Bipolar Affective Disorder

Bipolar affective disorder can be classified as a serious mood disorder that has the following characteristics: mood swings that range from mania to depression. Symptoms of mania in bipolar disorder include an exaggerated feeling of well-being, extra energy and grandiosity in which a person begins to lose touch with reality. Symptoms of depression include a strong feeling of sadness, anxiety, and low self-esteem which can include suicidal thoughts and even attempts at suicide.

This disorder usually appears around the age of 25 and affects men and women equally but children are rarely affected by this severe disorder. It is estimated that more than two million American Adults are affected with bipolar disorder and this number includes only adults with bipolar affective disorder that are aged 18 years or older or about one percent of the total population.

Survey on the Prevalence of Bipolar Disorder
A survey conducted in 2002 which screened for bipolar disorder in the United States found the following results.

• This study showed three times as many people suffer from bipolar disorder than what was recently estimated. The total number of people affected is about3% of the adult population.
  
• Approximately one third of the affected adults that were screened positive for Bipolar disorder were previously misdiagnosed with uni-polar depression.
  
• The same study showed that 4 out of 5 adults who were screened positive for bipolar disorder had not been previously diagnosed with bipolar affective disorder.
  
• A higher number of adults aged 18 to 24 who are from low income situations and small or rural cities are more at risk for this disorder.
  
• A person with bipolar disorder has a 19 percent chance of being affected with a drug abuse or alcohol issues.
• Nearly 54% of adults with bipolar disorder will experience various symptoms that will put them at risk of losing their jobs.
• On an average 34% of adults who tested positive for bipolar disorder also suffered from anxiety problems.
• Adults who tested positive for this disorder also are at risk for other health conditions such as asthma, obesity, allergies and migraines.
• A person with bipolar disorder has a 15% chance of attempting suicide.
• More than 90 percent of suicide victims are affected with a psychiatric illness at the time of their death.
• On a global scale nearly one million adults commit suicide every year and between ten - twenty million adults attempt suicide every year.

Consider the following scenario:
A patient visits his psychiatrist in depressed and in the mind set of committing suicide. After screening for various possible causes of the patient's condition, the psychiatrist states that the patient suffers from clinical depression and the doctor prescribes a standard antidepressant.

The pill works as they should and within two or three days the patient's energy levels increase, his mindset returns to normal, he does not feel sad anymore and for a few minutes or even days the patient feels normal or even better than normal.

The patient starts making plans for his life since he is feeling better but after a few days the patient begins to feel depressed again. The patient thinks this is just a side effect that will fade away soon, so he takes another pill.

Even after taking another pill the patient does not feel any better in fact he feels even more blue and depressed. The patient cannot sleep, his heart starts pounding, he starts worrying about little things that are not significant and he also starts hallucinating.

The above symptoms describe bipolar disorder also known as manic depression. If the patient is not given a mood stabilizer along with an anti depressant then the medicine only works for a short time but after that the person goes back to being depressed. In extreme cases the person can display rage and even commit crimes.

Bipolar can cause such havoc on a person's state of mind that a University of Texas at Houston study has estimated that people with this illness for can spend anywhere from $11,720 $624,785 for treatment for this disorder. These costs include medical care, as well as unemployment and reduced earnings.

Someone who is in a state of sustained elevation is considered to be "hypomanic." Usually that person is the last one to think he or she needs help since he or she is either too intoxicating or the person feels that there is a problem with the rest of the world. If the patient hasn't wrecked his life while in a state of hypomania, he or she is a prime candidate for going into full blown mania. These cases tend to end up as typical 911 cases that border on and break through into psychosis. A powerful antipsychotic substance such as a tranquilizer or a medication can temporarily calm down the person in a matter of a few hours although long-term stabilization of the patient will require long term treatment.

Simple triggers like losing a night's sleep may trigger a full blown maniac episode and other triggers like stress from work or a relationship breakup can also cause such episodes. Other triggers include past trauma that leave an everlasting memory, bad lifestyle choices or failure to manage stress.

Many people with bipolar disorder are advised to keep mood journals which are used by them and their psychiatrists to track their moods and become alert in case the journal suggests that the person is heading towards a bad mood swing.

The symptoms of bipolar depression and "unipolar" depression are quite similar with similar suicide rates of about 15 percent. Researches do indicate that both these illnesses have different biological processes and different treatments.

When the course of the illness rapidly increases in some people, this is known as "rapid-cycles that go up and down and back again, sometimes in a matter of hours. Since rapid-cycles represent a moving target, treatment is difficult.

It is possible for people affected with bipolar disorder to experience mixed states where they feel a high and a low at the same time along with agitated depression or dysphoric mania. Some people with unipolar depression can also experience similar symptoms, and this is where depression gets especially dangerous, for if the person is feeling suicide. These ups and downs that is the manic highs and then the depressive lows are typical characteristics of bipolar disorder

Bipolar disorder is a chronic disease that affects more than 2 million Americans at some stage in their lives. The American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" states that there are two types of bipolar disorders.

