decreased ability to communicate with others.

There are different "stages" or "states" of mania. For example, a minor state may involve increased creativity, wit, gregariousness, and ambition. However, a more serious state of mania may involve lack of good judgment, lack of ability to focus, and even psychosis. The victim of mania may feel elated; however, he/she may also feel irritable, frustrated, and may experience derealization.

A mnemonic used to remember the symptoms of mania is DIGFAST:[5]

D = Distractibility
I = Indiscretion
G = Grandiosity
F = Flight of ideas
A = Activity increased
S = Sleep (decreased need for)
T = Talkativeness (pressured speech)

Mixed states
Main article: Mixed episode
Mania can be experienced at the same time as depression, in a mixed episode. Dysphoric mania is primarily manic and agitated depression is primarily depressed. This has caused speculation amongst doctors that mania and depression are two independent axes in a bipolar spectrum, rather than opposites.

There is an increased probability of suicide in the mixed state, as depressed individuals who are also manic have the energy needed to commit the act and the thoughts of depression that would lead them initially to suicide.

Main article: Hypomania
Hypomania is a lowered state of mania that does little to impair function or decrease quality of life according. In hypomania there is less need for sleep, goal motivated behavior and increased metabolism. Though the elevated mood and energy level typical of hypomania could be seen as a benefit, mania itself generally has many undesirable consequences including suicidal tendencies.

Associated disorders
A single manic episode is sufficient to diagnose Bipolar I Disorder. Hypomania may be indicative of Bipolar II Disorder or Cyclothymia. However, if prominent psychotic symptoms are present for a duration significantly longer than the mood episode, a diagnosis of Schizoaffective Disorder is more appropriate.

Medical treatment
Before beginning treatment for mania, careful differential diagnosis must be performed to rule out non-psychiatric causes.

Acute mania in bipolar disorder is typically treated with mood stabilizers and/or antipsychotic medication. Note that these treatments need to be prescribed and monitored carefully to avoid harmful side-effects such as neuroleptic malignant syndrome with the antipsychotic medications. It may be necessary to temporarily admit the patient involuntarily until the patient is stabilized. Antipsychotics and mood stabilizers help stabilize mood of those with mania or depression. They work by blocking the receptor for the neurotransmitter dopamine and allowing serotonin to still work, but in diminished capacity.

When the symptoms of mania have gone, long-term treatment then focuses on prophylactic treatment to try to stabilize the patient's mood, typically through a combination of pharmacotherapy and psychotherapy.

Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. Anticonvulsants such as valproic acid and carbamazepine are also used for prophylaxis. More recent drug solutions include lamotrigine.

The biological mechanism by which mania occurs is not yet known. One hypothesised cause of mania (among others), is that the amount of the neurotransmitter serotonin in the temporal lobe may be excessively high. This is likely to be only part of the puzzle. Dopamine, norepinephrine, glutamate and gamma-aminobutyric acid also appear to play important roles. The temporal lobe is involved in speech, listening, reading, word association and contains the amygdala, the almond shaped emotional center for the brain. The left amygdala is more active in women who are manic and the orbitofrontal cortex is less active (2005). Emotional stimulation creates the ability for life events to be stored more vividly in the memory. In women, the amygdala becomes similar to one of a manic woman during sex combined with menstruation.[citation needed]

Bipolar disorder is different for men than it is for women. Mania affects the hypothalamus and the pituitary-adrenal-axis by causing it to secrete hormones in different amounts, that accounts for hypersexuality, changes in metabolism, and misdiagnosis as hormonal imbalance. Because the hormone problem stems from a neurological problem hormone therapy isn't the best solution. If serotonin levels are stable, hormones secreted by the pituitary gland will stabilize. Bipolar disorder is similar to a thought disorder combined with hypothyroidism and hyperthyroidism.

In the study done by Brentwood VA Medical Center in Los Angeles, California, antidepressants were taken during mania. One third of bipolar patients developed antidepressant induced mania from their healthy state and one fourth developed antidepressant induced rapid cycling from their healthy state. For those with type II bipolar disorder, antidepressants decrease the gaps between the depression and mania (1995).

Mania and over the counter drugs
Phenylpropanolamine (PPA) is a sympathomimetic drug similar in structure to amphetamine which was formerly present in over 130 medications, primarily decongestants, cough/cold remedies, and anorectic agents.

A report on PPA, from the Dept. of Psychiatry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Pharmacopsychiatry 1988 stated:

We have reviewed 37 cases (published in North America and Europe since 1960) that received diagnoses of acute mania, paranoid schizophrenia, and organic psychosis and that were attributed to PPA product ingestion. Of the 27 North American case reports, more reactions followed the ingestion of combination products than preparations containing PPA alone; more occurred after ingestion of over-the-counter products than those obtained by prescription or on-the-street; and more of the cases followed ingestion of recommended doses rather than overdoses.
Failure to recognize PPA as an etiological agent in the onset of symptoms usually led to a diagnosis of schizophrenia or mania, lengthy hospitalization, and treatment with substantial doses of neuroleptics or lithium.
PPA is no longer available in any medication in the United States as of the year 2000.

Personal accounts
In Electroboy: A Memoir of Mania by Andy Behrman, he describes his experience of mania as "the most perfect prescription glasses with which to see the appears in front of you like an oversized movie screen" (2002). Behrman indicates early in his memoir that he sees himself not as a person suffering from an uncontrollable disabling illness, but as a director of the movie that is his vivid and emotionally alive life. "When I'm manic, I'm so awake and alert, that my eyelashes fluttering on the pillow sound like thunder" (2002).

See also
-mania (suffix)
abnormal psychology
Bipolar disorder
Clinical depression
International Society for Bipolar Disorders: a non-profit organization aimed at promoting research and advocacy in the field of bipolar disorders.
Social mania
Young Mania Rating Scale
Caveat: See "Symptoms" above.

^ Mania, Henry George Liddell, Robert Scott, A Greek-English Lexicon, at Perseus
^ Jamison, Kay R. (1996), Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, New York: Free Press, ISBN 0-684-83183-X
^ Lakshmi N. Ytham, Vivek Kusumakar, Stanley P. Kutchar. (2002). Bipolar Disorder: A Clinician's Guide to Biological Treatments, page 3.
^ Carlat DJ, The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians, American Academy of Family Physicians, URL:, Accessed on: August 13, 2005.
The many faces & facets of BP. 2007 Jul. NAMI. Retrieved October 1, 2007.
Expert Opin Pharmacother. 2001 Dec;2(12):1963–73.
Schizoaffective Dissorder. 2007 Sept. Mayo Clinic. Retrieved October 1, 2007.
Schizoaffective Dissorder. 2004 May. All Psych Online: Virtual Psychology Classroom. Retrieved October 2, 2007.
Increased Amygdala Activation During Mania: A Functional Magnetic Resonance Imaging Study. 2005 June. The American Journal of Psychiatry. Retrieved October 2, 2007.
Psychotic Disorders. 2004 May. All Psych Online: Virtual Psychology Classroom. Retrieved October 2, 2007.
Increased concentrations and lateral asymmetry of amygdala dopamine in schizophrenia. 1983 Oct. Nature. Retrieved October 2, 2007.
Antidepressant-induced mania and cycle acceleration: a controversy revisited. 1995 Aug. American Journal of Psychiatry. Retrieved October 2, 2007.
Risperidone therapy in treatment refractory acute bipolar and schizoaffective mania. 1996 Jan. Psychopharmacology Bulletin. Retrieved October 2, 2007.
Behrman, Andy. Electroboy: A Memoir of Mania, "Preface: Flying High", 2002.

External links
Look up Mania in Wiktionary, the free dictionary
Depression and Bipolar Support Alliance
Manic Episode Symptoms
Bipolar Episode Symptoms

WHO ICD-10 mental and behavioral disorders (F · 290–319)

Neurological/symptomatic Dementia (Alzheimer's disease, multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex, Frontotemporal dementia) · Delirium · Post-concussion syndrome

Psychoactive substance alcohol (drunkenness, alcohol dependence, delirium tremens, Korsakoff's syndrome, alcohol abuse) · opioids (opioid dependency) · sedative/hypnotic (benzodiazepine withdrawal) · cocaine (cocaine dependence) · general (Intoxication, Drug abuse, Physical dependence, Withdrawal)

Psychotic disorder Schizophrenia (disorganized schizophrenia) · Schizophreniform disorder · Schizotypal personality disorder · Delusional disorder · Folie à deux · Schizoaffective disorder

Mood (affective) Mania · Bipolar disorder · Clinical depression · Cyclothymia · Dysthymia

Neurotic, stress-related
and somatoform Anxiety disorder (Agoraphobia, Panic disorder, Panic attack, Generalized anxiety disorder, Social anxiety, Social phobia) · OCD · Acute stress reaction · PTSD · Adjustment disorder · Conversion disorder (Ganser syndrome) · Somatoform disorder (Somatization disorder, Body dysmorphic disorder, Hypochondriasis, Nosophobia, Da Costa's syndrome, Psychalgia) · Neurasthenia

behavioral Eating disorder (anorexia nervosa, bulimia nervosa) · Sleep disorder (dyssomnia, insomnia, hypersomnia, parasomnia, night terror, nightmare) ·
Sexual dysfunction (erectile dysfunction, premature ejaculation, vaginismus, dyspareunia, hypersexuality) · Postnatal depression

Adult personality
and behavior Personality disorder · Passive-aggressive behavior · Kleptomania · Trichotillomania · Voyeurism · Factitious disorder · Munchausen syndrome · Ego-dystonic sexual orientation · Fetishism

Mental retardation Mental retardation

Psychological development
(developmental disorder) Specific: speech and language (expressive language disorder, aphasia, expressive aphasia, receptive aphasia, Landau-Kleffner syndrome, lisp) · Scholastic skills (dyslexia, dysgraphia, Gerstmann syndrome) · Motor function (developmental dyspraxia)
Pervasive: Autism · Rett syndrome · Asperger syndrome

Behavioral and emotional,
childhood and adolescence onset ADHD · Conduct disorder · Oppositional defiant disorder · Separation anxiety disorder · Selective mutism · Reactive attachment disorder · Tic disorder · Tourette syndrome · Speech (stuttering · cluttering)

Retrieved from ""
Categories: Mood disorders | Greek loanwords

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Postby doug » Wed May 21, 2008 11:45 am

Manic Episode Symptoms
By Dr Greg Mulhauser
The formal diagnosis of a manic episode rests on these symptoms, which can be evaluated by psychiatrists and other mental health professionals.

Article Contents

Symptoms of Major Depressive, Manic, Hypomanic and Mixed Episodes
Diagnostic Criteria for Manic Episode
Please see our separate note on Treatment, Mental Disorders and Basic Science for important caveats on the role and definition of diagnostic criteria.

Symptoms of Major Depressive, Manic, Hypomanic and Mixed Episodes
Because the lists of symptoms for major depressive, manic, hypomanic and mixed episodes play closely interrelated roles in the diagnosis of mood disorders, all are included here separately. The following diagnostic criteria are reproduced verbatim from page 362 of the DSM-IV TR (where 'IV TR' indicates fourth edition, text revision).

Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

inflated self-esteem or grandiosity
decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
more talkative than usual or pressure to keep talking
flight of ideas, or subjective experience that thoughts are racing
distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet the criteria for a Mixed Episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hypothyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Tell a FriendPrintRelated Articles at
From the Depression and Bipolar section of our main blog:

New Bipolar Blog by Fink and Kraynak
Abuse and Silence: Male, Female, and Family Perspectives
Depression and Anxiety Across Cultures
Just How Strong is the Link between Anorexia and Suicide?
Long Live the Placebo!
Recent questions on Biplar Disorder from ‘Ask the Psychologist’:

I Give Plants, Numbers, and Letters Human Characteristics
Acquaintance of a Friend is Obsessed with My Husband
My Partner is Extremely Abusive — Can He Change?
Combining Alcohol and Medications for Bipolar Disorder
What Causes Inappropriate Laughing After Every Sentence?
This page was last reviewed by Dr Greg Mulhauser, Tuesday, 22 April 2008.

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Postby doug » Wed May 21, 2008 12:18 pm

Major depressive episode
From Wikipedia, the free encyclopedia

Major depressive episode is a symptom of a mood disorder. It is characterized by severe, highly persistent depression, which is often manifested by lack of appetite, chronic fatigue, lethargy, and sleep disturbances (somnipathy). The victim may think about suicide, and in fact an increased risk of actual suicide is present.[1]

In addition to the emotional pain endured by those suffering from depression, significant economic costs are associated with depression. In fact, American and Canadian studies have indicated that the costs associated with depression are greater than those associated with hypertension, and equal to those of heart disease, diabetes, and back problems.[2]

1 Criteria
1.1 Mood
1.2 Anhedonia and Loss of Interest
1.3 Eating disorders and weight gain/loss
1.4 Sleep
1.5 Motor activity
1.6 Fatigue
1.7 Self-worth
1.8 Concentration
1.9 Thoughts of Death
2 Diagnostic Caveats
3 Treatment
4 Demographics
5 See also
6 External links
7 Notes

In order to be diagnosed as suffering from a major depressive episode, the patient must meet the following criteria:

Over a two week period, the patient has consistently experienced five or more of the following symptoms, and these behaviours must be outside the parameters of the patient's normal behaviour. Either depressed mood or decreased interest or pleasure must be one of the five (although both are frequently concomitant).

