Version:                        1.0                                          
Release Date:                   8 June 1996                                  
Usenet Newsgroups:      alt.support.depression.manic (ASDM)          
                                        soc.support.depression.manic (SSDM)          
   
   Maintainers:         Barry Campbell ([email protected])          
                                http://www.concentric.net/~Btc/               
                                                                    
                                Marco Anglesio ([email protected]) 
                        http://cspo.queensu.ca/~anglesio              
                                                                    
   Archived at:                 http://www.concentric.net/~Btc/bipolar/       
                                http://cspo.queensu.ca/~anglesio/faq          
                                ftp://members.aol.com/bipolarfaq/public/      

                       DISCLAIMER AND COPYRIGHT NOTICE
                          (IMPORTANT - PLEASE READ)

The information presented in this FAQ is derived from published and unpublished sources, and from the experiences and contributions of readers of the Usenet newsgroups alt.support.depression.manic and soc.support.depression.manic.

Some of it is fact. Some of it is opinion. Some of it might well be controversial in some circles. NONE of it should be relied upon as expert opinion. This FAQ is provided as-is, without any express or implied warranties.

While we have made every effort to make it as accurate, responsible, and helpful as possible, this FAQ is NOT the place to go if you're seeking expert medical, psychological, or legal advice. The authors, maintainers, and contributors responsible for the content of this FAQ assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein.

If you have questions or concerns, contact a psychiatrist, psychologist, licensed clinical social worker, pharmacist, nurse, other qualified and licensed therapist or practitioner, or attorney, as the case may be.

This FAQ may contain short, excerpted material from texts or electronic media. Where materials are directly quoted, complete references have been cited. The Bipolar Disorders FAQ has been assembled for educational and informational purposes only, and with no intent to profit; it is distributed free of charge. No violation of U.S. copyright law is intended; all quotations are made under the "Fair Use" doctrine. All authors of quoted material retain full copyright protection.

The definitions of disorders used throughout this FAQ are those found in "Diagnostic and Statistical Manual of Mental Disorders," Fourth Edition (American Psychiatric Association, 1994). To obtain your own copy of this and other American Psychiatric Association publications in book or digital form, contact:

                 American Psychiatric Association
                 1400 K Street, NW; Suite 1101
                 Washington, DC 20005-2403
                 Phone: 1-800-368-5777 (M-F, 9 a.m.-5 p.m., EST)
                 Fax: 1-202-789-2648
                 http://www.appi.org

This FAQ may be posted to any USENET newsgroup, on-line service, or BBS, or pointed to or included on any WWW page, as long as it is posted in its entirety and includes this copyright statement.

This FAQ may not be distributed for financial gain.

This FAQ may not be included in commercial collections or compilations without express permission from the author(s).

ALL MATERIAL HEREIN NOT EXPRESSLY COVERED BY OTHER COPYRIGHT NOTICES IS COPYRIGHT 1996, ALL RIGHTS RESERVED, UNDER UNITED STATES LAW AND THE BERNE CONVENTION BY THE PRIMARY MAINTAINER, BARRY CAMPBELL ([email protected]). THE AUTHOR OF ALL UNATTRIBUTED MATERIAL FOR PURPOSES OF THE BERNE CONVENTION IS BARRY CAMPBELL. THIS FAQ MAY NOT BE USED OR REPRODUCED IN CD-ROM COLLECTIONS, PRINTED REPRODUCTIONS, OR ANY OTHER MEDIA FORMAT WITHOUT EXPRESS WRITTEN PERMISSION.

TABLE OF CONTENTS

1.0 Introduction and Acknowledgments to Contributors 2.0 Revision history and archive locations 3.0 Definitions (DSM-IV and "Extended") 3.1 What is Bipolar Disorder?
3.2 What is Depression?
3.3 What is Mania?
3.4 What is Hypomania?
3.5 What is the difference between euphoria and dysphoria? 3.6 What is a Mixed State?
3.7 What is Rapid Cycling?
3.8 What are delusions and hallucinations? 3.9 How do you tell unipolar depression and bipolar

disorder apart?
3.10 What is Cyclothymia?
3.11 What is Dysthymic Disorder?
3.12 What is Schizoaffective Disorder? 3.13 What is Seasonal Affective Disorder? 3.14 How do I distinguish between and among all of

these disorders?
4.0 How can I best take care of myself? 4.1 How can I assess my own mental status?

     (Includes: The Goldberg Depression and Mania
     Self-Rating Scales)

4.2 What treatment options are available? 4.3 How do I find a good health care provider? 4.4 What medications are commonly used in treatment? 4.5 What "alternative" therapies exist, and are they

any good?
4.6 How do I pay for all this? (Insurance-related

issues.)
4.7 What are my rights as a patient?
4.8 What are my rights as a person with Bipolar Affective

Disorder?
4.9 How can I tell my (friends, family, coworkers)? Should I? 4.10 Resource organizations
5.0 How do I help a friend or loved one? 5.1 What to do (and what not to do) when someone you care

about is diagnosed
5.2 What to do (and what not to do) if you suspect that

     someone you care about needs help, but resists
     seeking it for themselves.