In type I that was formerly known as manic depressive disorder, the person has experiences at least one full manic episode. People with this type of bipolar disorder may also experience frequent episodes of major depression.

In type II disorder periods of "hypomania" involve less severe manic symptoms that alternate with at least one significant episode of depression. When the affected patient has an acute exacerbation, he or she may be in a manic state, a depressed state, or a mixed state.

Causes, incidence, and risk factors
Everybody goes through minor mood swings where at times they feel happy and at times they feel angry, sad or depressed. People who suffer from bipolar disorder, however, go through severe pathological mood swings with a set pattern of exacerbation and remission that are sometimes cyclic. The manic phase a person affected by bipolar disorder goes through is characterized by elevated mood, hyperactivity, high energy levels, over-involvement in activities, high self-esteem, a tendency to be easily distracted and lack of sleep. These bipolar manic episodes may last from several days to months. In the depressive phase, there is a sudden loss of self-esteem, withdrawal from activities, sadness, and a risk of suicide. While in either phase, patients may abuse substances such as alcohol, nicotine, tobacco and drugs which cause the symptoms to significantly worsen.

People with bipolar II may appear to have chronic depression rather than bipolar affective disorder. People are wrongly diagnosed especially when they complain about periods of good mood and energy that don't cause problems. In people with Bipolar II type disorder mood stabilizers seem to help more than antidepressants. The type II bipolar disorder is noticed in people between the ages of 15 and 25, and this disorder affects men and women equally. The exact cause of this serious disorder is not known, but studies indicate that this disorder is caused due to disturbance of areas of the brain which regulate mood. There is also a strong genetic component and people who have relatives with bipolar disorder have a stronger chance of being affected.

Symptoms
Episodes of mania, in Bipolar type 1 disorder
Alternating episodes of mania and depression in Bipolar Type 2 disorder

In the manic phase the following symptoms can be seen:

Increase in goal-directed social or work related activities

• Increased energy
• Increased distraction
• Flight of ideas
• Racing thoughts
• Inflated self-esteem

Increased involvement in activities that may be pleasurable, but may have negative consequences

• Decreased need for sleep
• Patient may be more talkative than usual
• Easily agitated or irritated
• Lack of self-control

In hypomanic episodes
Symptoms are similar, but usually are less intense.
Delusions, if present, may be related with mood

In the depressive phase patients may experience:

• Persistent sadness and depressed mood
• Feelings of hopelessness, worthlessness and constant emptiness.
• Pessimistic approach to life
• Loss of interest or pleasure in activities that were once enjoyed, including sex
• Sleep disturbances
• Psychomotor retardation or agitation
• Withdrawal from life as a whole
• Feelings of guilt and worthlessness
• Fatigue
• Overwhelming sluggishness
• Difficulty concentrating, remembering, or making decisions
• Loss of appetite and/or weight loss, or overeating and weight gain
• Thoughts of death or suicide
• If delusions are present, they may be attached to moods.

Symptoms of Various Episodes of Bipolar Disorder

Mania
Mania in Bi polar disorder usually begins with an intense burst of energy along with a feeling of creativity and social ease. Patients with mania most often deny that there is anything wrong with them and they also angrily blame the person who points out that there is a problem.

When the patient is undergoing a manic episode he will experience the following symptoms for at least 1 week.
Feeling unusually "high," euphoric, or irritable

In addition the patient will experience at least 4 of the following symptoms:

• Resting very little due to a sudden burst of energy
  
• Talking extremely fast which makes others unable to follow the patient's thought pattern
• Having racing thoughts
• Being very distracted and jumping from one topic to another
• Having an unusual boost of ego or self worth
• Engaging in reckless activities without concern about possible negative consequences
• In severe cases, the person may also hallucinate or experience delusions.

Hypomania also known as Hypomanic Episode
Hypomania is a milder form of mania but hypomania has similar symptoms that are less severe. In a hypomanic episode the patient will experience symptoms for at least 4 days.
Below is a quote from someone describing a hypomanic episode:

Depression also known as Major Depressive Episode
When a patient with bipolar is in the depressed state he will experience the following symptoms for at least 14 days:

Feeling sad or down in the dumps
Losing interest in the things the patient normally enjoyed doing

The patient will also experience at least 4 of the following symptoms:

• Changes in appetite or weight
• Changes in sleep patter
• Sleep disturbance
• Difficulty thinking or making decisions>
• Difficulty concentrating
• Feeling mentally slowed
• Feeling worthless or guilty for no reason
• Contemplating suicide
• Hallucinations or delusions.

Mixed Episode
In a mixed episode the patient experiences symptoms of both mania and depression for a minimum period of 1 week. This phase is considered to be one of the most disabling episodes as well as one of the most dangerous periods due to risk of suicide.