For the better part of nearly every day, the patient reports a depressed mood or appears depressed to others.[3]
The patient may state that he or she has been feeling sad, depressed, blue, empty, "down in the dumps," hopeless, etc. If the patient is in denial about these feelings, yet appears to be on the verge of tearfulness, manifests a depressed facial expression and disposition, or appears to be overly irritable, these may also indicate the presence of depressed mood. NOTE: Some people may be more likely to report physical complaints (i.e., aches, pains, headaches) rather than depressed mood, however physical symptoms without physical cause are often indicators of depression. See Myalgia and Neuralgia [4]

Anhedonia and Loss of Interest
For most of nearly every day, interest or pleasure is markedly decreased in nearly all activities (noted by the patient or by others). (See Anhedonia)[3]
People suffering with depression tend to lose interest in things they once found enjoyable. Activities are no longer enjoyable and there is often a loss of interest in or desire for sex. People who are depressed may say, "I just don't care anymore," or "nothing matters anymore." Friends and family of the depressed person may notice that he/she has withdrawn from friends, or has neglected or quit doing activities that were once a source of enjoyment.[4]

Eating disorders and weight gain/loss
Although not dieting, there is a marked loss or gain of weight (such as five percent in one month) or appetite is markedly decreased or increased nearly every day.[3]
Changes in appetite take on two manifestations: under- or over-eating. In the first instance, some people never feel hungry, can go long periods of time without wanting to eat, may forget to eat, or if they do eat a small amount of food may be sufficient. A reduction in weight is often associated with a melancholic type of depression.
In the second instance, some people tend toward an increase in appetite and may gain significant amounts of weight. They may tend to crave certain types of food such as sweets or carbohydrates. People with seasonal affective disorder (SAD) often crave foods high in carbohydrates. Weight gain is often associated with atypical depression.[4]

Nearly every day the patient sleeps excessively, known as hypersomnia or not enough, known as insomnia.[3]
Insomnia is the most common type of sleep disturbance for people who are clinically depressed. Waking in the middle of the night and being unable to go back to sleep is known as "middle insomnia"; waking too early as "terminal insomnia", and; having difficulty falling asleep at night as insomnia. Insomnia is often associated with a melancholic type of depression.
A less frequent sleeping problem is oversleeping (called "hypersomnia"). This may occur in the form of sleeping for prolonged periods at night or increased sleeping during the daytime. Even with excess sleep, a person may still feel tired and sluggish during the day. People with seasonal affective disorder (SAD) may sleep longer during the winter months. Hypersomnia is often associated with an atypical depression.[4]

Motor activity
Nearly every day others can see that the patient's activity is agitated or retarded.[3]
People suffering from depression may be either quite agitated (psychomotor agitation), or very lethargic (psychomotor retardation) in their mannerisms and behavior. If a person is agitated, he or she may find it difficult to sit still, may pace the room, wring his/her hands, or fidget with clothes or objects. Someone with psychomotor retardation will tend to move sluggishly, may move across a room very slowly, avert his/her eyes, sit slumped in a chair and speak slowly, saying little.
In terms of diagnosis, the agitation or slowing down of one's demeanor must be to the degree that it can be observed by others.[4]

Nearly every day the person experiences extreme fatigue.[3]
A decrease in energy and feeling fatigued are very common symptoms for those who are clinically depressed. A person may feel tired without having engaged in any physical activity, and day-to-day tasks become difficult, including getting washed and dressed in the morning. Job tasks or housework become very tiring, and the person finds his/her work at home, school, or on the job suffers.[4]

Nearly every day the patient feels worthless or inappropriately guilty. These feelings are not just about being depressed, they may be delusional.[3]
Depressed people may think of themselves in very negative, unrealistic ways such as manifesting a preoccupation with past "failures", personalisation of trivial events, or believing that minor mistakes prove their inadequacy. They also may have an unrealistic sense of personal responsibility and see things beyond their control as being their fault. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms. [4]

Noted by the patient or by others, nearly every day the patient is indecisive or has trouble thinking or concentrating.[3]
A person with depression frequently experiences negative and pessimistic thoughts, and reports that his/her ability to think, concentrate, or make decisions becomes impaired. Memory and distraction problems are common. This problem can be notably pronounced, causing significant difficulty in functioning for those involved in intellectually demanding activities.[4]

Thoughts of Death
The patient has had repeated thoughts about death (other than the fear of dying), suicide (with or without a plan) or has made a suicide attempt.[3]
The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Less severely suicidal people may have regular thoughts of suicide, while those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.[4]

Diagnostic Caveats
In diagnosing the symptoms, the Psychiatrist or Psychologist must take the following into account:

These symptoms must cause clinically important distress, or impair work, social or personal functioning, and they should not fulfill the criteria for Mixed Episode.
The symptoms are not due to the direct physiological effects of a substance (e.g., abuse of a drug or medication) or a general medical condition (e.g., hypothyroidism).[1]
Other than in the case of severe symptoms (severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations or psychomotor retardation), the episode should not have begun within two months of the loss of a loved one. (See Bereavement) [3]

If left untreated, a typical major depressive episode will last for about six months, while about 20% of these episodes can last two years or more, with only 50% of depressive episodes ending spontaneously. However, even after the major depressive episode is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability. Additionally, between 50% and 85% of people who experience one major depressive episode will experience another in the future. [2]

Estimates of the numbers of people suffering from major depressive episodes and Major Depressive Disorder (MDD) vary significantly. Between 10% and 25% of women and between 5% and 12% of men will suffer a major depressive episode. Fewer people, between 5% and 9% of women and between 2% and 3% of men will have MDD, or full-blown depression. Depression occurs nearly twice as often in adolescent and adult females as in males, and the peak period of development is between the ages of 25 and 44 years. Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. Prepubescent girls and boys are affected equally. Additionally, socio-economic or environmental factors do not appear to have any bearing on the incidence of a major depressive episode or MDD. [2]

See also
Depressive personality disorder

External links
Depression and Bipolar Support Alliance - Depression and Bipolar Support Alliance
National Institutes of Health

^ a b Diagnostic and Statistical Manual of Mental Disorders, fourth Edition.
^ a b c [1] Medscape
^ a b c d e f g h i j [2]
^ a b c d e f g h i [3] All About Depression

Retrieved from ""
Categories: Mood disorders

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Postby doug » Wed May 21, 2008 1:20 pm

Bipolar disorder
From Wikipedia, the free encyclopedia

Bipolar disorder
Classification and external resources
ICD-10 F31.
ICD-9 296.80
OMIM 125480 309200
DiseasesDB 7812
MedlinePlus 001528
eMedicine med/229
MeSH D001714
Bipolar disorder is not a single disorder, but a category of mood disorders defined by the presence of one or more episodes of abnormally elevated mood, clinically referred to as mania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present. These episodes are normally separated by periods of normal mood, but in some patients, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. The disorder has been subdivided into bipolar I, bipolar II, Bipolar NOS, and cyclothymia based on the type and severity of mood episodes experienced.

Also called bipolar affective disorder until recently, the current name is of fairly recent origin and refers to the cycling between high and low episodes; it has replaced the older term manic-depressive illness coined by Emil Kraepelin (1856-1926) in the late nineteenth century.[1] The new term is designed to be neutral, to avoid the stigma in the non-mental health community that comes from conflating "manic" and "depression."

Onset of symptoms generally occurs in young adulthood. Diagnosis is based on the person's self-reported experiences, as well as observed behavior. Episodes of illness are associated with distress and disruption, and a relatively high risk of suicide.[2] Studies suggest that genetics, early environment, neurobiology, and psychological and social processes are important contributory factors. Psychiatric research is focused on the role of neurobiology, but a clear organic cause has not been found. Bipolar disorder is usually treated with medications and/or counseling. The mainstay of medication are a number of drugs termed 'mood stabilizers', in particular lithium and sodium valproate; these are a group of unrelated medications used to prevent relapses of further episodes. Antipsychotic medications, sometimes called neuroleptics, in particular olanzapine, are used in the treatment of manic episodes and in maintenance. The benefits of using antidepressants in depressive episodes is unclear. Depending on the jurisdiction, in serious cases where there is risk to self or others involuntary commitment may be used; these cases generally involve severe manic episodes with dangerous behaviour or depressive episodes with suicidal ideation. Hospital stays are less frequent and for shorter periods than they were in previous years.[citation needed]

Some studies have suggested a significant correlation between creativity and bipolar disorder. Though studies consistently show a positive correlation between the two, the exact nature of the relationship between the disorder and creativity is still unclear.[3][4][5] One study indicated increased striving for and attainment of goals and achievements was correlated with onset of manic symptoms.[6] While the disorder affects people differently, individuals with bipolar disorder tend to be much more outgoing and daring than individuals without bipolar disorder. The disorder is also found in a large number of people involved in the arts. It is an ongoing study as to why many creative geniuses had bipolar disorder.

1 Course
1.1 Major depressive episode
1.2 Manic episode
1.3 Hypomanic episode
1.4 Mixed affective episode
2 Diagnosis
2.1 Diagnostic criteria and classification
2.1.1 Bipolar I
2.1.2 Bipolar II
2.1.3 Cyclothymia
2.1.4 Bipolar-NOS
2.2 Delay in diagnosis
2.3 Children
2.4 Other theoretical models
3 Associated features
3.1 Cognitive impairment
3.2 Creativity
4 Epidemiology
4.1 Controversy
5 Causes
5.1 Heritability or inheritance
5.2 Genetic research
6 Treatment
6.1 Medication
7 Research
7.1 Medical imaging
7.2 New treatments
8 Prognosis
8.1 Recurrence
8.2 Mortality
9 History
10 See also
11 References
11.1 Cited texts
12 Further reading
13 External links

Bipolar disorder is often a cyclic illness where people periodically exhibit elevated (manic) and depressive episodes. Most people will experience a number of episodes, averaging 0.4 to 0.7 a year with each lasting three to six months, although some will experience only a single mood episode.[7][8] Late adolescence and early adulthood are peak years for the onset of the illness.[9][10] These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset.

Rapid cycling, defined as having four or more episodes per year, is found in a significant fraction of patients with bipolar disorder. It has been associated with greater disability or a worse prognosis, due to the confusing changeability and difficulty in establishing a stable state. Rapid cycling can be induced or made worse by antidepressants, unless there is adjunctive treatment with a mood stabilizer.[11][12]

The definition of rapid cycling most frequently cited in the literature is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period.[13] There are references that describe very rapid (ultra-rapid) or extremely rapid[14] (ultra-ultra or ultradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24–48-hour period.

Major depressive episode
Main article: Major depressive episode
Signs and symptoms of the depressive phase of bipolar disorder include: persistent feelings of sadness, anxiety, guilt, anger, isolation and/or hopelessness, disturbances in sleep and appetite, fatigue and loss of interest in usually enjoyed activities, problems concentrating, loneliness, self-loathing, apathy or indifference, depersonalization, loss of interest in sexual activity, shyness or social anxiety, irritability, chronic pain (with or without a known cause), lack of motivation, and morbid/suicidal ideation.[15] In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features.

Manic episode
Main article: Manic episode
Mania is generally characterized by a distinct period of an elevated, expansive, or irritable mood state. People commonly experience an increase in energy and a decreased need for sleep. A person's speech may be pressured, with thoughts experienced as racing. Attention span is low and a person in a manic state may be easily distracted. Judgment may become impaired; sufferers may go on spending sprees or engage in behavior that is quite abnormal for them. They may indulge in substance abuse, particularly alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their behavior may become aggressive or intrusive. People may feel they have been "chosen", are "on a special mission", or other grandiose or delusional ideas. Sexual drive may increase. At more extreme phases, a person in a manic state can begin to experience psychosis, or a break with reality, where thinking is affected along with mood.[16] Many people in a manic state experience severe anxiety and are very irritable (to the point of rage), while others are euphoric and grandiose.

In order to be diagnosed with mania according to DSM-IV a person must experience this state of elevated or irritable mood, as well as other symptoms, for at least one week, less if hospitalisation is required. According to the National Institute of Mental Health, "A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present."[17]

Hypomanic episode
Main article: Hypomanic episode
Hypomania is generally a less extreme state than mania, and people in the hypomanic phase generally experience fewer symptoms of mania than those in a full-blown manic episode. During an episode, one might feel an uncontrollable impulse to laugh at things he or she does not normally find funny. The duration is usually also shorter than in mania. This is often a very "artistic" state of the disorder, where there is a flight of ideas, extremely clever thinking, and an increase in energy.

Mixed affective episode
Main article: Mixed state (psychiatry)
In the context of bipolar disorder, a mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously (for example, agitation, anxiety, aggressiveness or belligerence, confusion, fatigue, impulsiveness, insomnia, irritability, morbid and/or suicidal ideation, panic, paranoia, persecutory delusions, pressured speech, racing thoughts, restlessness, and rage).[18]

Diagnosis is based on the self-reported experiences of the patient as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm bipolar disorder, tests are carried out to exclude medical illnesses which may rarely present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions.[citation needed] There are several psychiatric illnesses which may present with similar symptoms; these include schizophrenia,[19] drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder. Alternately, patients currently in a hypomanic or mixed affective episode may display symptoms resembling borderline personality disorder.[citation needed]

The last is important as both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months (notwithstanding Rapid Cycling variant of greater than four episodes a year). The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.[20]

The relationship between bipolar disorder and borderline personality disorder has been debated; some hold that the latter represents a subthreshold form of affective disorder,[21][22] while others maintain the distinctness, though noting they often coexist.[23][24]

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, lithium or valproate level to check compliance or toxicity with those medications, renal or thyroid function if lithium has been previously prescribed and taken regularly. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.[citation needed]

The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies.

Recent studies by Dr. John Kelsoe have linked bipolar disorder to genetic defects. “…[M]utations in the G protein receptorhinase (GRK3) gene—which regulates sensitivity to brain neurotransmitters such as dopamine…”[25] Dr. John Kelsoe is currently with the University of California in San Diego in the Department of Psychiatry[26] Kelsoe’s genetic discovery seeks to provide alternative treatments for those with bipolar disease. In 1997 a genome survey was completed and Dr. Kelsoe, along with his colleges reported that, “results support the presence of a susceptibility locus for bipolar disorder on chromosome 22…These molecular data raise the possibility that common susceptibility genes may be involved.”[27] In February 2008, Dr. Kelsoe released an at-home bipolar test. The tests are sold over the internet to consumers for $399 through his company, La Jolla, Calif.-based Psynomics. This new form of diagnostics seeks to move away from diagnosing people based solely on their behavior. Bipolar disorder is derived from a combination of genetic factors and life experiences[28] Although Dr. Kelsoe is well-respected in his field of study, the test has become controversial and concerning to medical experts. To avoid misdiagnosis, the DNA results from the tests are sent only to the consumers’ doctors from Psynomics.