6.0 Resources for education and support 6.1 Internet Resources
6.2 Books
6.3 Magazine and Journal Articles
7.0 Controversial Issues - making sense of them 7.1 To drug, or not to drug?
7.2 Should I participate in a study or other

research program?
7.3 How do I evaluate "alternative" therapies? 7.4 The Psychiatric Survivors' Movement 7.5 Critics of Psychiatry and Psychology 8.0 Is there life (and hope) after diagnosis? 8.1 Coping hints from readers and participants 8.2 Research trends and directions

The Bipolar Disorder FAQ is based largely on the FAQ from the Usenet newsgroup alt.support.depression.manic. The alt.support.depression.manic FAQ was originated and maintained until recently by PsyberNut/Bipolar Bear/Scott ([email protected]), and this FAQ document contains much of his original work, essentially unmodified; in particular, the "more complete list of symptoms" sections are his writing. We gratefully acknowledge our enormous debt to Scott, and wish him the very best.

Many readers of alt.support.depression.manic (ASDM) and soc.support.depression.manic (SSDM) have contributed directly and indirectly to the development of this FAQ; many more have read it and offered comments and criticism. So have readers and contributors to the PENDULUM mailing list.

A few contributors, in particular, must be singled out for their extraordinary contributions. Thanks to:

Joy Ikelman ([email protected]), who allowed us to ransack her "Media File," an excellent resource for finding mood disorder information and references in print. Joy also completely rewrote and updated the "definitions" section of the FAQ, based on DSM-IV, and read early drafts, giving many helpful editorial criticisms along the way.

Millie Niss ([email protected]), for her well-researched contributions to the Drug Therapy section of the FAQ.

Dr. Ivan K. Goldberg, M.D ([email protected]) for his permission to reproduce the Goldberg Depression and Mania Scales.

This is Version 1.0 of the Bipolar Disorder FAQ, released 8 June 1996.

This FAQ is posted periodically to the Usenet newsgroups alt.support.depression.manic and soc.support.depression.manic.

The current version of the Bipolar Disorder FAQ may always be found on the World Wide Web at: http://www.concentric.net/~Btc/bipolar/ (in the US) and http://cspo.queensu.ca/~anglesio/faq (in Canada)

We're always looking for folks who are willing to locate the FAQ for us in their own countries. The Web IS international by definition, but it's always nicer to hit a nearby server if you can. :-) It is also available via anonymous FTP from ftp://members.aol.com/bipolarfaq/public/

There are many different mood disorders, and discussing them all thoroughly is beyond the scope of this FAQ.

This FAQ focuses on the mood disorders which tend to be characterized by "mood swings": alternating cycles of abnormally depressed and elevated (manic) moods. You're up, you're down, you're up, you're down, you're up... and some (or most) of the time, you're in the middle, trying to figure out what happened.

While reading these definitions, it may be useful to think of Bipolar Disorder and related disorders as existing along a continuum of "affects," or moods.

Bipolar Disorder is the medical name for Manic Depression; at various times, it has also been known as Bipolar Affective Disorder and Manic-Depressive Illness. It is a mood disorder that affects approximately 1% of the adult population of the United States--and roughly the same percentage in other countries, as far as we know. :-)

It's in the same family of illnesses (called "affective disorders") as clinical depression. However, unlike clinical depression, which seems to affect far more women than men, Bipolar Disorder seems to affect men and women in approximately equal numbers.

It's characterized by mood swings. Though there is no known cure, most forms of bipolar disorder are eminently treatable with medication and supportive psychotherapy.

The textbook definition of Bipolar Disorder is: one or more Manic or Hypomanic Episodes, accompanied by one or more Major Depressive Episodes. These episodes typically happen in cycles.

All of these terms will be defined at greater length below...but in plain English, a person who has Bipolar Disorder will be severely up some of the time, severely down some of the time, and in the middle some or most of the time.

There are two main types of Bipolar Disorder:

• Bipolar I is the "classic" form of Bipolar Disorder. It most often involves widely spaced, long-lasting bouts of mania followed by long-lasting bouts of depression and vice-versa. However, the essential definition is depression plus mania, or "mixed states."
• Bipolar II involves at least one Hypomanic Episode and one Major Depressive Episode, but never either a full-blown Manic Episode or Cyclothymia. The essential definition is depression plus hypomania.

Although the shifts from one state to another are usually gradual, they can be quite sudden. The "rapid-cycling" form of the disorder involves four or more complete mood cycles within a year's time, and some rapid-cyclers can complete a mood cycle in a matter of days--or, more rarely, in hours.

It is also possible for someone who has Bipolar Disorder to be in a "mixed state." This means that they're in a mood state which has some characteristics of depression and some of mania or hypomania.

There are a few rare documented cases of mania without depression, but DSM-IV does not currently include a category for just "mania". (This diagnosis was present in DSM-III, but is unaccountably absent in DSM-IV!)

Using DSM-IV, a person exhibiting the symptoms of mania will almost always be diagnosed as bipolar. The general feeling in the mental health community seems to be that what or whom goes up, must eventually come down.

The DSM-IV and "extended" definitions of depression and mania are presented in the sections that follow. It is very important to remember the following:

• These definitions are not a guide for self-diagnosis!
• One does not need to exhibit *all* of the symptoms of depression to be depressed, nor does one need to display *all* of the symptoms of mania to be manic.