Living with Bipolar Disorder

Living with bipolar disorder is exactly like living with any other chronic illness. With proper medication, education, and support systems like therapy, support groups family or friends bipolar disorder can be controlled effectively. Patients who have bipolar disorder need to be made to understand that this disease can be kept under control provided they are careful.

Tools to live with Bipolar Disorder

Wellness Checklist for Patients to be given by therapists

• Communicate concerns with his counsellor or his mental health care professional.
  
• Do not miss any appointments.
  
• Take all medication exactly as prescribed
  
• Confide in a friend
  
• Do exercises to relax the mind and reduce stress
  
• Participate in fun and creative activities
  
• Record thoughts and feelings in a diary
• Create a daily planning calendar
• Refrain from drugs and alcohol use since these trigger depression
• Get fresh air and sunlight
• Improve your diet
• Avoid caffeine, sugar, processed food items and products with high amounts of sodium.
• Attend a local support group regularly

Triggers for Depression in Bi Polar Disorder

Knowing what are the patient's triggers that cause an attack is important since by knowing these triggers the patient can be prepared in case an attack is about to occur.

Triggers can be categorized into the following categories:

• Places
• Things
• People
• Memories

Going to a certain place, meeting a certain person, using certain things or remembering certain things can act as triggers which will cause the person to experience a maniac episode or go into depression. It is usually recommended to avoid these triggers so that the patient does not experience an episode but in certain cases patients cannot avoid triggers. An instance of an unavoidable trigger is the work place or one's spouse. If the patient cannot completely avoid these triggers then he should be taught coping strategies to help him relax. Coping strategies include deep breathing, controlled breathing and thinking of something else to distract himself. Deep breathing involves taking in a deep breath and exhaling after a few seconds. This technique increases the blood supply to the muscles in the body and brain which cause the body to relax and the brain to think clearly. The therapist should remember to tell the patient that he needs to exhale completely after taking in a deep breath since if the patient only inhales and doesn't exhale then the brain will get too much oxygen and this can lead to a panic attack.

Alcohol, nicotine and drugs also act as triggers since they stimulate the brain. Nicotine products, tobacco products and caffeine products should also be avoided. Dark chocolate, cola and cigarettes are 3 items that should not be consumed by patients who have bipolar disorder.

Signs and tests
A psychiatric history of mood swings, and observation of current behavior and mood are important in determining if the person has this disorder or not. A family history of similar depressive illness may be taken by the psychiatrist. A physical examination may be performed to rule out any physical causes for the symptoms such as potentially drug-induced symptoms.

Sometimes, severe episodes of mania or depression include psychotic symptoms. Common psychotic symptoms experienced include hallucinations like hearing, seeing, or otherwise sensing the presence of things not actually there and delusions that are false such as fake beliefs that are not influenced by logical reasoning.

Psychotic symptoms in bipolar disorder usually reflect the extreme mood state of the person at the time. For instance, delusions of grandiosity such as believing one is the God or has special powers or extraordinary wealth, may occur during mania and delusions of guilt or worthlessness, such as believing that one is worthless or very poor or has committed some terrible crime may appear during depression. People with bipolar disorder who display these symptoms are sometimes incorrectly diagnosed as having schizophrenia which is another serious mental illness.

The various mood states in bipolar disorder are a spectrum or continuous range. At one extreme end is severe depression, above which is moderate depression and then the low mood, which many people call "the blues" when it is short-lived but is termed as "dysthymia" when it is long lasting. There is also the normal or balanced mood, above which comes hypomania that is also known as mild to moderate mania, and then finally comes severe mania.

Symptoms of mania and depression may occur together in some people. This is known as a mixed bipolar state and symptoms of a mixed state often include agitation, trouble sleeping, insomnia, mild to severe psychosis, significant change in appetite, and suicidal thinking. An instance of this is a person may be in a sad, hopeless mood while at the same time he may feel extremely energized.

Bipolar disorder may appear to be a problem other than mental illness-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.

Classification of Bipolar Disorder
Bipolar I - Mania and Major Depression
Bipolar II - Hypomania and Major Depression
Bipolar III - Cyclothymia
Bipolar IV - Antidepressant induced hypo along with mania
Bipolar V - Major Depression with a relative in the family having bipolar disorder
Bipolar VI - Unipolar Mania

This classification is based on the concepts of Young and Klerman in the year 1992, has been used in descriptive work and in identifying groups of subjects in the bipolar spectrum.

Bipolar I is the condition that has the best inter-rated reliability and has been most studied in terms of phenomenology, course and outcome with and without treatment.

Bipolar II is being now being recognized to be common than previously thought, particularly in young adults, and this disorder should be screened for in every patient who presents with depression. There is an increasing amount of evidence that suggests that patients with Bipolar II also respond to mood stabilizers like patients with Bipolar I.

Cyclothymia also known as Bipolar III can be dominant in a person for a lifetime without the development of a full-blown Bipolar Disorder. Some medical health workers treat Cyclothymia as they would a rapid-cycling bipolar disorder.