Diagnostic criteria and classification
Main article: Current diagnostic criteria for bipolar disorder
There is no clear consensus as to how many types of bipolar disorder exist.[29] In DSM-IV-TR and ICD-10, bipolar disorder is conceptualized as a spectrum of disorders occurring on a continuum. The DSM-IV-TR lists four types of mood disorders which fit into the bipolar categories: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Not Otherwise Specified).

Bipolar I
In Bipolar I disorder, an individual has experienced one or more manic episodes with or without major depressive episodes. For a diagnosis of Bipolar I disorder according to the DSM-IV-TR, there requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder but it frequently occurs.

Bipolar II
Bipolar II disorder is characterized by hypomanic episodes as well as at least one major depressive episode. Hypomanic episodes do not go to the extremes of mania (i.e. do not cause social or occupational impairment, and without psychosis), and this can make Bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression. For both disorders, there are a number of specifiers that indicate the presentation and course of the disorder, including "chronic", "rapid cycling", "catatonic" and "melancholic".

Cyclothymia involves a presence or history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. A diagnosis of Cyclothymic Disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning.

Bipolar Disorder Not Otherwise Specified is a catch-all diagnosis that is used to indicate bipolar illness that does not fit into the other diagnostic categories. If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of Bipolar Disorder NOS (Not Otherwise Specified).

Although a patient will most likely be depressed when they first seek help,[citation needed] it is important to find out from the patient or the patient's family or friends if a manic or hypomanic episode has ever occurred. This will prevent misdiagnosis of Depressive Disorder and avoids the use of an antidepressant which may trigger a "switch" to hypomania or mania or induce rapid cycling. Recent screening tools such as the Hypomanic Check List Questionnaire (HCL-32) have been developed to assist the quite often difficult detection of Bipolar II disorders.

Delay in diagnosis
The behavioral manifestations of bipolar disorder are often not understood by patients nor recognized by mental health professionals, so diagnosis may sometimes be delayed for 10 years or more.[30] That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Recent TV specials, for example the BBC's The Secret Life of the Manic Depressive,[31] MTV's True Life: I'm Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby further raising public awareness. Despite this increased focus, individuals are still commonly misdiagnosed.[32]

Main article: Bipolar disorder in children
Children with bipolar disorder do not often meet the strict DSM-IV definition, tending to have rapid-cycling or mixed-cycling pattern.[33] The incidence in this age group has been traditionally held to be very rare.[citation needed] In September 2007, experts (from New York, Maryland and Madrid) found that the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, and it was increasing ever since. They concluded that doctors had been more aggressively applying the diagnosis to children, and not that the incidence of the disorder had increased. The study calculated the number of visits which increased, from 20,000 in 1994 to 800,000 in 2003, or 1% of the population under age 20.[34][35]

Often other psychiatric conditions are diagnosed in bipolar children. These other diagnoses may be concurrent problems, or they may be misdiagnosed as bipolar disorder. Depression, ADHD, ODD, schizophrenia, and Tourette syndrome are common comorbid conditions. Furthermore some children with histories of abuse or neglect may have Bipolar I Disorder.

Other theoretical models
Flux is the fundamental nature of bipolar disorder.[36] Individuals with the illness have continual changes in energy, mood, thought, sleep, and activity. The diagnostic subtypes of bipolar disorder are thus static descriptions — snapshots, perhaps — of an illness in continual flux, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness (Goodwin & Jamison, 1990). The DSM V, to be published in 2011, will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).

Associated features
Associated features are clinical phenomenon that often accompany the disorder, but are not part of the diagnostic criteria for the disorder.

Cognitive impairment
Recent studies have found that bipolar disorder involves certain cognitive deficits or impairments, even in states of remission.[37][38][39][40][41]

It is not known whether specific cognitive deficits are mood state dependent or disorder-specific features of bipolar disorder. Few studies have examined impairments throughout all the different mood states, and many studies show conflicting data compared to other studies on account of methodological differences. Furthermore, the presence of mixed mood states complicates the identification of accurate cognitive models for this condition. Some use theories that conform to the cognitive models for unipolar depression and others on theories that focus soley on physiological or biological aspects of mania. However, Deborah Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has argued that some deficits should be included as a core feature of bipolar disorder. According to McIntyre et al. (2006),

Study results now press the point that neurocognitive deficits are a primary feature of BD; they are highly prevalent and persist in the absence of overt symptomatology. Although disparate neurocognitive abnormalities have been reported, disturbances in attention, visual memory, and executive function are most consistently reported.[42]

However, in the April-June 2007 issue of the Journal of Psychiatric Research (41, 3-4, 265-272) Spanish researchers (Selva et al.) reported that people with bipolar 1 who have a history of psychotic symptoms do not necessarily experience an increase in cognitive impairment. As those correctly diagnosed with bipolar 1 experience only mood congruent psychotic symptoms, the nature of psychotic involvement suggests a less severe long-term effect.

Main article: Creativity and mental illness
A number of recent studies have observed a correlation between creativity and bipolar disorder,[3][4][5] although it is unclear in which direction the cause lies, or whether both conditions are caused by some third, unknown, factor. It has been hypothesized that temperament may be one such factor.

Clinical depression and bipolar disorder are classified as separate illnesses. Some researchers increasingly view them as part of an overlapping spectrum that also includes anxiety and psychosis.

According to Hagop Akiskal, M.D., at the one end of the spectrum is bipolar type schizoaffective disorder, and at the other end is unipolar depression (recurrent or not recurrent), with the anxiety disorders present across the spectrum. Also included in this view is premenstrual dysphoric disorder, postpartum depression, and postpartum psychosis. This view helps to explain why many people who have the illness do not have first-degree relatives with clear-cut "bipolar disorder", but who have family members with a history of these other disorders.

In a 2003 study, Hagop Akiskal M.D. and Lew Judd M.D. re-examined data from the landmark Epidemiologic Catchment Area study from two decades before.[43] The original study found that 0.8 percent of the population surveyed had experienced a manic episode at least once (the diagnostic threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for bipolar II).

By tabulating survey responses to include sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, the authors arrived at an additional 5.1 percent of the population, adding up to a total of 6.4 percent of the entire population who can be thought of as having a bipolar spectrum disorder. This and similar recent studies have been interpreted by some prominent bipolar disorders researchers as evidence for a much higher prevalence of bipolar conditions in the general population than previously thought.

However these re-analyses should be interpreted cautiously because of substantive as well as methodological study limitations. Indeed, prevalence studies of bipolar disorder are carried out by lay interviewers (that is, not by expert clinicians/psychiatrists who are more costly to employ) who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity.

Furthermore, a well-known statistical problem arises when ascertaining disorders and conditions with a relatively low population prevalence or base-rate, such as bipolar disorder: even assuming that lay interviews diagnoses are highly accurate in terms of sensitivity and specificity and their corresponding area under the ROC curve (that is, AUC, or area under the receiver operating characteristic curve), a condition with a relatively low prevalence or base-rate is bound to yield high false positive rates, which exceed false negative rates; in such a circumstance a limited positive predictive value, PPV, yields high false positive rates even in presence of a specificity which is very close to 100%.[44] To simplify, it can be said that a very small error applied over a very large number of individuals (that is, those who are *not affected* by the condition in the general population during their lifetime; for example, over 95%) produces a relevant, non-negligible number of subjects who are incorrectly classified as having the condition or any other condition which is the object of a survey study: these subjects are the so-called false positives; such reasoning applies to the 'false positive' but not the 'false negative' problem where we have an error applied over a relatively very small number of individuals to begin with (that is, those who are *affected* by the condition in the general population; for example, less than 5%). Hence, a very high percentage of subjects who seem to have a history of bipolar disorder at the interview are false positives for such a medical condition and apparently never suffered a fully clinical syndrome (that is, bipolar disorder type I): the population prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, continues to be estimated at 1%.[45] "Mild-to-severe versions of bipolar disorder afflict nearly 4 percent of adults at some time in their lives."[46]

A different but related problem in evaluating the public health significance of psychiatric conditions has been highlighted by Robert Spitzer of Columbia University: fulfillment of diagnostic criteria and the resulting diagnosis do not necessarily imply need for treatment.[47] As a consequence, subjects who experience bipolar symptoms but not a full-blown, impairing bipolar syndrome should not be automatically considered as patients in need of treatment.

Recent studies have indicated that at least 50% of adult sufferers report manifestation of symptoms before the age of 17. Moreover, there is a growing consensus that bipolar disorder originates in childhood. In young children the illness is now referred to as pediatric bipolar disorder. Today about 0.5% of children under 18 are believed to have the condition. For children, the main concern is that bipolar disorder needs to be diagnosed correctly and treated properly because it can look like unipolar depression, ADHD, or conduct disorder. Young children, adolescents and adults each express the condition differently according to child and adolescent bipolar disorders expert Demitri Papolos M.D. and the Child and Adolescent Bipolar Foundation. There is, however, controversy about this last point.[48]

Bipolar disorder manifests in late life as well. Some individuals with "hyperthymic" temperament (or "hypomanic" personality style) who experience depression in later life appear to have a form of bipolar disorder. Much more needs to be elucidated about late-life bipolar disorder.

A debate rages in the medical community on the prevalence of bipolar disorders.[49] Concerns have arisen about the potential for overdiagnosis of BD.[50] One controversy has been the validity of the construct of a mental disorder across different cultural perspectives (Lopez & Guarnaccia 2000, Sher & Trull 1996).[51] Culture-bound syndromes represent recurrent patterns of maladaptive behaviors and/or troubling experiences specifically associated with different cultures or localities (APA, 1994b).[52] It can be difficult to distinguish between age-appropriate restlessness, the fidgeting of children with ADHD, and the purposeful busy activity of mania (Harrington & Myatt, 2003).[53] Further complicating the diagnosis: Abused or traumatized children can seem to have bipolar disorder when they are actually reacting to horrors in their lives.[54] Assumptions regarding behavior, particularly in regard to diagnosing bipolar disorder, ADHD, and mania in children and adolescents, have raised considerable questions regarding unnecessary treatment. Antipsychotic drugs prescribed for the treatment of BD may increase risk to health including heart problems, diabetes, liver failure, and death.[55] "Consequences of overdiagnosis … include exposure to a greater medication burden (in some cases requiring additional monitoring) as well as lesser likelihood of clinical improvement."[56] When checking for a misdiagnosis of Bipolar disorder or confirming a diagnosis of Bipolar disorder, it is useful to consider what other medical conditions might be possible misdiagnoses or other alternative conditions relevant to diagnosis.[57]

According to the U.S. government's National Institute of Mental Health (NIMH), "There is no single cause for bipolar disorder — rather, many factors act together to produce the illness." "Because bipolar disorder tends to run in families, researchers have been searching for specific genes passed down through generations that may increase a person's chance of developing the illness." "In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.".[58]

It is well established that bipolar disorder is a genetically influenced condition which can respond very well to medication (Johnson & Leahy, 2004; Miklowitz & Goldstein, 1997; Frank, 2005). (See treatment of bipolar disorder for a more detailed discussion of treatment.)

Psychological factors also play a strong role in both the psychopathology of the disorder and the psychotherapeutic factors aimed at alleviating core symptoms, recognizing episode triggers, reducing negative expressed emotion in relationships, recognizing prodromal symptoms before full-blown recurrence, and, practising the factors that lead to maintenance of remission (Lam et al, 1999; Johnson & Leahy, 2004; Basco & Rush, 2005; Miklowitz & Goldstein, 1997; Frank, 2005). Modern evidence based psychotherapies designed specifically for bipolar disorder when used in combination with standard medication treatment increase the time the individual stays well significantly longer than medications alone (Frank, 2005). These psychotherapies are interpersonal and social rhythm therapy for bipolar disorder, family focused therapy for bipolar disorder, psychoeducation, cognitive therapy for bipolar disorder, and prodrome detection. All except psychoeducation and prodrome detection are available as books.

Abnormalities in brain function have been related to feelings of anxiety and lower stress resilience. When faced with a very stressful, negative major life event, such as a failure in an important area, an individual may have his first major depression. Conversely, when an individual accomplishes a major achievement he may experience his first hypomanic or manic episode. Individuals with bipolar disorder tend to experience episode triggers involving either interpersonal or achievement-related life events. An example of interpersonal-life events include falling in love or, conversely, the death of a close friend. Achievement-related life events include acceptance into an elite graduate school or by contrast, being fired from work (Miklowitz & Goldstein, 1997). Childbirth can also trigger a postpartum psychosis for bipolar women, which can lead in the worst cases to infanticide.

The "kindling" theory asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events,[59] each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and becomes recurrent) by itself. Not all individuals experience subsequent mood episodes in the absence of positive or negative life events, however.

Individuals with late-adolescent/early adult onset of the disorder will very likely have experienced childhood anxiety and depression. Some argue that childhood-onset bipolar disorder should be treated early.

A family history of bipolar spectrum disorders can impart a genetic predisposition towards developing a bipolar spectrum disorder.[60] Since bipolar disorders are polygenic (involving many genes), there are apt to be many unipolar and bipolar disordered individuals in the same family pedigree. This is very often the case (Barondes, 1998). Anxiety disorders, clinical depression, eating disorders, premenstrual dysphoric disorder, postpartum depression, postpartum psychosis and/or schizophrenia may be part of the patient's family history and reflects a term called "genetic loading".

Bipolar disorder is not either environmental or physiological, it is multifactorial; that is, many genes and environmental factors conspire to create the disorder (Johnson & Leahy, 2004).

Since bipolar disorder is so heterogeneous, it is likely that people experience different pathways towards the illness (Miklowitz & Goldstein, 1997).

Recent research done in Japan indicates a hypothesis of dysfunctional mitochondria in the brain (Stork & Renshaw, 2005).

Heritability or inheritance
The disorder runs in families.[61] More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression.

Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes, using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

Genetic research
There is increasing evidence for a genetic component in the causation of bipolar disorder, provided by a number of twin studies and gene linkage studies.