Criteria for Major Depressive Episode (DSM-IV, p. 327)

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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

E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Well, the APA gives us a good starting point, but it all sounds sort of clinical. Here's a more complete list of symptoms of depression that our readers and participants have identified:

• Reduced interest in activities (like writing FAQs)
• Indecisiveness (maybe)
• Feeling sad, unhappy, or blue (pervasive attitude that life sucks)
• Irritability, dammit.
• Getting too much (hypersomnia) or too little (insomnia) sleep.
• Loss of, um, what were we talking about? Oh yeah, concentration.
• Increased or decreased appetite (my ex-mother-in-law's cooking notwithstanding)
• Loss of self-esteem, such as my understanding that I suck.
• Decreased sexual desire.
• Problems with, whaddya call it? Oh yeah, memory.
• Despair and hopelessness
• Suicidal thoughts.
• Reduced pleasurable feelings.
• Guilt feelings, which are all my fault anyway.
• Crying uncontrollably and/or for no apparent reason.
• Feeling helpless, which I can't do anything about.
• Restlessness, especially when I can't hold still.
• Feeling disorganized (hell, look at my desk).
• Difficulty doing things (again, like finishing this FAQ)
• Lack of energy and feeling tired.
• Self-critical thoughts
• Moving and thinking slooooooowwwwwwwly.
• Feeling that one is in a stupor, or that one's head is in a fog.
• Speeeeeeeakiiinnnnng slooooooowwwwwwwly.
• Emotional and/or physical pain.
• Hypochondriacal worries; fears or illnesses which prove to be psychosomatic.
• Feeling dead or detached.
• Delusions of guilt or of financial poverty.
• Hallucinating.

Criteria for Manic Episode (DSM-IV, p. 332)

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
2. 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:

(1) inflated self-esteem or grandiosity

(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3) more talkative than usual or pressure to keep talking

(4) flight of ideas or subjective experience that thoughts are racing

(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7) 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 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 treatments) or a general medical condition (e.g., hyperthyroidism).

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.

Again, the APA gives us a good starting point for studying mania, but the language is awfully clinical. Here's a plain-English version, with some extensions:

• Decreased need for sleep.
• Restlessness.
• Feeling full of energy.
• Distractibility (what was that?)
• Increased talkativeness (or increased typeativeness)
• Creative thinking.
• Increase in activities.
• Feelings of elation.
• Laughing inappropriately
• Inappropriate humor.
• Speeded up thinking.
• Rapid, pressured speech, that you can teach, eating a peach, while on a beach.
• Impaired judgment
• Increased religious thinking or beliefs.
• Feelings of exhilaration.
• Racing thoughts, which can't be taught, and can't be bought, although they ought, you might get caught.
• Irritability (dammit, there it is again!)
• Excitability.
• Inappropriate behaviors.
• Impulsive behaviors.
• Increased sexuality (also known as "platoon-of-Marines-onshore -leave syndrome")... or
• "clang associations" (the association of words based on their sound, a possible reason so many poets are bipolar, also why we have pun fun)
  • _decreased_ interest in sex, or any other interpersonal

    relationships, due to obsessive interest in some other subject or activity

• Inflated self-esteem (so prove I'm NOT the world's leading authority!)
• Financial extravagance.
• Grandiose thinking.
• Heightened perceptions.
• Bizarre hallucinations.
• Disorientation.
• Disjointed thinking.
• Incoherent speech.
• Paranoia, delusions of being persecuted.
• Violent behavior, hostility
• Severe insomnia
• Profound weight loss
• Exhaustion

Hypomania means, literally, "mild mania."

It's sometimes difficult to draw a distinct line between "manic" and "hypomanic," as "marked impairment" is a necessarily subjective evaluation.

Also, one of the reasons that bipolar disorder often has a delayed diagnosis may be that hypomanic episodes are often overlooked amid the "Sturm und Drang" of adolescense and early adulthood.

The associated features of mania are present in Hypomanic Episodes, except that delusions are never present and all other symptoms are *generally* less severe than they would be in Manic Episodes.

Criteria for Hypomanic Episode (DSM-IV, p. 338)

1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
2. 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:

(1) inflated self-esteem or grandiosity

(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3) more talkative than usual or pressure to keep talking

(4) flight of ideas or subjective experience that thoughts are racing

(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7) 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 episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F. 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., hyperthyroidism).

Note: Hypomanic-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 II Disorder.

There are two basic types of mania (or hypomania): euphoric and dysphoric.

A person can experience both types when they have bipolar disorder.

In euphoria, a person is high, in love with the world, one with the world, feeling boundless energy, talking a mile a minute, mind is racing, deluded with grandiose thoughts, etc. This kind of mania is generally the kind described in the popular literature.

Dysphoria is another type of mania. In dysphoria one is "high" but in a different sense: agitated, destructive, full of rage, talking a mile a minute, mind racing, deluded with grandiose thoughts, paranoid, full of anxiety, panic-stricken.

In addition, dysphoria can also come into the depressive side. These are often referred to as "mixed episodes." Mixed episodes are quite dangerous; suicidal ideation often accompanies this state.

What's the difference between agitated depression and dysphoric (hypo)mania?

Dr. Ivan Goldberg ([email protected]) explains: "While folks in an agitated depression show increased motor activity, they never show increased sociability, increased creative thinking, joking and punning that may be seen in someone experiencing a dysphoric (hypo)manic state."

Criteria for Mixed Episode (DSM-IV, p. 335)

1. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
2. 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.
3. 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., hyperthyroidism).

Comment: This may be an instance in which the DSM-IV definition is a bit too narrow. Many readers and participants in ASDM and SSDM report experiencing mixed states with hypomanic, but not fully manic, features.

The "rapid-cycling" form of Bipolar Disorder involves four or more complete mood cycles within a year's time, and some rapid-cyclers can complete a mood cycle in a matter of days--or, more rarely, in hours. Studies show that women are more likely than men to be diagnosed as rapid-cyclers.