There is no significant research that clarifies if Bipolar IV that is antidepressant Induced Mania is basically a negative effect of medication or the unveiling of the true underlying vulnerability for bipolar disorder.

Re occuring major depression without either hypomania or mania along with a significant family history of Bipolar Disorder is now a well recognized condition. A significant proportion of patients with bipolar disorder may begin their cycle of mood problems with depression.

Unipolar Mania that is Bipolar VI is a relatively uncommon yet well recognized problem, and if it appears for the first time after the age of 40 the person should then be screened for medical or neurological etiology.

Age of Onset and Gender Issues in Bipolar Disorder
It is now being recognized that bipolar disorder often begins in patients during the adolescent years. Active symptoms of this disorder first appear in early teen years, and sometimes in the preadolescence age. In most bipolar cases there is a significant time difference between the onset of the illness and first treatment. Since many patients get treatment only after the disorder has progressed, this may put patients at risk of increased risk of morbidity, along with negative effects on their personalities and their performance at work, school. There is Increasing evidence in the schizophrenia literature suggest that this time difference may cause the patient to give a proper response to bipolar disorder treatment. Although there is no clear evidence of this specifically in the case of bipolar disorder, this potential problem should be kept in mind.

Usually in early onset the patient is affected with this disorder before the age of 25. Researches indicate that the younger the age of the patient, the more likely it that one of the relatives of the patient also have this condition. Early onset bipolar disorder most commonly starts with chronic depression. The patient may also go through cycles of depression before the first hypomania episode occurs. Depression with psychotic features that occur in mania episodes is usually a predictor of future full-blown bipolar disorder in the early onset group.

It is also believed that syndromal dysthymia with its early onset in young patients, particularly with the evident presence of a family history of this disorder, may be a sign of bipolar disorder. Rapid cycling, mixed states, and other psychotic features are more common in young patients who have experienced an early onset of the disorder. The presence abusing substances at an early age can be an indicator of the early onset of bipolar disorder. Early onset of this condition is commonly associated with response to Divalproex and a relative failure of response to the medicine Lithium because substance use, rapid cycling and mixed states and are common in this group and also because adolescents are less tolerant to the side effects of Lithium.

Studies also indicate that the women are more commonly associated with rapid cycling bipolar disorder and they may or may not also be affected with other conditions such as thyroid dysfunction, the risk of exacerbation post-partum and being diagnosed as borderline personality disorder, perimenopausal exacerbation of the condition when, in reality, some of these other conditions can be explained by rapid cycling of bipolar disorder. Biphasic mood dysregulation is now being recognized as being common in patients that have borderline personality functioning and there are various benefits in treating patients that have biphasic mood dysregulation even if they are affected with personality dysfunction. Postpartum psychotic and serious mood disorders are also considered to be a part of bipolar disorder. Evidence also suggests that many psychotropic medications such as mood stabilizers need to be altered in pregnancy, post-partum and even around menstruation. Bipolar disorder can also occur in elderly patients who have underlying medical or neurological conditions.

Bipolar Disorder in Pregnancy and Post-Partum

The decision whether or not to use medications, particularly medicines like mood stabilizers, during pregnancy should start with a risk-benefit exercise in which both the patient and her family should be fully involved. The risks of teratogenicity that can be caused by many mood stabilizers, should be considered against the risks of reoccurring symptoms and other problems such as suicide and the inability of the patient to look after self and the unborn child. If the patient has low severity and reduced episodes then a planned pregnancy without mood stabilizers can be considered provided there is a gradual discontinuation of medication. If the patient is opting for a planned pregnancy then there should be a four week medication-free period before conception. Elective use of ECT therapy, neuroleptics and SSRls in the first trimester of pregnancy can pose a comparatively lower risk to the fetes compared with using mood stabilizers.

If the patient is being given any mood stabilizers in the first trimester of pregnancy, the psychiatrist should also consider prescribing folic acid supplements along with anticonvulsants. The patient should also be monitored for teratogenicity using appropriate techniques. It is recommended to gradually discontinue medications such as mood stabilizers, about four weeks before delivery provided all the conditions mentioned above are met. If the mood stabilizer is being continued during a few weeks before then the dosage needs to be reduced drastically in order to avoid the toxicity that is caused by decreasing blood and fluid volumes immediately that occurs soon after childbirth. The newborn should also be tested for and protected from the toxicity of mood stabilizers.

The immediate period after post partum carries an increased 50% risk of recurrence or aggravation of the condition hence it is advisable to recommend re start prescribing mood stabilizers if they had been discontinued during the pregnancy. The other option is to ensure that serum therapeutic levels are achieved and maintained during the post partum period. Short term data suggests that although all mood stabilizers are transferred to the child through breast-milk this does not pose a significant risk to the newborn. It should be kept in mind that there is no long-term data available to completely rule out any behavioral effects that may happen to the child if he is exposed to mood stabilizers during the newborn period. Hence it is usually advised to discontinue breast-feeding a newborn child if the mother is taking mood stabilizers.