The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Dizygotic twins have a 23% concordance rate. These concordance rates are not universally replicated in the literature; recent studies have shown rates of around 40% for monozygotic and <10% for dizygotic twins (see Kieseppa, 2004 and Cardno, 1999).[62][63]

In 2003, a group of American and Canadian researchers published a paper that used gene linkage techniques to identify a mutation in the GRK3 gene as a possible cause of up to 10% of cases of bipolar disorder. This gene is associated with a kinase enzyme called G protein receptor kinase 3, which appears to be involved in dopamine metabolism, and may provide a possible target for new drugs for bipolar disorder.[64]

A 2007 gene-linkage study by an international team coordinated by the NIMH has identified a number of genes as likely to be involved in the etiology of bipolar disorder, suggesting that bipolar disorder may be a polygenic disease. The researchers at NIMH have found a correlation between DGKH (diacylglycerol kinase eta) and bipolar disorder. The portion of the genome that encodes DGKH, a key protein in the lithium-sensitive phosphatidyl inositol pathway.[65]

Main article: Treatment of bipolar disorder
Bipolar disorder cannot be cured; instead, the emphasis of treatment is on effective management of acute episodes and prevention of further episodes by use of pharmacological and psychotherapeutic techniques.

Hospitalization may occur, especially with manic episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur.[66] Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups.[67]

The mainstay of treatment is a mood stabilizer medication; these comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is lithium,[68] while almost as widely used is sodium valproate,[69] originally used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder, and lamotrigine, which is the first one to be shown to be of benefit in bipolar depression.[70]

Treatment of the agitation in acute manic episodes has often required the use of antipsychotic medications, such as Quetiapine, Olanzapine and Chlorpromazine. More recently, Olanzapine and Quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder.[71] A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.[72]

The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes, especially if no mood stabiliser is used. However, most mood stabilizers are of limited effectiveness in depressive episodes.

Main article: Bipolar disorders research
The following studies are ongoing, and are recruiting volunteers:

The Maudsley Bipolar Twin Study, based at the Institute of Psychiatry in London is conducting research about the genetic basis of bipolar disorder using twin methodology. Currently recruiting volunteers: identical and non-identical twins pairs, where either one or both twins has a diagnosis of bipolar I or II.

The Maudsley Bipolar eMonitoring Project, another research study based at the Institute of Psychiatry in London, is conducting novel research on electronic monitoring methodologies (electronic mood diaries and actigraphy) for tracking bipolar symptom fluctuations in Bipolar individuals who are interested in self-managing their condition. The study is currently recruiting volunteers from all over the world (see Remote eMonitoring)

Medical imaging
Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the functional MRI and positron emission tomography. An important area of neuroimaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders, and studies have found anatomical differences in areas such as the amygdala,[73] prefrontal cortex[74] and hippocampus.

Better understanding of the neural circuits involved in regulating mood states, and genetic factors such as the cadherin gene FAT linked to bipolar disorder,[75] may influence the development of new and better treatments, and may ultimately aid in early diagnosis and even a cure.

New treatments
In late 2003, researchers at McLean Hospital found tentative evidence of improvements in mood during echo-planar magnetic resonance spectroscopic imaging (EP-MRSI), and attempts are being made to develop this into a form which can be evaluated as a possible treatment.[76][77]

NIMH has initiated a large-scale study at 20 sites across the United States to determine the most effective treatment strategies for people with bipolar disorder. This study, the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), will follow patients and document their treatment outcome for 5-8 years. For more information, visit the Clinical Trials page of the NIMH Web site.[78]

Transcranial magnetic stimulation is another fairly new technique being studied.

Pharmaceutical research in the United States is extensive and ongoing, as seen at

A good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder continues to have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.

Bipolar disorder can be a severely disabling medical condition. However, with appropriate treatment, many individuals with bipolar disorder can live full and satisfying lives. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.

Ultimately one's prognosis depends on many factors, which are, in fact, under the individual's control: the right medicines; the right dose of each; a very informed patient; a good working relationship with a competent medical doctor; a competent, supportive and warm therapist; a supportive family or significant other; and a balanced lifestyle including a regulated stress level, regular exercise and regular sleep and wake times.

There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.[79]

Even when on medication, some people may still experience weaker episodes, or have a complete manic or depressive episode. In fact, a recent study found bipolar disorder to be "characterized by a low rate of recovery, a high rate of recurrence, and poor interepisodic functioning." Worse, the study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately 2-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States."[80]

The following behaviors can lead to depressive or manic recurrence:

Discontinuing or lowering one's dose of medication, without consulting one's physician.
Being under- or over-medicated. Generally, taking a lower dosage of a mood stabilizer can lead to relapse into mania. Taking a lower dosage of an antidepressant, may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania.
An inconsistent sleep schedule can destabilize the illness. Too much sleep (possibly caused by medication) can lead to depression, while too little sleep can lead to mixed states or mania.
Caffeine can cause destabilization of mood toward irritability, dysphoria, and mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can have effects ranging from anti-depressant to mania-inducing.
Inadequate stress management and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress still causes relapse.
Often bipolar individuals are subject to self-medication, the most common drugs being alcohol, and marijuana. Sometimes they may also turn to hard drugs, which can cause the condition to worsen. Studies show that tobacco smoking induces a calming effect on most bipolar people, and a very high percentage suffering from the disorder smoke.[81]
Recurrence can be managed by the sufferer with the help of a close friend, based on the occurrence of idiosyncratic prodromal events.[82] This theorizes that a close friend could notice which moods, activities, behaviours, thinking processes, or thoughts typically occur at the outset of bipolar episodes. They can then take planned steps to slow or reverse the onset of illness, or take action to prevent the episode from being damaging.[83] These sensitivity triggers show some similarity to traits of a highly sensitive person.

"Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD. The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder."[84]

Although many people with bipolar disorder who attempt suicide never actually complete it, the annual average suicide rate in males and females with diagnosed bipolar disorder (0.4%) is 10 to more than 20 times that in the general population.[85]

Individuals with bipolar disorder may become suicidal, especially during mixed states such as dysphoric mania and agitated depression.[86] Persons suffering from Bipolar II have high rates of suicide compared to persons suffering from other mental health conditions, including Major Depression. Major Depressive episodes are part of the Bipolar II experience, and there is evidence that sufferers of this disorder spend proportionally much more of their life in the depressive phase of the illness than their counterparts with Bipolar I Disorder (Akiskal & Kessler, 2007).

Main article: History of bipolar disorder
Varying moods and energy levels have been a part of the human experience since time immemorial. The words "melancholia" (an old word for depression) and "mania" have their etymologies in Ancient Greek. The word melancholia is derived from melas/μελας, meaning "black", and chole/χολη, meaning "bile" or "gall",[87] indicative of the term’s origins in pre-Hippocratic humoral theories. Within the humoral theories, mania was viewed as arising from an excess of yellow bile, or a mixture of black and yellow bile. The linguistic origins of mania, however, are not so clear-cut. Several etymologies are proposed by the Roman physician Caelius Aurelianus, including the Greek word ‘ania’, meaning to produce great mental anguish, and ‘manos’, meaning relaxed or loose, which would contextually approximate to an excessive relaxing of the mind or soul (Angst and Marneros 2001). There are at least five other candidates, and part of the confusion surrounding the exact etymology of the word mania is its varied usage in the pre-Hippocratic poetry and mythologies (Angst and Marneros 2001).

The idea of a relationship between mania and melancholia can be traced back to at least the 2nd century AD.[citation needed] Soranus of Ephesus (98-177 AD) described mania and melancholia as distinct diseases with separate etiologies;[88] however, he acknowledged that “many others consider melancholia a form of the disease of mania” (Cited in Mondimore 2005 p.49).

A clear understanding of bipolar disorder as a mental illness was recognized by early Chinese authors. The encyclopedist Gao Lian (c. 1583) describes the malady in his Eight Treatises on the Nurturing of Life (Ts'un-sheng pa-chien).[89]

The earliest written descriptions of a relationship between mania and melancholia are attributed to Aretaeus of Cappadocia. Aretaeus was an eclectic medical philosopher who lived in Alexandria somewhere between 30 and 150 AD (Roccatagliata 1986; Akiskal 1996). Aretaeus is recognized as having authored most of the surviving texts referring to a unified concept of manic-depressive illness, viewing both melancholia and mania as having a common origin in ‘black bile’ (Akiskal 1996; Marneros 2001).

Avicenna, a Persian physician and psychological thinker who wrote The Canon of Medicine in 1025, identified bipolar disorder as a manic depressive psychosis, which he clearly distinguished from other forms of madness (Junun) such as as mania, rabies, and schizophrenia (Junun Mufrit or severe madness).[90]

Emil Kraepelin (1856–1926) refined the concept of psychosis.The basis of the current conceptualisation of manic-depressive illness can be traced back to the 1850s; on January 31, 1854, Jules Baillarger described to the French Imperial Academy of Medicine a biphasic mental illness causing recurrent oscillations between mania and depression, which he termed folie à double forme (‘dual-form insanity’). Two weeks later, on February 14, 1854, Jean-Pierre Falret presented a description to the Academy on what was essentially the same disorder, and designated folie circulaire (‘circular insanity’) by him.(Sedler 1983) The two bitterly disputed as to who had been the first to conceptualise the condition.

These concepts were developed by the German psychiatrist Emil Kraepelin (1856-1926), who categorized and studied the natural course of untreated bipolar patients. He coined the term manic depressive psychosis, after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally.[91]

After World War II, Dr. John Cade, an Australian psychiatrist, was investigating the effects of various compounds on veteran patients with manic depressive psychosis. In 1949, Cade discovered that lithium carbonate could be used as a successful treatment of manic depressive psychosis.[92] Because there was a fear that table salt substitutes could lead to toxicity or death, Cade's findings did not immediately lead to treatments. In the 1950s, U.S. hospitals began experimenting with lithium on their patients. By the mid-'60s, reports started appearing in the medical literature regarding lithium's effectiveness. The U.S. Food and Drug Administration did not approve of lithium's use until 1970.[93]

The term "manic-depressive reaction" appeared in the first American Psychiatric Association Diagnostic Manual in 1952, influenced by the legacy of Adolf Meyer who had introduced the paradigm illness as a reaction of biogenetic factors to psychological and social influences.[94] Subclassification of bipolar disorder was first proposed by German psychiatrist Karl Leonhard in 1957; he was also the first to introduce the terms bipolar (for those with mania) and unipolar (for those with depressive episodes only).[95]

In 1968, both the newly revised classification systems ICD-8 and DSM-II termed the condition "manic-depressive illness" as biological thinking came to the fore.[96]

The current nosology, bipolar disorder, became popular only recently, and some individuals prefer the older term because it provides a better description of a continually changing multi-dimensional illness.[citation needed]

See also
Neurobiological brain disorder
Mood (psychology)
List of people affected by bipolar disorder
Dark Therapy
Light therapy