• What are delusions?

Delusions are, in general, "false beliefs." The DSM-IV (p. 763) defines a delusion as:

     A false belief based on incorrect inference about external
     reality that is firmly sustained despite what almost
     everyone else believes and despite what constitutes
     incontrovertible and obvious proof or evidence to the
     contrary.

People who are in a manic or depressed episode may have delusions. Some of these might include delusions of reference, where the individual feels like events, objects, or other persons have a particular and unusual significance. The individual may also have grandiose delusions or delusions of persecution (such as paranoia).

It's important to note that delusions must be diagnosed in terms of cultural, social, and religious norms. A belief that one is in direct communication with God, for example, might be either a delusion or an expression of certain kinds of religious faith. :-)

• Can people with bipolar disorder have hallucinations?

Most certainly. The DSM-IV (p. 766) defines a hallucination as:

     A sensory perception that has the compelling sense of
     reality of a true perception but that occurs without
     external stimulation of the relevant sensory organ.
     Hallucinations should be distinguished from illusions, in
     which an actual external stimulus is misperceived or
     misinterpreted.

Some people know that they are having hallucinations, and others do not. Most people who have bipolar disorder realize that the hallucinations are not actual perceptions of reality. However, this realization does not keep them from occurring.

• What kind of hallucinations are there?

Hallucinations may occur in any of the senses: auditory (for example, hearing voices or music), gustatory (for example, unpleasant tastes), olfactory (for example, unpleasant smells), somatic (for example, a feeling of "electricity"), tactile (for example, a sensation of being touched, or "skin crawling" sensations), visual (for example, flashes of light, colors, images on the periphery).

disorder apart?

If the person in question is known to have had even a single Manic or Hypomanic Episode, then there is virtually no question; the diagnosis is a form of bipolar disorder (or, in the case of hypomania, possibly cyclothymia.)

If the person in question is currently depressed, and his or her history is not known, or is incomplete, the following guidelines by Dr. Ivan Goldberg may prove to be useful:

      The things that make me suspect bipolarity in a patient
      diagnosed as unipolar are:

      - oversleeping when depressed

      - overeating when depressed

      - a history of bipolarity in the family

      - a patient who when depressed can still joke and laugh

      - anyone with a history of frequent depressive episodes
        (rapidly cycling unipolar disorder)

      - success as a salesperson, politician, or actor  (in school
        or real world)

      - extreme rejection sensitivity

      - a history of having ever been diagnosed as bipolar or given
        lithium (except to potentiate antidepressants)

Of course, a unipolar patient can still sleep too much, unipolar depression or bipolar disorder can surface earlier or later in life, and so on. These are guidelines, not hard-and-fast rules.

Diagnostic Criteria for Cyclothymic Disorder (DSM-IV, p. 365)

1. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet criteria for a Major Depressive Episode. Note: In children and adolescents, the duration must be at least 1 year.
2. During the above 2-year period (1 year in children and adolescents), the person has not been without the symptoms in Criterion A for more than 2 months at a time.
3. No Major Depressive Episode, Manic Episode, or Mixed Episode has been present during the first 2 years of the disturbance.

Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may be superimposed Manic or Mixed Episodes (in which case both Bipolar I Disorder and Cyclothymic Disorder may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II Disorder and Cyclothymic Disorder may be diagnosed).

D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

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., hyperthyroidism).

F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• 3.11 What is Dysthymic Disorder?

• Section under construction - BC *

  ---

  • 3.12 What is Schizoaffective Disorder?

• Section under construction - BC *

  ---

  • 3.13 What is Seasonal Affective Disorder?

• Section under construction - BC *

  ---

  • 3.14 How do I distinguish between and among all of

    these disorders?

• Section under construction - BC *

  ---

If you've been diagnosed with a form of bipolar disorder, you'll probably find no shortage of people (doctors, family members, members of support groups) offering advice, whether you ask for it or not. :-)

And now here we are, getting in line behind all of those people.

The advice we're presenting here is GENERAL. Everyone with this illness is a unique individual, and individuals respond in unique and sometimes unexpected ways; use your best judgment and common sense about whether this advice is right for you.

That being said:

The most important general guideline for self-care is to establish a sound therapeutic relationship with one or more doctors: a psychiatrist or psychopharmacologist for drug therapy, and, if you prefer not to use this person for more traditional forms of therapy but want a professional to talk to, a psychologist, licensed clinical social worker, or similar licensed counselor.

Bipolar Disorder is a lifelong, chronic medical condition. It cannot be cured, but it can in almost all cases be managed to at least some extent.

Some more general guidelines, which mostly fall into the category of common sense but bear repeating (and please note that these are GENERAL statements, and that everyone is an individual--your mileage may vary!):

• Take responsibility for your own well-being.

You can have the finest medical team in the world working on "your case," but if you don't first accept that you *have* a chronic medical condition and take responsibility for doing what it takes to manage it, you're wasting time and money. Obviously, if you're in the throes of an incapacitating depression or mania, this can be hard if not impossible to do, and someone else may (temporarily) need to make these sorts of decisions for you; also, people respond in different ways to various kinds of medication and therapy.

But in general, remember: you're the boss, you're the one calling the shots and deciding which resources to utilize (or not.)

The key thing to remember is that there's a LOT of help out there if you want to get things under control--but you have to decide to seek it out, and you have to decide that you will commit to a healthy course of action.

• Work with your doctors, not against them--and insist that they work with you.