Effects of Under-treated and Untreated Bipolar Disorder
Bipolar is often misdiagnosed as another condition for an average of 8 years. Many patients who are affected with this disorder usually do not seek professional help for up to ten years after the first appearance of maniac and depressive symptoms. More than 60% of patients are not treated, under treated or wrongly treated at any given time.

The majority of patients that have this disorder usually have multiple recurrences, and it is extremely rare for any patient to have a single episode of mania or depression episodes over a lifetime. The length of intervals where symptoms do not appear often decreases with age. The presence of symptoms may also indicate long lasting psychosocial dysfunction and the risk of relapse is extremely high in the presence of mood-incongruent psychotic features.

Patients who do not receive treatment for bipolar disorder is usually use substances, abuse them and their school and life suffers due to this. These patients also suffer from interpersonal dysfunctions, relationship breakdown. Personality dysfunction in affected patients is usually the result of a turbulent clinical course at the important stages of development. In patients with bipolar disorder the lifetime risk of suicide is nearly 10-15% and there is also an additional chance of them committing like violence and homicide, especially with patients who have poorly controlled psychotic bipolar disorder.

Studies also indicate that women with bipolar disorder that are affected at the age 25 will lose nearly 9 years of life expectancy along with 14 years of lost productivity and also 12 years of good health compared with normal control over her mind .These problems are in addition to the dangerous risk of suicide.

Changed Outcome with Mood Stabilizer Treatment
Mood stabilizer treatment can significantly reduce the course of this disorder and they can also reduce the risk of suicide along with increasing life expectancy and increasing productivity, functioning. Approximately 40-75% of patients who respond well to mood stabilizers achieve manage to do well at their jobs and have a normal social life.

Psycho education, Psychotherapy and Life Style Changes
Bipolar disorder is not only a life-long condition that can cause a person to have multiple episodes but it also has high morbidity and nearly 10-15% suicide due to this condition. Patients with this affective disorder usually respond well to long-term mood stabilizer treatment provided the clinician and his team focuses on developing an effective cognitive treatment program with the patient and his family and friends. The basis of treatment should include psycho-education, psychotherapy, biological treatments and regular monitoring.

Understanding and acknowledging by the patient and the family that the patient has a disorder often leads to the patient taking his medications and readily opting for therapy. The psychiatrist treating the patient should pay attention to not only regulating social and bio rhythms but also helping the patient avoid or reduce alcohol and substance use. Since lack of sleep can trigger a hypomanic or manic episode the patient should not use substances like nicotine and caffeine since these substances may magnify the effects of a mood disorder, particularly rapid cycling. Patients with bipolar disorder have reported to have more negative life events and they also state that they are significantly reactive to stress. Stressful situations caused by high expressed negative emotions within the family cause immense problems for patients. Thus it is the therapists responsibility to help the family deal with interpersonal conflict such as high expressed negative emotions and loss while helping the patient achieve healthy functioning and regain his self esteem. Inter family conflicts should be included in regular interventions along with biological treatments. To improve the possibility of treatment the therapist should use specific techniques to monitor moods, reduce any attempt to suicide and improve medication adherence.

Helpful medication information along with adequate education about necessary medications is extremely useful in promoting a wholesome therapeutic relationship and good treatment adherence. Interventions conducted between the patient and his family along with supportive social network have shown a higher success rate compared to interventions that only focus on the person affected with this disorder. Negative attitudes towards medication of the patient along with negative attitudes of an important family member or friend can have adverse effects on the patient.

If a member of the health care team has a negative attitude about treating the patient then this can also cause problems in controlling the disorder. If the staff members are uncomfortable treating a patient with bipolar disorder then they should first get rid of their problems and then attempt to treat the patient. Negative statements of health care professionals can not only cause the patient to be confused but they can also cause the patient to opt out of treatment programs. Mental health care professionals should be especially calm and composed while treating patients with bipolar disorder of minority communities since many patients of minority communities are especially sensitive.

While treating homosexual adults the therapist should concentrate on treating the issue at hand rather than making any personal comments about the patient's sexual preference. If the therapist is uncomfortable treating a homosexual person then he should either opt out of the case or deal with his own problems before treating the patient. Failure to deal with his own problems can cause the therapist to negatively impact the homosexual patient which can cause the patient to opt out of treatment permanently.

Illnesses that Co-Exist with Bipolar Disorder
Substance abuse - This is the most common illness that co exists with bipolar disorder since many patients try to treat their own symptoms using harmful substances. Substance abuse often triggers symptoms, prolongs symptoms and makes it hard for patients to control their thoughts. Substance abuse can also cause behavioural disorders in patients that are already affected with bipolar disorder.

Anxiety disorders such as panic disorders, post traumatic stress disorder and social phobia are commonly seen in patients who have bipolar disorder.

Patients who have bipolar disorder are also susceptible to physical illnesses such as thyroid problems, migraines, diabetes, obesity and heart conditions.