^ International Kraepelin Society
^ Ösby, U; Brandt, L; Correia, N; Ekbom, A & Sparén, P (2001), "Excess Mortality in Bipolar and Unipolar Disorder in Sweden", Archives of General Psychiatry 58 (9): 844-850, <>
^ a b Santosa et al. Enhanced creativity in bipolar disorder patients: A controlled study. J Affect Disord. 2006 23 November; PMID 17126406.
^ a b Rihmer et al. Creativity and mental illness. Psychiatr Hung. 2006;21(4):288-94. PMID 17170470.
^ a b Nowakowska et al. Temperamental commonalities and differences in euthymic mood disorder patients, creative controls, and healthy controls. J Affect Disord. 2005 Mar;85(1-2):207-15. PMID 15780691.
^ Johnson SL. (2005) Mania and dysregulation in goal pursuit: a review. Clin Psychol Rev. Feb;25(2):241-62.
^ Kessler, RC; McGonagle, KA; Zhao, S; Nelson, CB; Hughes, M; Eshleman, S; Wittchen, HU & Kendler, KS (1994), "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States", Archives of General Psychiatry 51 (1): 8-19, <>
^ Angst, J & Selloro, R (15 September 2000), "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry 48 (6): 445-457, DOI 10.1016/S0006-3223(00)00909-4
^ Christie KA, Burke JD Jr, Regier DA, Rae DS, Boyd JH, Locke BZ (1988). "(abstract) Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults". Am J Psychiatry 145: 971-975. Retrieved on 2007-07-01.
^ Goodwin & Jamison. p121
^ Treatment of refractory and rapid-cycling bipolar disorder.
^ Sachs, GS, MD, et al (2007) Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression New England Journal of Medicine, Volume 356:1711-1722 (Abstract)
^ Mackin, P & Young, AH (2004), "Rapid cycling bipolar disorder: historical overview and focus on emerging treatments", Bipolar Disorders 6 (6): 523–529, DOI 10.1111/j.1399-5618.2004.00156.x
^ Papolos, DF; Veit, S; Faedda, GL; Saito, T & Lachman, HM (1998), "Ultra-ultra rapid cycling bipolar disorder is associated with the low activity catecholamine-O-methyltransferase allele", Molecular Psychiatry 3 (4): 346-349, <>
^ Bipolar Disorder: Signs and symptoms. Mayo Clinic.
^ NIMH · Bipolar Disorder · Complete Publication
^ NIMH · Bipolar Disorder · Complete Publication
^ Bipolar Disorder: Complications. Mayo Clinic.
^ Pope HG (1983). "Distinguishing bipolar disorder from schizophrenia in clinical practice: guidelines and case reports". Hospital and Community Psychiatry 34: 322-28.
^ Goodwin & Jamison. p108-110
^ Akiskal HS, Yerevanian BI, Davis GC, King D, Lemmi H (1985). "The nosologic status of borderline personality: Clinical and polysomnographic study". Am J Psychiatry 142: 192-198.
^ Gunderson JG, Elliott GR (1985). "The interface between borderline personality disorder and affective disorder". Am J Psychiatry 142: 277-288.
^ McGlashan, TH (1983). "The borderline syndrome:Is it a variant of schizophrenia or affective disorder?". Arch Gen Psychiatry 40: 1319-1323.
^ Pope HG Jr, Jonas JM, Hudson JI, Cohen BM, Gunderson JG (1983). "The validity of DSM-III borderline personality disorder: A phenomenologic, family history, treatment response, and long term follow up study". Arch Gen Psychiatry 40: 23-30.
^ …”(“Role for gene in bipolar disorder.” The Lancet 22 June 2003: 2137.
^ Akiskal HS, Benazzi F (May 2006). "(abstract) The DSM-IV and ICD-10 categories of recurrent [major depressive and bipolar II disorders: evidence that they lie on a dimensional spectrum.]". J Affect Disord. 92 (1): 45-54. Retrieved on 2007-06-29.
^ S. Nassir Ghaemi (2001). Bipolar Disorder: How long does it usually take for someone to be diagnosed for bipolar disorder?. Retrieved on 2007-02-20.
^ The Secret Life of the Manic Depressive. BBC (2006). Retrieved on 2007-02-20.
^ Roy H. Perlis (2005). Misdiagnosis of Bipolar Disorder. Retrieved on 2007-02-20.
^ Kranowitz, C.S. & Post, R., (1996). Ultra-rapid and ultradian cycling in bipolar affective illness. British Journal of Psychiatry, 168, 314-323.
^ New York Times, Bipolar Illness Soars as a Diagnosis for the Young
^ Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. (September 2007) "National trends in the outpatient diagnosis and treatment of bipolar disorder in youth," Archives of General Psychiatry. 64(9):1032-9. PMID 17768268
^ Depression and Bipolar Support Alliance: About Mood Disorders
^ Martínez-Arán, A; Vieta, E; Reinares, M; Colom, F; Torrent, C; Sánchez-Moreno, J; Benabarre, A; Goikolea, JM; et al. (February 2004), "Cognitive Function Across Manic or Hypomanic, Depressed, and Euthymic States in Bipolar Disorder", American Journal of Psychiatry 161 (2): 262-270, <>
^ Rossi, A; Arduini, L; Daneluzzo, E; Bustini, M; Prosperini, P & Stratta, P (July 2000), "Cognitive function in euthymic bipolar patients, stabilized schizophrenic patients, and healthy controls", Journal of Psychiatric Research 34 (4-5): 333-339, DOI 10.1016/S0022-3956(00)00025-X
^ "Second Biennial Conference of the International Society for Bipolar Disorders, 2–4 August 2006, Edinburgh, Scotland, Thursday, August 3, 09:00-10:00, Cognitive Function in BD", Bipolar Disorders 8 (Supplement 1): 2–3, August 2006, DOI 10.1111/j.1399-5618.2006.00379_2.x
^ Zubieta, J-K; Huguelet, P; O'Neil, RL & Giordani, BJ (10 May 2001), "Cognitive function in euthymic Bipolar I Disorder", Psychiatry Research 102 (1): 9-20, DOI 10.1016/S0165-1781(01)00242-6
^ Kerr, N; Scott, J & Phillips, M (2005), "Patterns of attentional deficits and emotional bias in bipolar disorder and major depressive disorder", British Journal of Clinical Psychology 44: 343-356
^ Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski (2006). "Bipolar Disorder: Defining Remission and Selecting Treatment". Psychiatric Times. .
^ Judd, Lewis L.; Hagop S. Akiskal (January 2003). "The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases". Journal of Affective Disorders 73 (1-2): 123-131. doi:10.1016/S0165-0327(02)00332-4 .
^ Baldessarini, Ross J.; Finklestein S., Arana G. W. (May 1983). "The predictive power of diagnostic tests and the effect of prevalence of illness". Archives of General Psychiatry 40 (5): 569-573.
^ Soldani, Federico; Sullivan P. F. Pedersen N. L. (Apr 2005). "Mania in the Swedish Twin Registry: criterion validity and prevalence". Australian and New Zealand of Psychiatry 39 (4): 235-243.
^ Bipolar Surprise, Science News, March 31, 2007, vol. 171, #13, p.196
^ Spitzer, Robert (Feb 1998). "Diagnosis and need for treatment are not the same". Archives of General Psychiatry 55 (2): 120.
^ Bipolar Disorder in Children and Adolescents: a Caution.
^ » Bipolar Controversy - Psych Central News
^ Bipolar Disorder: Particle or Wave? DSM Categories or Spectrum Dimensions?
^ Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder
^ Log In Problems
^ Bipolar labels for children stir concern - The Boston Globe
^ - New antipsychotic drugs carry risks for children
^ Misdiagnosis of Bipolar disorder -
^ NIMH. What Causes Bipolar Disorder?.
^ Link and reference involving kindling theory
^ Genetics and Risk
^ McGuffin, P; Rijsdijk, F; Andrew, M; Sham, P; Katz, R & Cardno, A (2003), "The Heritability of Bipolar Affective Disorder and the Genetic Relationship to Unipolar Depression", Archives of General Psychiatry 60 (5): 497-502, <>
^ [1] Kieseppa T, Partonen T, Haukka J, Kaprio J, Lonnqvist J. (2004) High concordance of bipolar I disorder in a nationwide sample of twins.
^ [2] Cardno AG, Marshall EJ, Coid B, Macdonald AM, Ribchester TR, Davies NJ, Venturi P, Jones LA, Lewis SW, Sham PC, Gottesman II, Farmer AE, McGuffin P, Reveley AM, Murray RM. (1999) Heritability estimates for psychotic disorders: the Maudsley twin psychosis series.
^ Barrett TB, Hauger RL, Kennedy JL, Sadovnick AD, Remick RA, Keck PE, McElroy SL, Alexander M, Shaw SH, Kelsoe JR. (May 2003). "Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder". Molecular Psychiatry 8 (5): 546-57. doi:10.1038/ doi:10.1038/
^ Baum, A E & McMahon, F J (8 May 2007), "A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and several other genes in the etiology of bipolar disorder.", Molecular Psychiatry, <>
^ Becker T, Kilian R. (2006) Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? Acta Psychiatrica Scandinavica Supplement, 429, 9–16. PMID 16445476
^ McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. Am J Psychiatry. Mar;164(3):437–41. PMID 17329468
^ Poolsup N, Li Wan Po A, de Oliveira IR. (2000) Systematic overview of lithium treatment in acute mania. J Clin Pharm Ther 25: 139-156 PMID: 10849192
^ Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G. (2002). "(abstract) Valproate for acute mood episodes in bipolar disorder". The Cochrane Database of Systematic Reviews (2). John Wiley and Sons, Ltd.. doi:10.1002/14651858.CD004052. ISSN 1464-780X.
^ Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD.(1999) A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. J Clin Psychiatry 60: 79-88
^ Now Approved: ZYPREXA for maintenance therapy for bipolar disorder. Official Zyprexa Website.
^ Tohen, Mauricio; Waldemar Greil, Joseph R. Calabrese, Gary S. Sachs, Lakshmi N. Yatham, Bruno Müller Oerlinghausen, Athanasios Koukopoulos, Giovanni B. Cassano, Heinz Grunze, Rasmus W. Licht, Liliana Dell’Osso, Angela R. Evans, Richard Risser, Robert W. Baker, Heidi Crane, Martin R. Dossenbach and Charles L. Bowden (July 2005). "Olanzapine Versus Lithium in the Maintenance Treatment of Bipolar Disorder: A 12-Month, Randomized, Double-Blind, Controlled Clinical Trial". American Journal of Psychiatry 162 (7): 1281-1290. doi:0.1176/appi.ajp.162.7.1281.
^ Strakowski, S.M., DelBello, M.P, Sax, K.W. et. al. (1999). "Brain magnetic resonance imaging of structural abnormalities in bipolar disorder," Archives of General Psychiatry, 56:254–60.
^ Prefrontal Cortex in Bipolar Disorder
^ Emma Young (2006). New gene linked to bipolar disorder. New Scientist.
^ LFMS: Low Field Magnetic Stimulation: Original EP-MRSI Study in Volunteers with Bipolar Disorder McLean Hospital Neuroimaging Center.
^ Rohan, Michael; Aimee Parow, Andrew L. Stoll, Christina Demopulos, Seth Friedman, Stephen Dager, John Hennen, Bruce M. Cohen, and Perry F. Renshaw (January 2004). "Low-Field Magnetic Stimulation in Bipolar Depression Using an MRI-Based Stimulator". American Journal of Psychiatry 161 (1): 93-98. doi:0.1176/appi.ajp.161.1.93. PubMed.
^ Introduction. Retrieved on 2008-02-16.
^ Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski "Bipolar Disorder: Defining Remission and Selecting Treatment" Vol. XXIII, No. 11 (October 2006)
^ Bipolar Disorder
^ Perry A, Tarrier N, Morriss R, McCarthy E, Limb K “Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of recurrence and obtain treatment” BMJ 1999;318:149-153 (16 January)
^ Kelly, M., Bipolar and the Art of Roller-coaster Riding, Two Trees Media 2000, 2005
^ Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski. Bipolar Disorder: Defining Remission and Selecting Treatment. Psychiatric Times, October 2006, Vol. XXIII, No. 11.
^ Leslie Citrome, MD, MPH; Joseph F. Goldberg, MD. Bipolar disorder is a potentially fatal disease.
^ Psychopathologic Correlates of Suicidal Ideation in Major Depressive Outpatients: Is It All Due to Unrecognized (Bipolar) Depressive Mixed States?
^ Liddell, Henry George and Robert Scott (1980). A Greek-English Lexicon (Abridged Edition). United Kingdom: Oxford University Press. ISBN 0-19-910207-4.
^ Bipolar_disorders_beyond_major_depression_and_euphoric_mania. Retrieved on 2008-02-16.
^ Youssef, Hanafy A.; Fatma A. Youssef & T. R. Dening (1996), "Evidence for the existence of schizophrenia in medieval Islamic society", History of Psychiatry 7: 55-62 [57]
^ Kraepelin, Emil (1921) Manic-depressive Insanity and Paranoia ISBN 0-405-07441-7
^ Cade J. F. J. (1949). "Lithium salts in the treatment of psychotic excitement". Medical Journal of A
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From Wikipedia, the free encyclopedia

The anticonvulsants, also called antiepileptic drugs (abbreviated "AEDs"), belong to a diverse group of pharmaceuticals used in prevention of the occurrence of epileptic seizures. Anticonvulsants are also increasingly finding ways into the treatment of bipolar disorder, since many seem to act as mood stabilizers. The goal of an anticonvulsant is to suppress the rapid and excessive firing of neurons that start a seizure. Failing this, a good anticonvulsant would prevent the spread of the seizure within the brain and offer protection against possible excitotoxic effects that may result in brain damage. However, anticonvulsants themselves have been linked to lowered IQ.[1]

The major molecular targets of marketed anticonvulsant drugs are voltage-gated sodium channels; components of the GABA system, including GABAA receptors, the GAT-1 GABA transporter, and GABA transaminase; and voltage-gated calcium channels.[2]

Some anticonvulsants have shown antiepileptogenic effects in animal models of epilepsy. That is, they either prevent the expected development of epilepsy or can halt or reverse the progression of epilepsy. However, no drug has shown this effect in human trials.[3]

1 Approval
2 Drugs
2.1 Aldehydes
2.2 Aromatic allylic alcohols
2.3 Barbiturates
2.4 Benzodiazepines
2.5 Bromides
2.6 Carbamates
2.7 Carboxamides
2.8 Fatty acids
2.9 Fructose derivatives
2.10 Gaba analogs
2.11 Hydantoins
2.12 Oxazolidinediones
2.13 Propionates
2.14 Pyrimidinediones
2.15 Pyrrolidines
2.16 Succinimides
2.17 Sulfonamides
2.18 Triazines
2.19 Ureas
2.20 Valproylamides (amide derivatives of valproate)
3 Diet
4 Devices
5 Marketing approval history
6 See also
7 References
8 External links

The usual method of achieving approval for a drug is to show it is effective when compared against placebo, or that it is more effective than an existing drug. In monotherapy (where only one drug is taken) it is considered unethical by most to conduct a trial with placebo on a new drug of uncertain efficacy. This is because untreated epilepsy leaves the patient at significant risk of death. Therefore, almost all new epilepsy drugs are initially approved only as adjunctive (add-on) therapies. Patients whose epilepsy is currently uncontrolled by their medication (i.e., it is refractory to treatment) are selected to see if supplementing the medication with the new drug leads to an improvement in seizure control. Any reduction in the frequency of seizures is compared against a placebo.[3]

Once there is confidence that a drug is likely to be effective in monotherapy, trials are conducted where the drug is compared to an existing standard. For partial-onset seizures, this is typically carbamazepine. Despite the launch of over ten drugs since 1990, no new drug has been shown to be more effective than the older set, which includes carbamazepine, valproate and phenytoin. The lack of superiority over existing treatment, combined with the lack of placebo-controlled trials, means that few modern drugs have earned FDA approval as initial monotherapy. In contrast, Europe only requires equivalence to existing treatments, and has approved many more. Despite their lack of FDA approval, the American Academy of Neurology and the American Epilepsy Society still recommend a number of these new drugs as initial monotherapy.[3]

In the following list, the dates in parentheses are the earliest approved use of the drug.

Main article: Aldehydes

Paraldehyde (1882). One of the earliest anticonvulsants. Still used to treat status epilepticus, particularly where there are no resuscitation facilities.

Aromatic allylic alcohols
Stiripentol (2001 - limited availability). Indicated for the treatment of severe myoclonic epilepsy in infancy (SMEI).

Main article: Barbiturates

Barbiturates are drugs that act as central nervous system (CNS) depressants, and by virtue of this they produce a wide spectrum of effects, from mild sedation to anesthesia. The following are classified as anticonvulsants:

Phenobarbital (1912). See also the related drug primidone.
Methylphenobarbital (1935). Known as mephobarbital in the US. No longer marketed in the UK
Metharbital (1952). No longer marketed in the UK or US.
Barbexaclone (1982). Only available in some European countries.
Phenobarbital was the main anticonvulsant from 1912 till the development of phenytoin in 1938. Today, phenobarbital is rarely used to treat epilepsy in new patients since there are other effective drugs that are less sedating. Phenobarbital sodium injection can be used to stop acute convulsions or status epilepticus, but a benzodiazepine such as lorazepam, diazepam or midazolam is usually tried first. Other barbiturates only have an anticonvulsant effect at anaesthetic doses.