It's vitally important that you be able to communicate with the doctors and health-care professionals that you choose to use as resources.

If you're not comfortable talking with someone, or if they don't listen to you, look for another therapeutic relationship. Period. It's *vital* that you and your doctor(s) listen to and respect each other.

• Develop a survival mentality.

A few of us who start medical treatment for Bipolar Disorder are pretty much asymptomatic afterwards--in other words, we never, ever have another flare-up. A few of us don't seem to respond satisfactorily to ANYTHING we try. Almost all of us fall somewhere in-between-- we get some measure of control over our bipolar disorder, but we still experiences ups and downs, and still have tough times that must be endured.

A "survival mentality" means, first of all, deciding that there's life after diagnosis. Getting the news that you have a medical condition that you'll be dealing with (in all probability) for the rest of your life can be a major shock to the system! Recognize that there are literally *millions* of people around the world dealing with this disorder; you're not alone, and there are many resources available to help you cope.

Second of all, it means that when times DO get tough, you do what it takes to get through it. In extreme cases, this may involve voluntarily checking yourself in to a hospital under a doctor's care. This isn't an experience that most people would seek out for themselves, but when things get badly out of hand, it can literally be a lifesaver.

Remember: your first goal is to *survive*--to take care of yourself. Your secondary goal might be to contribute as much as you can to the lives of your friends, family, loved ones, co-workers, etc... or it might be something else entirely.

But if you don't take care of the first goal, the other ones are utterly meaningless.

• Become aware of your mood states.

At first glance, this seems like a really stupid thing to say. If you're depressed, you know damn well that you feel awful... though you may not identify "depression" as the cause at the time. Hypomania and mania can be harder to recognize when it's happening to you, but as you gain more experience in dealing with this disorder, you'll become more sensitized to your moods and their cycles.

If you become more aware and conscious of your mood states, however, you may find that you can spot trends earlier and head off potential problems.

Many bipolar folks chart their moods on a calendar or in a diary; this helps them understand their cycles better, and can also provide important clues about possible environmental stimuli that might either be causing problems or giving relief. For instance, if you note that your mood is generally better for a day or two after you work out vigorously, you might want to consider making exercise a regular part of your coping strategy... or if you notice that you feel especially depressed after a certain activity or eating/drinking certain foods or beverages, you might consider limiting that sort of thing.

One simple way to do this is to choose some kind of arbitrary numeric scale... let's say that "1" is severe depression, "5" is "normal," whatever that means, and "10" is severe mania. Something as simple as jotting down a number reflecting your own assessment of your mood state *at roughly the same time every day* can give you very important information about the length and quality of your mood cycles.

Also, many folks establish "contracts" with trusted friends or family members--they work out ways in which the trusted outside observer can communicate to them, in a friendly, loving, and nonthreatening way, that they think that you are becoming depressed or (hypo)manic.

Finally, remember that even though you have a mood disorder, you're almost certainly still prone to everyday, ordinary moodiness! If you wake up in the morning feeling bad, it might be a precursor to a serious depression, or you might just be having a bad hair day. If you wake up feeling on top of the world, you might be getting (hypo)manic, or you might just be having, um, a good hair day. ;-) Watch the overall *trends* over time, and try not to watch yourself under a microscope and obsess over the tiny details. ;-)

• Structure your life to the extent possible.

Without becoming fanatical about it, many bipolar folks find that sticking to as regular a schedule as possible of eating, sleeping, working, and so forth is helpful in stabilizing their moods. Sleep deprivation can DEFINITELY precipitate (hypo)mania, for one thing.

• Educate yourself about this illness.

Ignorance and fear are the Big Enemies. Educate yourself about your condition. At a minimum, know what your diagnosis is and what the symptoms are, and know what meds you're taking and what the side-effects are likely to be.

• Exercise regularly and vigorously, if you're physically able.

Many readers and participants in ASDM and SSDM say that regular exercise really helps them stay on an even keel.

• Avoid artificial stimulants and depressants.

Some bipolar folks tolerate caffeine (stimulant) and alcohol (depressant) just fine in moderation--though both substances can potentially interact in nasty ways with commonly used medications, alcohol especially.

Some folks find that they need to avoid these substances entirely.

If you ARE going to drink espresso and Scotch (hopefully not at the same time!) make sure that your doctor(s) know(s) about it, and that you're not setting yourself up for a nasty drug interaction...

...and remember that moderation, as in so many things, is key, and abstinence might very well be the best choice.

• Enlist the support of family and friends.

The importance of having a good support structure cannot be overemphasized.

Sadly, sometimes friends and family members can't handle the idea of a loved one with a "mental illness." This is usually ignorance and fear talking, and often these people can be educated and brought around.

If there are people that you can really trust and talk to, let them know about what's going on with you.

• Join a support group.

Check the "Resources" section of the FAQ for information on how to find a "real-world" support group near you... but don't neglect the many online support groups that are available. :-)

Q: How can I tell if I am depressed or just in a bad mood?

1. Frequently, it is more obvious to those around us that we are depressed than it is to ourselves. Distorted judgment is part of having a mood disorder, so it is not uncommon for our family and friends to recognize signs before we do.

This section and the next involve the Goldberg Mood Scales, by Dr. Ivan K. Goldberg, M.D. They are reprinted with his permission.

The scales ARE NOT designed to diagnose any psychiatric disorder, nor are they intended to replace evaluation by a qualified psychiatrist. They are only intended to measure the severity of depressive and/or manic symptoms, and thus to help the reader decide whether to seek a psychiatric evaluation.