Genetics and Bipolar Disorder
Since bi polar effective disorder occurs in people who have a family history of this condition, researchers are looking for genes that may increase chances of a person being affected by this illness. Children who either have a parent or a sibling affected with this disorder are 4 - 6 times at the risk of contracting this disorder.

Using existing data researchers are trying to determine visible signs of this disorder with this gene. According to these researchers people with bipolar disorder had one or more family members with these symptoms:

History of psychiatric hospitalization
Co occurring psychiatric illness of obsessive compulsive disorder
Age of first hypo or manic episode
Number and frequency of hypo or manic episodes
Missed work due to their condition
Treated for Bipolar disorder
Hospitalized for bipolar disorder
Other co existing illnesses such as anxiety disorders and substance abuse.

Screening Test
Before starting the actual treatment the therapist has to screen the patient to identify if he has bipolar disorder and to determine the severity of the disorder. The therapist can alternatively ask the patient to complete a self screen test. These questions have to be answered in a yes or no format. If the patient answers 75% of the questions with a yes then this indicates that he has bipolar disorder. These self screening tests give the therapist an estimate of the severity of the condition but to confirm the diagnosis additional tests have to be done. The following questions can be used in the self screening test.

• Some days I am more talkative that usual
• There are times when I lose interest in activities I usually enjoy
• There are days where I am much more active than the others
• On some days I feel excessively sleepy and uninterested in life
• There are days when I am very irritable and my mind races.
• There are days when I feel both elated and depressed
• There are days when I am extremely interested in sex
• On some days I do not have any interest in sex although I usually enjoy sex
• My self confidence levels do not always remain the same, on some days I feel very confident on other days I feel worthless
• On some days I can work well but on other days I cannot get myself to work or my work quality is not good
• On some days I get angry for no apparent reasons
• At times I shout and scream for no reason
• On some days I feel mentally dulled but on some days I feel exceptionally creative
• On some days I like being with people but on some days I do not enjoy being near people
• My mind wavers a lot and I cannot stick to any decision I make
• There are days when I am very optimistic and there are days when I am extremely pessimistic
• I have gone through phases where in I cry and am depressed for no apparent reason and on some days I remain very happy.
• I have tried to hurt myself when I have been depressed
• I have had episodes where I have tried to hurt others due to rage
• On some days I do not feel like eating at all
• There are days where I do not feel the need to sleep
• On some days I am very forgetful and I find it hard to concentrate
• On some days I think a lot about death
• On some days I feel like there is no point of living and everything is meaningless
• At times for no reason I feel don't like myself
• My friends and relatives tell me that on some days I act different.
• My mood swings cause problems in my personal life
• My mood swings affect the quality of my work

Treatment
Hospitalization may be required during a severe and short term phase to control the symptoms and to ensure that the patient does not harm himself or others.

Medication
Lithium was the first medicine used for treating bipolar disorder and even these days it is used for treating this disorder. This medicine is now used along with antidepressants provided the patient suffers from clinical depression and not mania. Lithium may cause side effects like include weight gain, nausea, tremor, and a need to urinate frequently. Lithium may affect the thyroid gland along with the kidneys, so periodic blood tests are needed to be sure these organs are functioning properly. Monitoring blood levels of lithium is important since this ensures that there are no side effects and that the patient is getting the required dosage.

Predictors of Lithium Response
These factors are associated with good response to the medication lithium.
Previous good response of the patient to the medication lithium
No family history of bipolar disorder
Less severe mania
Classical bipolar disorder
Normal serum lithium levels that are regulated periodically

Predictors of Lithium Failure
These factors are associated with failure to respond to lithium treatments.
Multiple previous episodes
Rapid cycling and mixed states
Significant co-morbidity
Alcohol or substances
Personality disorder

Mood stabilizers
Mood stabilizers keep episodes of mania in control, though it is not exactly known how the medication affects the brain. Lithium, which is also a common salt, was first discovered as a treatment for bipolar by accident.

Other mood stabilizers that are used to treat this disorder include:

• Depakote (valproic acid),
• Tegretol (carbamazepine),
• Trileptal (oxcarbazepine),
• Neurontin (gabapentin),
• Topamax (topiramate)
• Lamictal (lamotrigine)

Mood stabilizers were first used to treat seizures and epilepsies but now they are used to treat bipolar disorders. These medicines are known as anticonvulsants. Some of the common anticonvulsants used these days include Divalproex and carbamazepine. Divalproex is one of the few medications that is equally effective in rapid cycling bipolar disorder, euphoric and mixed manic episodes. This medicine can also be used in people whose illness is further complicated due to substance abuse. Divalproex can be given in large doses initially for acute mania. Common side effects of this medicine include sedation, gastrointestinal problems, tremor and weight gain.

Carbamazepine is supposed to have the same effect as Divalproex and this medicine is effective for various sub types of bipolar disorder including euphoric and mixed manic episodes. Since this medicine can cause bone marrow suppression and liver inflammation in rare cases, periodic blood testing is also needed while the patient is undergoing carbamazepine treatment.