Main article: Benzodiazepines

The benzodiazepines are a class of drugs with hypnotic, anxiolytic, anticonvulsive, amnestic and muscle relaxant properties. Benzodiazepines act as a central nervous system depressant. The relative strength of each of these properties in any given benzodiazepine varies greatly and influences the indications for which it is prescribed. Long-term use can be problematic due to the development of tolerance and dependency. Of the many drugs in this class, only a few are used to treat epilepsy:

Clobazam (1979). Notably used on a short-term basis around menstruation in women with catamenial epilepsy.
Clonazepam (1974).
Clorazepate (1972).
The following benzodiazepines are used to treat status epilepticus:

Diazepam (1963). Can be given rectally by trained care-givers.
Midazolam (N/A). Increasingly being used as an alternative to diazepam. This water-soluble drug is squirted into the side of the mouth but not swallowed. It is rapidly absorbed by the buccal mucosa.
Lorazepam (1972). Given by injection in hospital.
Nitrazepam, temazepam, and especially nimetazepam are powerful anticonvulsant agents, however their use is rare due to an increased incidence of side effects and strong sedative and motor-impairing properties.

Main article: Bromides

Potassium bromide (1857). The earliest effective treatment for epilepsy. There would not be a better drug for epilepsy until phenobarbital in 1912. It is still used as an anticonvulsant for dogs and cats.

Main article: Carbamates

Felbamate (1993). This effective anticonvulsant has had its usage severely restricted due to rare but life-threatening side effects.

Main article: Carboxamides

The following are carboxamides:

Carbamazepine (1963). A popular anticonvulsant that is available in generic formulations.
Oxcarbazepine (1990). A derivative of carbamazepine that has similar efficacy but is better tolerated.

Fatty acids
Main article: Fatty acids

The following are fatty-acids:

The valproates — valproic acid, sodium valproate, and divalproex sodium (1967).
Vigabatrin (1989).
Tiagabine (1996).
Vigabatrin and progabide are also analogs of GABA.

Fructose derivatives
Main article: Fructose
Topiramate (1995).

Gaba analogs
Gabapentin (1993).
Pregabalin (2004).

Main article: Hydantoins

The following are hydantoins:

Ethotoin (1957).
Phenytoin (1938).
Fosphenytoin (1996).

Main article: Oxazolidinediones

The following are oxazolidinediones:

Trimethadione (1946).

Main article: Propionates


Main article: Pyrimidinediones

Primidone (1952).

Main article: Pyrrolidines

Levetiracetam (1999).

Main article: Succinimides

The following are succinimides:

Ethosuximide (1955).

Main article: Sulfonamides

Acetazolamide (1953).
Zonisamide (2000).

Main article: Triazines

Lamotrigine (1990).

Main article: Ureas


Valproylamides (amide derivatives of valproate)
Main article: Amides


The ketogenic diet is a strict medically supervised diet that has an anticonvulsant effect. It is typically used in children with refractory epilepsy.

The vagus nerve stimulator (VNS) is a device that sends electric impulses to the left vagus nerve in the neck via a lead implanted under the skin. It was FDA approved in 1997 as an adjunctive therapy for partial-onset epilepsy.

Marketing approval history
The following table lists anticonvulsant drugs together with the date their marketing was approved in the US, UK and France. Data for the UK and France is incomplete. In recent years, the European Medicines Agency has approved drugs throughout the European Union. Some of the drugs are no longer marketed.

Drug Brand US UK France
acetazolamide Diamox 1953-07-271953-07-27[4] 1988[5]
carbamazepine Tegretol 1974-07-151974-07-15[6][7] 1965[5] 1963[8]
clobazam Frisium 1979[5]
clonazepam Klonopin/Rivotril 1975-06-041975-06-04[9] 1974[5]
diazepam Valium 1963-11-151963-11-15[10]
divalproex sodium Depakote 1983-03-101983-03-10[11]
ethosuximide Zarontin 1960-11-021960-11-02[12] 1955[5] 1962[8]
ethotoin Peganone 1957-04-221957-04-22[13]
felbamate Felbatol 1993-07-291993-07-29[14]
fosphenytoin Cerebyx 1996-08-051996-08-05[15]
gabapentin Neurontin 1993-12-301993-12-30[16] 1993-05May 1993[5][8] 1994-10October 1994[8]
lamotrigine Lamictal 1994-12-271994-12-27[17] 1991-10October 1991[5][8] 1995-05May 1995[8]
levetiracetam Keppra 1999-11-301999-11-30[18] 2000-09-292000-09-29[5][19] 2000-09-292000-09-29[19]
mephenytoin Mesantoin 1946-10-231946-10-23[20]
metharbital Gemonil 1952[21][22]
methsuximide Celontin 1957-02-081957-02-08[23]
methazolamide Neptazane 1959-01-261959-01-26[24]
oxcarbazepine Trileptal 2000-01-142000-01-14[25] 2000[5]
phenobarbital 1912[5] 1920[8]
phenytoin Dilantin/Epanutin 1938[26][8] 1938[5] 1941[8]
phensuximide Milontin 1953[27][28]
pregabalin Lyrica 2004-12-302004-12-30[29] 2004-07-062004-07-06[5][30] 2004-07-062004-07-06[30]
primidone Mysoline 1954-03-081954-03-08[31] 1952[5] 1953[8]
sodium valproate Epilim 1977-12December 1977[8] 1967-06June 1967[8]
stiripentol Diacomit 2001-12-052001-12-05[32] 2001-12-052001-12-05[32]
tiagabine Gabitril 1997-09-301997-09-30[33] 1998[5] 1997-11November 1997[8]
topiramate Topamax 1996-12-241996-12-24[34] 1995[5]
trimethadione Tridione 1946-01-251946-01-25[35]
valproic acid Depakene/Convulex 1978-02-281978-02-28[36] 1993[5]
vigabatrin Sabril 1989[5]
zonisamide Zonegran 2000-03-272000-03-27[37] 2005-03-102005-03-10[5][38] 2005-03-102005-03-10[38]

See also
ATC code N03

^ Loring, David W (2005-09-01). "Cognitive Side Effects of Antiepileptic Drugs in Children". Psychiatric Times XXII (10).
^ Rogawski MA, Löscher W. The neurobiology of antiepileptic drugs. Nat Rev Neurosci. 2004 Jul;5(7):553-564. PMID 15208697
^ a b c Abou-Khalil BW (2007). "Comparative monotherapy trials and the clinical treatment of epilepsy". Epilepsy currents / American Epilepsy Society 7 (5): 127–9. doi:10.1111/j.1535-7511.2007.00198.x. PMID 17998971.
^ NDA 008943

Epilepsy Action: Druglist. Retrieved on 2007-11-01.
^ NDA 016608 (Initial approval on 1968-03-11 was for trigeminal neuralgia.)
^ Schain, Richard J. (March 1978). "Pediatrics—Epitomes of Progress: Carbamazepine (Tegretol) in the Treatment of Epilepsy". Western Journal of Medicine 128 (3): 231–232. Retrieved on 2007-03-14.
^ a b c d e f g h i j k l m Loiseau, Pierre Jean-Marie (June 1999). "Clinical Experience with New Antiepileptic Drugs: Antiepileptic Drugs in Europe" (PDF). Epilepsia 40 (Suppl 6): S3–8. doi:10.1111/j.1528-1157.1999.tb00925.x. PMID 10530675. Retrieved on 2007-03-26.
^ NDA 017533
^ NDA 013263
^ NDA 018723
^ NDA 012380
^ NDA 010841
^ NDA 020189
^ NDA 020450
^ NDA 020235
^ NDA 020241
^ NDA 021035
^ a b EPAR: Keppra. Retrieved on 2007-11-01.
^ NDA 006008
^ NDA 008322
^ Dodson, W. Edwin; Giuliano Avanzini; Shorvon, Simon D.; Fish, David R.; Emilio Perucca (2004). The treatment of epilepsy. Oxford: Blackwell Science, xxviii. ISBN 0-632-06046-8.
^ NDA 010596
^ NDA 011721
^ NDA 021014
^ NDA 008762 (Marketed in 1938, approved 1953)
^ NDA 008855
^ Kutt, Henn; Resor, Stanley R. (1992). The Medical treatment of epilepsy. New York: Dekker, 385. ISBN 0-8247-8549-5. (first usage)
^ NDA 021446
^ a b EPAR: Lyrica Retrieved on 2007-11-01.
^ NDA 009170
^ a b EPAR: Diacomit. Orphan designation: 2001-12-05, full authorisation: 2007-01-04 Retrieved on 2007-11-01.
^ NDA 020646
^ NDA 020505
^ NDA 005856
^ NDA 018081
^ NDA 020789
^ a b EPAR: Zonegran. Retrieved on 2007-11-01
Drug Reference for FDA Approved Epilepsy Drugs
Epilepsy Action: UK Anti-Epileptic Drugs List

External links
eMedicine: Antiepileptic Drugs: an overview
NINDS: Anticonvulsant Screening Program
Use of Anticonvulsants in Pharmacotherapy of Bronchial Asthma
MDNG: Anticonvulsants and Bone Health
[show]v • d • eAnticonvulsants (N03)

Barbiturates Barbexaclone, Metharbital, Methylphenobarbital, Pentobarbital, Phenobarbital, Primidone

Hydantoins Ethotoin, Fosphenytoin, Mephenytoin, Phenytoin

Oxazolidinediones Ethadione, Paramethadione, Trimethadione

Succinimides Ethosuximide, Mesuximide, Phensuximide

Benzodiazepines Clobazam, Clonazepam, Clorazepate, Diazepam, Lorazepam, Midazolam, Nimetazepam, Nitrazepam, Temazepam

Carboxamides Carbamazepine, Oxcarbazepine, Rufinamide

Fatty acid derivatives Valpromide, Valnoctamide

Carboxylic acids Valproic acid (Sodium valproate & Valproate semisodium), Tiagabine

Others GABA analogs: Gabapentin, Pregabalin, Progabide, Vigabatrin -- Monosaccharides: Topiramate -- Aromatic allylic alcohols: Stiripentol -- Ureas: Phenacemide, Pheneturide -- Phenyltriazines: Lamotrigine
Carbamates: Emylcamate, Felbamate, Meprobamate -- Pyrrolidines: Brivaracetam, Levetiracetam, Nefiracetam, Seletracetam

Sulfa drugs: Acetazolamide, Ethoxzolamide, Sultiame, Zonisamide -- Propionates: Beclamide -- Aldehydes: Paraldehyde -- Bromides: Potassium bromide, Sodium bromide

Major drug groups

Gastrointestinal tract/metabolism (A) stomach acid (Antacids, H2 antagonists, Proton pump inhibitors) • Antiemetics • Laxatives • Antidiarrhoeals/Antipropulsives • Anti-obesity drugs • Anti-diabetics • Vitamins • Dietary minerals

Blood and blood forming organs (B) Anticoagulants • Antihemorrhagics • Antiplatelets • Thrombolytics

Cardiovascular system (C) Antiarrhythmics • Antihypertensives • Diuretics • Vasodilators • Antianginals • Beta blockers • ACE inhibitors • Antihyperlipidemics

Skin (D) Emollients - Antipruritics

Reproductive system (G) Hormonal contraception • Fertility agents • SERMs • Sex hormones

Endocrine system (H) Corticosteroids • Sex hormones • Thyroid hormones

Infections and infestations (J, P) Antibiotics • Antivirals • Vaccines • Antifungals • Antiparasitic (Antiprotozoals, Anthelmintics)

Malignant and immune disease (L) Anticancer agents • Immunostimulators • Immunosuppressants

Muscles, bones, and joints (M) Anabolic steroids • Anti-inflammatories • Antirheumatics • Corticosteroids • Muscle relaxants

Brain and nervous system (N) Anesthetics • Analgesics • Anticonvulsants • Mood stabilizers • Psycholeptic (Anxiolytics, Antipsychotics, Hypnotics/Sedatives) • Psychoanaleptic (Antidepressants, Stimulants/Psychostimulants)

Respiratory system (R) Bronchodilators • Decongestants • H1 antagonists

Retrieved from ""
Categories: Anticonvulsants | Epilepsy

This page was last modified on 28 June 2008, at 09:52.
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Postby doug » Wed Oct 01, 2008 11:32 am

Doctors Seeing More Cases of Bipolar Disorder
Posted: Sep 6, 2007
Carrboro, N.C. — Most people are familiar with depression, but you might not know much about the other extreme called "mania". It is a manic-depressive illness also referred to as bipolar disorder. People with bipolar disorder suffer from severe, frequent mood swings.

The National Institute of Mental Health reports about 5.7 million American adults have bipolar disorder.

Researchers used to think bipolar disorder was mostly an adult problem, but a new study shows more doctors are seeing the symptoms in children. The UNC Center of Excellence for Research and Treatment of Bipolar Disorder is conducting research to pin down the causes of bipolar disorder and improve treatment options.

Sean Delaney said he knew he was suffering from depression but was unaware his illness was more severe.

"Just wasn't familiar with that and didn't think anything was wrong at first," said Delaney.

"It's not just feeling good, I mean, it's really excessive. I mean, lots of energy and they might feel less inhibited," said Dr. Jair Soares, director of the UNC Center of Excellence for Research and Treatment of Bipolar Disorder.

The manic phase of bipolar disorder can also include irritability, impulsive or reckless behavior, problems sleeping, irrational beliefs and inflated self esteem. Delaney's experience was not that extreme, but it was troubling enough for him to seek help at the UNC bipolar disorder center.

Delaney takes the drug Lithium, to help stabilize his mood. He also attends psychotherapy sessions and has a good support system.

"That's how we can get best outcomes for people that suffer from bipolar disorder," said Dr. Soares.

The UNC bipolar disorder center provides patients in clinic trials with medications and also conducts research, looking for the genetic and environmental factors that cause bipolar disorder. The goal is early diagnosis, because left untreated, symptoms of mania progress.

"They may go into full blown mania and that takes longer after-wards to get them back to feeling normal," said Dr. Soares.