The Goldberg Depression Scale, below, is a self-administered questionnaire designed to measure the severity of depressive thinking and behavior.

Goldberg Depression Scale

Name______________________________________ Date__________________________

The items below refer to how you have felt and behaved DURING THE PAST WEEK. For each item, indicate the extent to which it is true, by circling one of the numbers that follows it. Using the following scale:

0 = Not at all 1 = Just a little 2 = Somewhat

3 = Moderately 4 = Quite a lot 5 = Very much

1. I do things slowly. 0 1 2 3 4 5
2. My future seems hopeless. 0 1 2 3 4 5
3. It is hard for me to concentrate on reading. 0 1 2 3 4 5
4. The pleasure and joy has gone out of my life. 0 1 2 3 4 5
5. I have difficulty making decisions. 0 1 2 3 4 5
6. I have lost interest in aspects of life that used to be important to me. 0 1 2 3 4 5
7. I feel sad, blue, and unhappy. 0 1 2 3 4 5
8. I am agitated and keep moving around. 0 1 2 3 4 5
9. I feel fatigued. 0 1 2 3 4 5
10. It takes great effort for me to do simple things. 0 1 2 3 4 5
11. I feel that I am a guilty person who deserves to be punished. 0 1 2 3 4 5
12. I feel like a failure. 0 1 2 3 4 5
13. I feel lifeless - - - more dead than alive. 0 1 2 3 4 5
14. My sleep has been disturbed---too little, too much, or broken sleep. 0 1 2 3 4 5
15. I spend time thinking about HOW I might kill myself. ~~~ 0 1 2 3 4 5
16. I feel trapped or caught. 0 1 2 3 4 5
17. I feel depressed even when good things happen to me. 0 1 2 3 4 5
18. Without trying to diet, I have lost, or gained, weight. 0 1 2 3 4 5

A score of 15 or higher on the depression scale indicates the possible need for a psychiatric evaluation.

Copyright (c) 1993 Ivan Goldberg

Q: How can I tell if I am manic or just unusually cheerful?

1. Much like depression, it is frequently more obvious to those around us that we are becoming manic or hypomanic than it is to us. Impaired judgment is every bit as much a part of mania as it is a part of depression, and it is not uncommon for someone on a manic upswing to think they simply feel so good because the damn depression is finally over. Family and friends can usually tell the difference quite easily, although convincing the manic subject of his/her mania can be quite a different matter.

This section, like the last, involves one of the Goldberg Mood Scales by Dr. Ivan K. Goldberg, M.D. Again, the scales ARE NOT designed to diagnose any psychiatric disorder, nor are they intended to replace evaluation by a qualified psychiatrist. They are only intended to measure the severity of depressive and/or manic symptoms, and thus to help the reader decide whether to seek a psychiatric evaluation.

The Goldberg Mania Scale, below, is a self-administered questionnaire designed to measure the severity of manic thinking and behavior.

Goldberg Mania Scale

Name_________________________________________ Date_______________________

The items below refer to how you have felt and behaved DURING THE PAST WEEK. For each item, indicate the extent to which it is true, by circling one of the numbers that follows it. Using the following scale:

0 = Not at all 1 = Just a little 2 = Somewhat

3 = Moderately 4 = Quite a lot 5 = Very much

1. My mind has never been sharper. 0 1 2 3 4 5
2. I need less sleep than usual. 0 1 2 3 4 5
3. I have so many plans and new ideas that it is hard for me to work. 0 1 2 3 4 5
4. I feel a pressure to talk and talk. 0 1 2 3 4 5
5. I have been particularly happy. 0 1 2 3 4 5
6. I have been more active than usual. 0 1 2 3 4 5
7. I talk so fast that people have a hard time keeping up with me. 0 1 2 3 4 5
8. I have more new ideas than I can handle. 0 1 2 3 4 5
9. I have been irritable. 0 1 2 3 4 5
10. It's easy for me to think of jokes and funny stories. 0 1 2 3 4 5
11. I have been feeling like "the life of the party." 0 1 2 3 4 5
12. I have been full of energy. 0 1 2 3 4 5
13. I have been thinking about sex. 0 1 2 3 4 5
14. I have been feeling particularly playful. 0 1 2 3 4 5
15. I have special plans for the world. 0 1 2 3 4 5
16. I have been spending too much money. 0 1 2 3 4 5
17. My attention keeps jumping from one idea to another. 0 1 2 3 4 5
18. I find it hard to slow down and stay in one place. 0 1 2 3 4 5

A score of 20 or higher on the mania scale suggests the possible need for an evaluation by a qualified psychiatrist.

Copyright (c) 1993 Ivan Goldberg

• 4.2 What treatment options are available?

• Section under construction - BC *

  ---

  • 4.3 How do I find a good health care provider?

• Section under construction - BC *

  ---

First, we'll lead off this section with an excellent introduction, written by Joy Ikelman ([email protected]), with additions by Dr. Ivan Goldberg ([email protected]):

Ten Little Things I Have Learned About Drug Therapy

(1) We believe what we want to believe (about this topic or any topic).

(2) We bipolars know how it feels to be on these drugs--despite what the docs might say about how we "should" feel. Side effects are often more complex and difficult than the drug companies/PDR say they are.

(3) We bipolars know that the cycles sometimes break through despite the best of drug therapies--even though docs say we "should" be completely stable on this stuff. A lot of the time we just keep quiet when these breakthrough episodes happen or else the doc might raise our dose or hospitalize us. (See Item 2.)