Lamotrigine is a new medication and it can be used as a mood stabilizer for depressed phases of bipolar disorder. Since 3 out of every 1,000 individuals can develop a serious rash by taking this medicine it is advised to keep the dosage into check and reduce the dosage very slowly if the patient develops a rash.

Gabapentin is also used as a mood stabilizer although there is not much research on the effects of this medicine for bipolar disorder. This medicine is especially helpful with anxiety and it does not interfere with other medications.

Topiramate is an anticonvulsant that is helpful in treating mania. This medicine causes the patient to lose weight and this is often seen as an advantage. Side effects of this medicine include memory difficulties, sedation and dizziness.

Antidepressants have to be used with a mood stabilizer while treating a patient for bipolar disorder.

What you need to know about antidepressants from a bipolar perspective is there is divided opinion in psychiatry concerning the safety of bipolar patients on antidepressants. This is because an antidepressant without a concomitant antimania med is almost certain to switch a patient into mania. Some authorities contend that even with an antimania drug, the danger is there. Accordingly, the American Psychiatric Association in its bipolar guidelines issued in 2002 does not recommend an antidepressant-antimania combination as a first option, and another guideline recommends tapering and discontinuing soon after remission is achieved.
On the other hand, there is a body of opinion that feels the risk is overstated. One study found that those who stayed on their antidepressants fared better over 12 months than those who quit on them before six months. But the same study also found that antidepressants did not work for the large majority of those in the study.

Some of the common antidepressants used for bipolar disorder and its sub categories include

• Bupropion
• fluoxetine
• fluvoxamine
• paroxetine
• sertraline
• Venlafaxine

If these medicines cause unpleasant side effects then instead the following antidepressants can be used:

• Mirtazapine
• Nefazodone

Monoamine oxidase inhibitors: phenelzine , tranylcypromine
Tricyclic antidepressants: amitriptyline , desipramine , imipramine nortriptyline .

Remember : Tricyclics can cause side effects or set off manic episodes or rapid cycling.

Antipsychotics are powerful another anti-mania medications that originally came to the market to treat schizophrenia. These drugs work by binding dopamine receptors that exist in the brain, which prevents over stimulation from of dopamine. The older antipsychotics would tightly bind dopamine receptors, which resulted in significant side effects that included sexual dysfunction along with increased lactation which can also result in loss of menses in female patients and lower testosterone in male patients. Other side effects included dulled cognition, involuntary facial spams, sedation, and muscular spasms. Haldol, is an older anti psychotic medicine that is still in common use.

The newer and improved "atypical" antipsychotics bind the dopamine receptors more loosely, which results in lesser chance of side effects although they some side effects do occur. The APA and other guidelines recommend that psychiatrists should first prescribe atypicals an option for treating mania, used in combination with a potent mood stabilizer. Atypicals anti psychiatric medicationsinclude Clozapine, Geodon , Olanzapine, Abilify , Risperidone and Quetiapine.

Antipsychotic medications are used to control psychotic symptoms like hallucinations along with delusions that can occur in very severe depressive or even in manic episodes. Antipsychotics can be used as sedatives even when no psychotic symptoms are noticed. Certain Antipsychotics medicines can also be used as mood stabilizers. The older Antipsychotics were known as typical antipsychotics and the newer antipsychotics are known as atypical antipsychotics. Older antipsychotic medicines often cause tardive dyskinesia that is a permanent movement disorder but atypical psychotics usually do not cause this problem. Other side effects of old antipsychotics include muscle stiffness, restlessness and tremors.

Five atypical antipsychotic medicines include
olanzapine
quetiapine
risperidone
clozapine
aripiprazole

Typical Psychotic medicines include
Haloperidol
Perphenazine
Chlorpromazine

Although medications form the base of a treatment program for bipolar disorders patients and their families benefit from educational and supportive interventions that promote symptom management along with adequate coping skills. Patients and families also benefit from joining a support group where members share common experiences and problems.

For some people, treatment with lithium or recently found anticonvulsant and mood stabilizers have successfully prevented recurrence of bipolar symptoms. However, the outcome of these medications may be different for various individuals as some patients will experience rapid cycling or frequent acute episodes.

Complications
Non compliance with treatment can lead to a recurrence of the illness.
Bipolar disorder may be complicated by alcohol and drug abuse, often used as a strategy to self-medicate in order to improve mood.

Side effects of Medicines that are Used to Treat Bi Polar Disorder

Although anticonvulsant medicines, anti psychotic medicines and anti depressants are used to treat bi polar disorders, these medicines can have mild to severe side effects. The treating psychiatrist should inform the patient of these side effects so that the patient knows what to expect. If the patient is very uncomfortable with certain side effects then the psychiatrist should adjust the dose or change the combination of medicines prescribed.