Delaney is glad he got help when he did.

"I could have been a lot worse off than I am now," said Delaney.

A study in the Archives of General Psychiatry reported diagnosis of bipolar disorder skyrocketed from 20,000 children in 1994 to 800,000 children in 2003.

Dr. Soares said he has seen the symptoms of bipolar disorder in children as young as age six.

Reporter: Allen Mask, M.D.
Photographer: Rick Armstrong
Web Editor: Minnie Bridgers
Copyright 2008 by All rights reserved.
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Postby doug » Wed Oct 01, 2008 11:39 am

Monday, September 17, 2007
New Center for Study in North Carolina
Center focusing on bipolar disorder
Emphasis on research, treatment of disease in adults, children
(Raleigh) News & Observer
Twenty years ago, bipolar disorder was considered a disease of adults, and a rare one at that. Now, however, psychiatrists are increasingly willing to make the diagnosis -- and at younger and younger ages. A study published this month in the journal Archives of General Psychiatry noted a 40-fold increase of bipolar diagnoses in youths up to age 19 since 1994. The increasing attention to the disorder has prompted UNC Hospitals in Chapel Hill to establish a center that will study and treat adults and children.

The new UNC Center of Excellence for Research and Treatment of Bipolar Disorder is part of the School of Medicine's department of psychiatry and is headed by Dr. Jair Soares. Soares became interested in bipolar disorder more than a decade ago while training at a University of Pittsburgh bipolar program. He said he's certain that heightened awareness is helping more children get treatment sooner.

"That's a wonderful thing," Soares said, noting that people with bipolar disorder are at increased risk of disability, hospitalization and suicide. "Treatment at the right time can be lifesaving." Some researchers at the center are looking for biological markers associated with bipolar disorder. Others are studying children of bipolar adults to gather clues about how the illness passes from parent to child. Three clinical trials under way have received National Institutes of Health funding totaling $6 million.

Paul Brinich, a Chapel Hill child psychologist, said he thinks bipolar disorder has become the latest fad diagnosis for children with behavioral problems. He is concerned about the drugs that almost always accompany such a diagnosis.

Many of the newer medicines used to treat bipolar disorder such as risperidone have worrisome side effects in children, such as rapid weight gain that might put them at risk for diabetes and other problems.

Posted by Tellymonster at 9:36 PM
Labels: Bipolar disorder, Children, News, Science, Treatment, UNC Chapel Hill

I am a woman diagnosed as Bipolar II. I am happily married with 3 cats, a Corgi, an Akita mix, and lots of fish. I am a home-owner with a post-graduate education (nearly) and a professional job. No children planned. A warning: I think too much. I am sarcastic, out-spoken, opinionated, and terrified of failure and completion (or, more accurately, finality). What will I talk or write about? Whatever matters to me or otherwise moves me. Life's too short to waste it on petty interpersonal conflicts or temporary discomforts. I believe there is always a time and place for silliness, outrage, and the occasional melancholy rant.....
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Postby doug » Wed Oct 01, 2008 11:47 am

Diary of a Tellymonster
A journal designed to share the latest in news, science, and my experience with bipolar disorder--and whatever else moves me.
Wednesday, September 17, 2008
My Social DNA
Considerate Director
You are a Director
As a DIRECTOR, you combine an unusual openness and passion for beauty and style with confidence and a down-to-earth sensibility that allow you to realize your vision.
You are practical and pay attention to the details that others tend to miss.
By focusing on what is real and concrete, you achieve more than those who always have their heads in the clouds.
When it comes to what really matters in your life, you are confident in your ability to succeed.
Having beautiful things in your life gives you pleasure and satisfaction - you have a keen eye for style.
Even when problems present themselves, deep down you know you will overcome these challenges.
When routines get too familiar, you become bored and start looking for ways to spice things up.
You are open to new types of experiences – you are not afraid to take a risk on something new.
You have a highly developed sense of taste – you know what looks good on you, in your home, and in the world at large.
You prefer to have time to plan for things, feeling better with a schedule than with keeping plans up in the air until the last minute.
You do your own thing when it comes to clothing, guided more by practical concerns than by other people's notions of style.
You are Considerate
You trust others, care about them, and are slow to judge them, making you CONSIDERATE.
You value your close relationships very much, and are more likely to spend time in small, tightly-knit groups of friends than in large crowds.
You enjoy exploring the world through observation, quietly watching others.
Relating to others so well, and understanding their emotions, leads you to trust people in general, even though you're somewhat shy and reserved at times.
Your belief that people are generally well-intentioned contributes to your sympathy regarding their problems.
Although you may not vocalize it often, you have an awareness of how society affects individuals, and you understand complex causes of people's behavior.
You like to look at all sides of a situation before making a judgment, particularly when that situation involves important things in other people's lives.
Your close friends know you as a good listener.

Posted by Tellymonster at 8:32 PM Links to this post
Labels: Considerate, Director, DNA, Personality, Social
Tuesday, September 9, 2008
Oprah and Bipolar Disorder
Oprah apparently covered bipolar disorder recently. A slideshow story about the episode can be found at the link below. I found that it echoed a lot of my experiences and fears.
Posted by Tellymonster at 9:19 PM Links to this post
Labels: Bipolar disorder, Celebrity, Children, Depression, Jennifer Lewis, Justice System, Kay Jamison, Lithium, Mania, Maurice Benard, Medication, Mental Illness, Mother, Murder, Oprah Winfrey
Saturday, September 6, 2008
Why Choice is Issue #1 for Me
Whenever I head to the polls, no matter how small the election, I go knowing which candidates support a safe and legal abortion. This is not because I am some baby-killing monster, or because I think sorority girls need another birth control option, or because I don't want any more kids on welfare. No, being pro-choice has nothing to do with anyone else but me.

I have bipolar disorder. It is a medical and mental illness that colors all of my major life decisions. It is one of the best reasons I have for not wanting to have biological children. That's because in order for me to function as a "normal" person, I have to take a number of psychotropic drugs. The drugs, not surprisingly, are not recommended for expectant women because of the potentially harmful effects they could have on a fetus.

Let me be clear, I am on birth control to prevent a pregnancy. But if I somehow became pregnant, I could not, would not, keep the pregnancy. I would not want to put myself and my husband through nine months of insane manias and mind-numbing depressions brought on by lack of medication and an influx of hormones. Not only that, but I can almost guarantee that I would suffer from post-partum depression (maybe even psychosis) which could put my life, as well as the baby's, in jeopardy. All this before even considering the fact that I could have a bipolar child and that child would have to face so many challenges in his or her life.

So if I could not access a safe and legal abortion, what then? Would I be forced to go through with the pregnancy, even though the stress of a pregnancy could cost me my marriage, my child, or my life? Would the government step in to decide what medications I could or couldn't take? Would I wind up one of those unfortunate women who kill their own child?

And the sad thing is that even if the only criteria that allowed an abortion is "for the life of the mother," I wouldn't qualify. The medical and legal system is not sensitive enough to the needs of the mentally ill. How could I possibly convince a doctor or a judge that my life would be endangered on the basis of the "what-ifs" and fears unique to my situation?

These are the thoughts and questions that terrify me. I am terrified that I could be forced by my government into an impossible situation, that I could be treated as a child or animal with no rights over their destinies, that I could become an unfortunate statistic or a "news-at-nine" headline.

That is why I am pro-choice.
Posted by Tellymonster at 6:09 PM Links to this post
Labels: Abortion, Bipolar disorder, Forced Treatment, Politics, Pregnancy, Pro-choice
Friday, September 5, 2008
The Invisible Disability
Many of us living well with invisible disability
Updated: 09/05/08 6:32 AM
by Karl Shallowhorn

It was this past January and the media was fixated on the story of Britney Spears and her alleged bout with what was described as bipolar disorder. I’d had it. Whether Spears was diagnosed or not as bipolar, this certainly was not the way that she should be treated. Why, I asked myself, do we only hear about the worst when it comes to mental illness in the news?

I have been living with bipolar disorder for 27 years. I’ve been to a variety of institutions, including the Buffalo Psychiatric Center and Erie County Medical Center. Early in my recovery, I’ve taken any number of medications, including Lithium and Mellaril, which I currently take to help control my bipolar disorder. It has by no means been an easy feat getting my disease under control.

One of the most valuable lessons I have learned on this journey is to take care of myself. I gave up drinking and drugging more than 20 years ago and took up running as a means of fitness and mood stabilization. I try to get enough sleep on a regular basis.

I also have a strong spiritual program of prayer and worship through my church. My family and close friends have been an incredibly important part of my recovery as well.

Having been free from hospitalization since 1995, I have maintained steady employment as well as a stable family life with my wife, two daughters and father, with whom we live.

Yes, life is good. Most people in my daily life are unaware of my condition, and why should they be? I am a responsible and productive member of society and I do not bring attention to the fact that my brain chemistry is different than theirs.

Just recently, I was speaking with someone I have known professionally for several years. When I disclosed that I had bipolar disorder she said, “Forgive me for saying this, but I never would have known that you were bipolar.”

So there you go. What does someone with bipolar disorder look like? Am I supposed to have a wild and freaky look, as if I’m having a manic episode? Or should I appear as though I have the weight of the world on my shoulders with no end in sight?

Yes, I have been to hell and back and have the scars to prove it. But by no means will I let the limitations of my past dictate the potential of my present, or my future.

I have learned so much about myself and my illness over the years. One of the most important is that despite how bad things can get, they can always improve. I have also learned the value of persistence. That is the one ingredient that drives motivation and provides the energy to not give up in the face of adversity.

The stigma that surrounds mental illness is stifling. This is due to the fear and misunderstanding that surrounds the disease. There is also a considerable amount of shame. Why? Considering that there are more than 4 million people in the United States living with bipolar disorder, chances are we all know someone who lives with it. What are we trying to hide?

So, the next time you are watching the news and hear another tragic story of someone whose unbalanced psyche pushed him over the edge, just remember, there are many others out there who are bravely facing their illness with courage and conviction. Chances are you encounter us every day — at work, school and in your neighborhood. That’s why it’s called an invisible disability.

Posted by Tellymonster at 10:55 PM Links to this post
Labels: Bipolar disorder, Britney Spears, Hospitalization, Lithium, Medication, Mental Illness, Myths, Support
The New Superdoc
Ok, so this may not be exciting to you all, but I am thrilled to report that I LOVE this new pdoc. Here’s the brief synopsis as to why:

-She reads a lot of stuff like I do--including stuff on color studies, aromatherapy, alternative treatments, etc.

-When I told her I wasn’t going to finish my thesis, she said that it was good for me to realize that if it was that difficult, maybe it really wasn’t what I wanted or needed. The old doc would have still been pushing me.

-She is supportive of my desire to switch careers to something animal-related. She shared a great story about a 50+ year old concert pianist who went to med school with her--because she had always wanted to be a doctor. That woman went on to practice medicine into her 80s. Very inspirational.

-When I told her that the rheumatologist thought my pain was "all in my head, " she rolled her eyes and asserted that this doc is the sort to easily dismiss women as crazy.

-She bumped up my Cymbalta (the Wellbutrin should still help with the side effects) because she didn’t want to add a new med (like Neurontin) that could throw all my other meds out of whack. I was really happy about that.

-If the Cymbalta bump doesn’t seem to make much of a difference in 6 weeks, she’s going to try to refer me to a rheumatologist that she thinks is far more thorough.

-Did I mention she is super funny and has a really good energy?

Seriously, I walked out of there yesterday feeling so good. With the old doc, I would always be dreading my sessions, trying to figure out what to talk about. Everything just sort of comes naturally with this doc. I just had to share. :)
Posted by Tellymonster at 9:07 PM Links to this post
Labels: Cymbalta, Psychiatrist, Rheumatologist, Therapy, Treatment, Wellbutrin

I am a woman diagnosed as Bipolar II. I am happily married with 3 cats, a Corgi, an Akita mix, and lots of fish. I am a home-owner with a post-graduate education (nearly) and a professional job. No children planned. A warning: I think too much. I am sarcastic, out-spoken, opinionated, and terrified of failure and completion (or, more accurately, finality). What will I talk or write about? Whatever matters to me or otherwise moves me. Life's too short to waste it on petty interpersonal conflicts or temporary discomforts. I believe there is always a time and place for silliness, outrage, and the occasional melancholy rant.
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Postby doug » Fri Dec 12, 2008 1:26 pm

Carrie Fisher and Manic Depression
(December 15, 2001) -- Perhaps one of manic-depression's best-known champions, the writer and actress shows us how she wrangles her many moods.


"HOW MANIC AM I?" ASKS Carrie Fisher as she climbs around her hillside with a potted plant. Dressed in a sleek black suit, she positions the shrub in an empty spot. "How's that?" Later, she points to a horticulture article highlighting a garden in a rainbow of color. "That's what I want." She confesses that lately, while she's writing, she looks at her garden and gets up to readjust the trees and flowers that are yet to be planted. The garden is her latest obsession.

Fisher is up-front about her manic behavior. At first glance, she doesn't seem any crazier than the rest of us. But when she pulls out her medications, you think again. All the little capsules and tablets--prescription drugs to tame her bipolar disorder--are organized in a weekly container. "Sunday, Monday, Wednesday," she mimics that famous scene from The Godfather.

She takes nearly two dozen pills a day. But recently, she blew off her daytime dosages and the result was a weeklong escapade that ended in a tattoo parlor on the west side of Los Angeles. Her manic side drives her to impulses, and as she notes, "Impulses become edicts from the Vatican." Fortunately, for her sake, two friends accompanied her. "They were concerned about me." And with good reason.

Nearly four years ago, the writer and actress suffered what she calls a "psychotic break." At the time, she was experiencing a deep depression--just getting out of bed to pick up eight-year-old daughter Billie was a major feat. She was also improperly medicated. She ended up in the hospital. There she was riveted to CNN, convinced that she was both the serial killer Andrew Cunanan as well as the police who were seeking him. "I was concerned that when he was caught, I would be caught," she recalls.