(4) We all hope to be the lucky ones in this crap shoot of drug therapy. Initially, we are optimistic. Maybe if we get just the right combination of drugs, just the right dosage, just the right psychopharmacologist, just the right attitude....something, something might just work....

(5) There are some combinations which work better than others. These should be tried first.

(6) However, there is no magic formula which works perfectly for everyone. It's mostly hit and miss. So, if something works, stick with it.

(7) And, after we find the right combo it may work wonderfully well for 30+ years, or sometimes after a few years it doesn't work any more and the search resumes for another combo that will work. We hope that by then something new and very effective will be available.

(8) Manic depression does not have a "cure." The mood stabilizing drugs are a way to cope with the illness. Take the accustomed drugs away and for most folks, the cycles come back full force, sometimes worse.

(9) We all have different ideas of what we will settle for, as a result of drug therapy. Some will settle for nothing less than the elimination of all cycling. Some will settle for a little cycling and learn to cope with it in different ways. Some will settle for quite a bit of cycling, as long as the manias aren't too high or the depressions too low.

(10) Drug therapy is a choice. The most important thing is stay alive and possibly make some contribution to the few people you interact with in your lifetime. Whatever it takes to stay alive (drugs or not), do it.

Now, on to a more general discussion of the meds. Thanks to Millie Niss ([email protected]) for researching and writing the following information:

There are three types of medications commonly used in treating Bipolar Disorder:

• mood stabilizers
• antidepressants, and
• antipsychotics.

Other medications may be given to help you sleep or to treat anxiety and/or panic attacks if you have them.

Because many people need a combination of two or three drugs to get stable, it can take quite some time to find the right medications (and the right dosages of each.) This is usually on the order of magnitude of weeks or months... but it's been known to take *years* to find the exact combination and dosages that work.

If the first medication you get does not help, it *does not mean* you are untreatable! Work with your doctor and make sure that he or she is listening to you, and don't give up!

Some drugs can potentially cause relatively severe side-effects. Don't hesitate to complain to your doctor and insist on lowering dosages or trying a new drug if the side-effects are intolerable.

In particular, mood stabilizers and antipsychotics in high doses can make you very tired and slowed down and "zombie-like."

Don't accept this as a "necessary" condition of getting well!

Sometimes, as with any drug, you will have to choose between total elimination of symptoms and a tolerable level of side-effects; the key thing is to *communicate* with your doctor about what you're experiencing, and make sure that you know all your options.

(That being said, many people do quite well on lithium, or lithium plus an antidepressant.)

We're listing potential side-effects below, as we discuss each drug. Our objective here is not to frighten, but to inform and share experiences. Everyone is different; some people will take these meds and experience no side effects; some people will experience side effects that aren't listed here.

*Communicate* with your doctor, your pharmacist, and the other members of your health-care team about what's going on with you and your meds.

Mood Stabilizers

Mood stabilizers are the primary treatment for most people. They are supposed to level your moods, so that you neither get too low (depressed) or too high (manic). In practice, they work much better at treating mania than depression, and may have a mood-dampening effect, so that you get more depressed on a mood stabilizer than you were before. For this reason, some people are now calling these drugs "antimanics."

Mood stabilizers take a week or two to get a therapeutic blood level and then it may take a few more weeks to get the full effect of the drug. In acute situations, another drug may be needed while you wait for the mood stabilizer to take effect.

The most common mood stabilizers are:

Lithium (Eskalith, Lithane, Lithobid, Lithonate, Lithotabs)

        This is the oldest and most common mood
        stabilizer and is usually the first drug you will get
        when diagnosed with bipolar disorder.  It tends to be
        fairly easy to tolerate for most people, and stabilizes
        50-60% of patients all by itself.

        Common side-effects are: lethargy, diarrhea, nausea,
        frequent urination, tremor, weight gain.

        Symptoms of lithium toxicity are: intense versions of
        the above, twitching, shaking, dizziness, loss of balance,
        thirstiness, blurred vision, confusion, convulsions.

        Note: if you cannot tolerate the side-effects of regular
        lithium, you may want to try a time-released form of it,
        such as Lithobid.

        It is very important to get frequent blood tests when
        first starting lithium because the therapeutic blood
        level is quite close to the toxic level.  After dosage
        is established, blood tests can be every six months.
        It is also a good idea to check liver and thyroid function
        because these can be damaged by long-term lithium use.

The other mood stabilizers are anticonvulsants, used primarily to treat epilepsy but also effective in the treatment of Bipolar Disorder:

Valproic Acid (Depakote, Depakene, Epival)

        Side effects are similar to lithium, long term toxicity may
        be less severe.  Some people find that Depakote gives them
        depression, or intensifies existent depression.  It can also
        cause sexual dysfunctions (anorgasmia, premature ejaculation,
        retrograde ejaculation, reduction of libido) in both men
        and women.

        Carbamazepine (Tegretol)
        ------------------------

        Tegretol is another anti-convulsant.

        Side effects of Tegretol are generally more severe than for
        lithium or Depakote, but some patients who cannot tolerate
        lithium do fine on Tegretol.  Tegretol is also especially
        effective for rapid cyclers.

        Side effects: nausea, dizziness, confusion, cognitive slowing,
        loss of coordination, tremor, sores in mouth & gums,
        *reduction in effectiveness of birth control pills.*

Other anticonvulsants are now being used as mood stabilizers experimentally. Also, Klonopin (an anti-anxiety drug which is also an anti-convulsant) may be used as a mood stabilizer.