Her brother, filmmaker Todd Fisher, feared that he was going to lose her. "The doctors said she might not come back." Awake for six days and six nights, she recalls hallucinating that a beautiful golden light was coming out of her head. Yet the confusing thing about her mania, says Todd, is her ability to remain articulate, clever and funny. Todd says she launched into a Don Rickles-like diatribe, "ripping everyone who came into her room."

Ex-partner Bryan Lourd, who has remained a friend, was by her side. She said to him, "She's in the chair, she let me out. I have to talk to you. I can't take care of Billie on my own."

At the hospital, she couldn't bear seeing her mother, actress Debbie Reynolds, and asked that she not visit her. The two remain close--actually, Reynolds bought the house next door.

FISHER ROLLS AROUND ON HER BED and does somersaults. "I have to get out of here," she pleads. We hop into her station wagon and head for the San Fernando Valley. At a garden nursery, we walk up and down the footpaths looking for color. She picks up purple roses and orange star clusters. While she talks about her garden, "I want everything to be right," she is all too aware of her obsessive tendencies. Yet her mania may well be an important part of her brilliance.

The daughter of Reynolds and 1950s crooner Eddie Fisher, Carrie watched her father run off with actress Elizabeth Taylor. "An unpleasant experience," as she puts it. Although she had an absent father, she knows she resembles him in the most worrisome way. She notes that he is an undiagnosed manic-depressive, "He bought 200 suits in Hong Kong, was married six times and bankrupt four. It's crazy."

In her teens, what she wanted most was to be near her mother, so Carrie made her Broadway debut in Irene at age 15. Reynolds was the star of the show. Not long after, Fisher played the scene-stealing nymphet in the movie Shampoo, then she was immortalized as Princess Leia in that metal bikini. Her role in the classic Star Wars trilogy shot her into superstardom.

This kind of celebrity, though, comes with trappings. It was sex, drugs and late-night partying with Hollywood heavies like John Belushi and Dan Akroyd. One night, she was so high Akroyd made her eat. She choked on a Brussels sprout, so he performed the Heimlich maneuver. Then he proposed to her.

Her longtime friend, director and actor Griffin Dunne, says she made partying look fun. "Getting stoned was a part of all our lives when we were younger. Her abuse only became apparent later to me. I told her she was taking too many pills, but of course I was drunk at the time, so I wasn't making a lot of sense."

Marijuana, acid, cocaine, pharmaceuticals--she tried them all. Being on the manic side of bipolar disorder, her drug use was a way to "dial down" the manic in her. In some respects it was a form of self-medication. "Drugs made me feel more normal," she says. "They contained me."

But her addictions were serious. At her worst, she took 30 Percodan a day. "You don't even get high. It's like a job, you punch in," she recalls. "I was lying to doctors and looking through people's drawers for drugs." Such relentless abuse landed her in rehab, at age 28, after she overdosed and wound up with a tube down her throat to pump her stomach. In the end, her misadventures were recounted in her autobiographical novel, Postcards From the Edge.

Writing, her secret ambition, helped her stay focused. Postcards won her wide acclaim. Later still, she continued to gain adulation when she wrote the book's screenplay. The film version, in fact, starred friend Meryl Streep as the drug addicted heroine.

When she wrote Postcards, she says she was, "uber-involved" in her 12-step recovery and subsequent addiction support groups, but not all her issues were addressed. Her friend Richard Dreyfuss told her that she suffered from more than just drug addiction. "You don't walk down the street, it's a parade."

Dunne never thought of Fisher's problem as a mental illness. That is, until he misplaced a rug she had lent him. She was very understanding and told him not to worry. Yet, four years later, Fisher brought up the rug. "She was furious about it, as if it just happened. Then we talked a few days later and the rug was not that big a deal."

At first, Fisher may have ignored her friends, but she eventually found a psychiatrist, proper medication and a support group for manic-depressives. "When the group started talking about their medications, it was such a relief," she remembers. She has since become vocal in the struggle for mental health care. Earlier this year she lobbied for more funding to treat mental illness at the Indiana statehouse.

Fisher has two moods, Roy the manic extrovert and Pam the quiet introvert. "Roy decorated my house and Pam has to live in it," she quips. If a home is any indication of one's state of mind, then Fisher's mind is both playful and bizarre. A chandelier dangles from a tree along the driveway and signs such as "beware of trains" hang everywhere.

Her 1933 ranch style home, once owned by Bette Davis, is littered with details that reveal her comic nature. One painting in her bedroom depicts Queen Victoria tossing a dwarf. And inside a triptych in the dining room you find an effigy of Princess Leia.

Throughout the house, there are irreverent references to the Princess, but as Fisher puts it, "Leia follows me like a vague smell." Her metal bikinied space babe is perhaps one of the most downloaded images on the Web. You would think, though, that Fisher's accomplishments as a writer might have eclipsed any memories of Leia. Since she wrote Postcards, she has written two additional novels.

One, Surrender the Pink, was about her relationship with ex-husband and pop icon Paul Simon, to whom she was married for 11 months. For Fisher, his words had a certain soothing rhythm. "Except when the words are organized against you, of course." She says she really didn't fit the stereotype of wife, and as her friends put it, there were two flowers and no gardener.

Fisher is perhaps one of the more productive manic-depressives. She has script-doctored countless Hollywood films including Milk Money and Sister Act. She is even hosting a talk show for Oxygen Media. And in recent years, she has written screenplays; one for Showtime is about a manic depressive writer who ends up in a mental hospital.

From working with her, Streep found how very disciplined Fisher is. She is focused and stays on task. For Fisher, working in spurts that may coordinate with her manic highs can be a good thing. "She has wonderful, undeluded inspirations. She has told me that she is sometimes reluctant to ameliorate a productive state by dulling it with medication," says Streep.

Friend and actress Meg Ryan agrees that Fisher has some tendencies to mess with herself, but she gets herself back in line. "She manages this disease with enormous integrity. She's a great example of how to do it, and she's very serious about it. She's serious about being a good mom and a good friend."

Fisher takes her role as parent very seriously. In fact, she will not take on any projects that might compromise her time with Billie. Streep notes, "Some mothers tend to use a high-pitched voice with their children. Carrie doesn't." She speaks to her daughter like a friend.

That loyal family and friends surround her is a testament to her character. After her hospitalization, she threw a well-attended party. "I was worried about how everyone would react to me." But as always, her humor saved her. She rented an ambulance and a gurney that had a life-size cutout of Princess Leia hooked up to an IV. "She plucks out that thing that would destroy the rest of us. Then she makes fun of it," says Streep. "I'm sure it saves her."

In her own words
A chat with Carrie Fisher

Q: Many of us know you as Princess Leia, the invincible heroine of Star Wars. Are you invincible?

Carrie Fisher: No. I don't think that anybody's invincible, but I can certainly outlast things. I don't want to be thought of as a survivor because you have to continue getting involved in difficult situations to show off that particular gift, and I'm not interested in doing that anymore.

Are you saying you'd like to have some peace in your life?

I don't want peace, I just don't want war.

At what point in your life did depression or mania become evident?

I was diagnosed at 24, but I had been seeing a therapist since I was about 15. I didn't like the diagnosis. I couldn't believe the psychiatrist told me that. I just thought it was because he was lazy and didn't want to treat me. I was on drugs, too, at the time, and I don't think you can accurately diagnose bipolar disorder when someone is actively drug addicted or alcoholic. Then I overdosed at 28, at which point I began to accept the bipolar diagnosis. It was [Richard] Dreyfuss who came to the hospital and said, "You're a drug addict, but I have to tell you that I've observed this other thing in you: You're a manic-depressive." So maybe I was taking drugs to keep the monster in the box.

What happened after the hospitalization?

I spent a year in a 12-step program, really committed, because I could not believe what had happened--that I might have killed myself. During that year, I started having episodes that were very unpleasant and very intense. Someone would hurt my feelings, and I would get upset and stay upset for hours. I'd sit in my house sobbing, unable to stop, inconsolable. Sometimes I'd get very frustrated, I broke a lot of phones. This was embarrassing to me because I really didn't think of myself as temperamental and spoiled. There was a lot of shame associated with some of the behaviors that I had. I went to a doctor and told him I felt normal on acid, that I was a light bulb in a world of moths. That is what the manic state is like. He put me on lithium. I liked that for a while, but soon I missed my little pal, my up mood. I didn't fully accept the bipolar diagnosis. I thought, well, everybody's moody...maybe I'm just telling myself a story. Maybe there's no such thing. Maybe it's an exaggeration. I went to Australia to do a film. I went off the lithium, and if I was ever manic, it was then. It came back with a vengeance and it wanted to go traveling and we (me and the mood and my brother) ended up in China because it was near. I looked at a map and I thought, "It's only six inches away. That's great."

So now you're in China, totally manic, and you're off your medication.

Yes, and a lot of it was funny in the beginning. I would just go on these rambles. For example, we went to the Great Wall of China and they said, "The left side is where the Chinese people go up, and the tourist side is on the right because it's easier..." And I thought, "They're lying to me," because I knew that at Disneyland, the left side of the Matterhorn was faster than the right side. This is the kind of logic I have when I'm manic.

When did you finally accept the fact that you were suffering from bipolar disorder?

I didn't accept it fully until I had the psychotic break four years ago, in 1997. There was a lot of pressure in my life. I was still wrangling with my moods, and I was living in a house, which is a lot of responsibility. I had a child, and for her sake I was trying to act as if I hadn't been hurt by her father, who had left me for a man. I was hiding, and I am not used to doing that. I just started to feel weirder and weirder, and I think I was improperly medicated. I was intermittently on drugs at this time too. I got unbelievably depressed. My daughter was going to camp, and I would get up every day out of this bed, this swamp, and go pick her up. That was the most complicated thing in the world. I don't know how I did it. It must have been very unpleasant for her. I went to a doctor who gave me all these new medications that sounded like they came from Venus--they had no vowels in them--and something very bad happened. The medications collided, and I became very, very ill. I collapsed, I stopped breathing, and I was taken to the hospital where they sent me home and put me on a "medication vacation." I didn't sleep for six days, and I was scared. My mind split open, and some bad thing oozed out, and that's what I was left with. I thought that if I fell asleep I would die. I wasn't connecting at all, but I kept talking and talking and talking. At a certain point, I lost my mind. The birthing was over, and I got to the other side of the looking glass. When I went back to the hospital, I was hallucinating.

How long was the treatment?

I'm not sure how long I was in the hospital, but I was an outpatient for five months. Afterward, my friend Penny Marshall and I had our big annual party. All the tables had IV hookups on them with colored water, and the cake was me in bed with Penny visiting. It was performance art. It was beautiful.

How are you now?

I'm fine, but I'm bipolar. I'm on seven medications, and I take medication three times a day. !his constantly puts me in touch with the illness I have. I'm never quite allowed to be free of that for a day. It's like being a diabetic.

Do you feel at this point that the problem is under control?

No. I feel that the medication that I'm on can handle it, but I still have the impulse to ride the "white lightning" again.

Do you have a message for people who suffer with bipolar disorder?

Oh, yes. You can outlast anything. It's complicated, it's a job, but it's doable. One of the greatest things that happened for me was that psychotic episode. Having survived it, I now know the difference between a problem and an inconvenience. Bipolar disorder can be a great teacher. It's a challenge, but it can set you up to be able to do almost anything else in your life.

You do seem like Princess Leia, after all--conquering foes even darker than Darth Vader. Is there turmoil in your future?

Most likely. I would like to keep that to a minimum. But now I know how to put these things in perspective.

Treating Bipolar Disorder: Present and Future
Bipolar disorder is a long-term illness requiring long-term treatment. Mood-stabilizer medications remain the mainstay of treatment. Lithium's effectiveness has been well-established for more than 30 years, end carbamazepine end valproate have also become widely accepted first-line treatments in the past decade. In general, these medications are effective in controlling symptoms of both depression and mania or agitation.

Antidepressant medications used to treat unipolar depression are a common supplement to mood stabilizers, but may actually trigger high or manic episodes--especially if used alone. These treatments are at least moderately effective for 50 to 75 percent of bipolar disorder sufferers.

Unfortunately, these standard treatments are often ineffective or only partially effective. To address this gap, recent research has identified several promising alternatives. Newer or atypical antipsychotic medications such as olanzapine, risperidone and quetiapine appear to help control manic episodes. Several new anticonvulsant or antiepilepsy drugs such as lamotrigine, topiramate end gabapentin may also help stabilize mood when traditional medications prove ineffective. Five years from now, there should be a wider range of effective mood-stabilizer medications to choose from.

Several forms of psychotherapy or counseling have also been developed specifically for treatment of bipolar disorder. Cognitive and behavioral treatments focus on recognizing early warning signs, interrupting unrealistic thoughts and maintaining positive activities. Social rhythm therapies focus on maintaining healthy patterns of sleep, activity and social involvement, while family therapies look at the ways family interactions can either support or undermine stability and health. Recent research suggests that these treatments may be valuable treatment components, adding significant benefit to medication management.

To successfully treat bipolar disorder, persistence is key. Different treatments help different people, and individual response to a particular treatment is difficult to predict. Side effects of medication also vary widely and unpredictably, but if treatment is unsatisfactory, good options likely remain. The one common element in any successful treatment is a long-term partnership with healthcare providers.

--Gregory Simon, M.D., M.P.H.

Carrie's Biography
1956: Born to Debbie Reynolds and Eddie Fisher

1972: Broadway debut in Irene, starring her mom

1975: Attended Central School of Speech and Drama, London. Appeared in first film, Shampoo

1977: Through 1983: Appeared in the classic Star Wars film trilogy as Princess Leia

1983: Married pop icon Paul Simon, divorced after 11 months

1987: Wrote autobiographical novel, Postcards From the Edge

1990: Wrote novel Surrender the Pink, about her marriage to Simon and wrote screenplay for Postcards

1992: Gave birth to daughter, Billie Catherine

1994: Wrote novel, Delusions of Grandma

2000: Cowrote These Old Broods, starring Debbie Reynolds

Since 1980s: Appeared in films--including When Harry Met Sally as witty best friend

Since 1990s: Script-doctored films including Hook, Sister Ret, Lethal Weapon 3, Outbreak, The Wedding Singer

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