Some people with mood swings who don't actually get fully manic may get stabilized on an antidepressant alone. (See WARNING below, however.)

Antidepressants

Antidepressants (ADs) are part of most people's treatment if their disease includes severe depression. However, they must be used cautiously by bipolars. Although ADs normally do not cause folks to get high even when taken in larger doses than needed, for a significant number of bipolars ADs can cause mania or hypomania and/or may trigger rapid cycling. This is most frequently reported with the older tricyclic ADs (like nortriptylene) and apparently least likely to occur with the AD Wellbutrin. Usually these undesirable effects can be avoided by using an "AD + mood stabilizer" combo, but even this does not eliminate the risk entirely. Any bipolar starting on an antidepressant should monitor their moods carefully and stay in close contact with their physician until it is clear that these effects do not appear or appear only to a degree that is acceptable.

Antidepressants can take a really long time to work--six weeks or more-- and then it may take a while to find the AD which works for you, so the hardest part about ADs is often the waiting!

Antidepressants come in several flavors:

SSRIs

"SSRI" means Selective Serotonin Reuptake Inhibitor.

        These are the newest class of ADs and tend to be the first
        drugs used these days, although there is no evidence that they
        work better than tricyclics or MAOIs.

        The SSRIs are:  Prozac, Paxil, Zoloft, Luvox, Effexor (partly)

        Side effects are: dry mouth, tremor, nausea, insomnia,
        drowsiness, anxiety, hypomania, sexual dysfunction.

        The SSRIs can cause rather extreme side-effects if they make
        you manic (or induce rapid cycling), but they are not very
        toxic so they are safest to use with a suicidal patient.

        Tricyclics
        ----------

        Common tricyclics include: Norpramin (desipramine),
        amitriptylene, nortriptylene, Sinequan, Elavil, Anafranil,
        Doxepin.

        The side-effects are the same as for SSRIs--supposedly more
        severe, but your mileage may vary.

        The tricyclics are generally more sedating than the SSRIs,
        and are often used as sleeping pills.  They also tend to
        cause weight gain.

        Tricyclics are quite toxic in overdose, and there is a danger
        of accidental overdose, especially when used as a sleeping
        pill "as needed."

        MAOIs
        -----

        "MAOI" = "Monoamine Oxidase Inhibitor."

        Common MAOIs are: Nardil (phenelezine) and Parnate.

        Side effects: Same as above, weight gain.

        MAOIs are safer for your heart than tricyclics, so they are
        safer to use with elderly patients or patients with heart problems.

        MAOIs may be effective in patients who don't respond to SSRIs
        or tricyclics.  They are thought to be especially helpful
        for people who are very tired and numb when depressed and
        who can be cheered up/made more active by outside stimulation.

        They may also be more effective with "atypical
        depression," (more depressed late in the day rather than early,
        weight gain rather than weight loss, too much sleep rather than too
        little, etc.).

        The main problem with MAOIs is that they interact dangerously
        with foods containing tyramine (an amino acid).  The
        combination can lead to acute hypertension (high blood
        pressure).  This can be very dangerous and cause stroke,
        heart attack, or death, though such a severe reaction is rare.
        Symptoms of a hypertensive attack are severe headache in the back
        of the head, nausea, weakness, sudden collapse.

        A partial list of foods to be avoided is: cheese, yogurt, soy
        sauce, avocado, ripe bananas or figs, smoked salmon, cured
        ham, salami, pickled herring, broad beans.

        Caffeine and chocolate should be used with caution.

        There are also interactions with many drugs, and you should
        not take any medication (including over-the-counter drugs)
        without asking your doctor or pharmacist.  Drugs to avoid
        include: antihistamines, decongestants, any cold remedy,
        codeine, amphetamines, Demerol and other narcotic pain
        relievers, some forms of general anesthesia.

        Because of these interactions with food and drugs, you should
        get a Medic Alert bracelet if you are on an MAOI.

        Other ADs
        ---------

        Some other antidepressants include:

        Wellbutrin
        ----------

        Thought not to cause mania as much, but can make
        people quite hyper and nervous.  Side effects are as for the
        others, with the addition of a significant risk of seizures
        in extreme doses.

        Serzone
        -------

        Desyrel (trazodone): used mainly as a sleeping pill as it is
        not a very effective AD.

Also called "neuroleptics" or "major tranquilizers," these drugs have several uses in bipolar patients. One main use is to calm people down in acute mania, while waiting for a mood stabilizer to work. These drugs are also used (in low doses) as sleeping pills or to combat anxiety, and in higher doses for psychotic symptoms such as hallucinations, delusions, etc. They are also used in combination with a mood stabilizer as part of the maintenance medications used to prevent further episodes.

The major antipsychotics are: Thorazine (chlorpromazine) , Mellaril (thioridazine), Stelazine, Haldol (haloperidol), Risperdal (risperidone), Clozaril (clopazine), Trilafon (perphenezine)

Side effects are similar for all of these although some drugs (Mellaril, Thorazine) are relatively mild in their side-effects while others (Haldol) have severe side-effects for many people.

The main side effects are: sleepiness, slowed speech and thinking, difficulty walking or with balance, restlessness, twitching, involuntary movements, confusion, stiffness

If the twitching/involuntary movement/stiffness becomes severe, this can sometimes be relieved with an antiparkinsonian drug such as Cogentin.

The major risk with these drugs is a condition called tardive dyskinesia--where the twitching or stiffness remains after the drug is d