Mood stabilizers can have the following side effects:

• Brittle nails
• Brittle hair
• Acne
• Joint pain
• Muscle pain
• Bloating
• Indigestion
• Restlessness
• Dry mouth
• Drowsiness
• Dizziness
• Diarrhea
• Constipation
• Headache
• Heartburn

Atypical ant psychotic medicines can have the following side effects:

• Drowsiness
• Dizziness when moving suddenly
• Skin rashes
• Menstruation problems
• Skin rash
• Sensitivity to the sun
• Rapid heartbeat
• Blurred vision

Since bipolar disorder represents itself in a number of varied symptoms in patients, treatment for this disorder will differ from patient to patient. This is mainly because each individual has a unique biochemistry, different diet, different genetics, degree of progression, and environment hence what works for one patient may not be as effective for another.

When a patient is diagnosed with bipolar disorder treatment usually begins immediately. After initial symptoms have been recognized and controlled the psychiatrist should recommend a maintenance program based on the following 3 components:

Preventive Medication
Prescription medication is required for almost all patients to control phases like manic, depressive, or mixed episodes. As the name suggests preventive medicine prevents the onset of bipolar episodes and it controls other symptoms associated with this disorder.

Education
The psychiatrist will need to educate the patient about the affective disorder and the psychiatrist will also need to inform the patient if there is any change in his condition. The psychiatrist can educate the patient through printed booklets that contains information about symptoms, the condition, the problems this condition can pose and things that can be done if the patient goes through an episode. Printed booklets can also be given to the family of the booklets to help them understand this disorder better and to help them understand what the patient is going through. By spreading awareness about this condition the psychiatrist will be helping the patient and his family cope better with their situation.

Psychotherapy
Along with medication, psychotherapy helps the affected patients along with their families solve any related problems that can otherwise cause stress. Psychotherapy consists of cognitive therapy also known as behavioral therapy. Family interventions also consist of psycho therapy.

It's important to keep in mind that some patients with bipolar disorder will need medication only periodically while others may need medicines on a daily basis. It is also possible for the symptoms to be controlled for many years only to reappear when medication is stopped or stress levels increased. Although this disorder is controllable, the best treatment plan is for patients to continue taking medication and visiting the psychiatrist even if the symptoms seem to have disappeared.

One of the most important ways psychiatrists can help patients manage their symptoms and cycles is to encourage them to note down their moods every day. There are significant benefits of writing down one's moods and thoughts that occur each day. By reminding your patient to maintain a personal diary, psychiatrists can help patients and their families recognize the cycle that occurs and ways to adjust during these cycles can be determined.

A Mood Chart is a written log created by the patient himself. It is a record of daily stressful events such as arguments that affected them emotionally. In the mood chart the patient should also note down the medications he took and what type of moods they experienced at various parts of the day. A Clinical Self-Report is also maintained by the patient himself. This is a record of various symptoms experienced by the patient since he last visited his psychiatrist.

Keeping a diary with records allows the patient and his or her doctor to understand if the medication is working and if the patient is improving or not. Through written records psychiatrists will find themselves in a better position to help a patient who is having difficulty managing bipolar disorder. If the patient is unable to manage keeping a daily record due to being affected severely a family member can be asked to note down these details instead.

Pharmacotherapy is considered to be the basis for treatment for this disorder, but many researches indicate that adjunctive psychosocial interventions that are personalized, time-limited and empirically supported can provide additional benefits.
Psycho education used in combination with pharmacotherapy may be beneficial, but questions remain about the usefulness of this treatment program for patients who are already taking medications to treat this disorder. Family educational interventions have proved to have positive results in relapse prevention, but follow-up data is limited and applying these principles to patients who have limited social support systems may be a problem.

Reports about the effects of interpersonal and social rhythm therapy in affected patients are not adequate and what is currently available shows no significant improvement remission or relapse, but it does have a significant impact on subsyndromal symptoms. Follow-up data suggests that patients undergoing cognitive behavior therapy have lesser manic and depressive episodes, shorter manic and depressive episodes, fewer hospitalizations, and less mood symptoms.

It is still unclear if cognitive behavior therapy is superior to other active psychosocial techniques and whether the mechanism of cognitive therapy in patients with bipolar disorder is changing dysfunctional cognitions or only allowing detection of early symptoms.

The psychotherapies mentioned above should be considered as soon as the disorder is detected to improve the effects of medications and to help patients identify symptoms of relapse in order to take the necessary steps for prevention. In addition, some psychotherapy strategies may have a positive effect on the remaining symptoms like symptoms of depression, and hence these therapies help patients move toward a successful recovery.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy was formerly known as shock therapy and this treatment program was given a bad name previously. Due to the new data collected over the years and the improved techniques, this treatment program is now considered safe. When medication, patient and family interventions and psychosocial treatment are ineffective or do not work fast enough to relieve severe symptoms such as psychosis or suicidal behaviour it is recommended to opt for electroconvulsive therapy instead. This alternate treatment program may also be used to treat acute episodes when the patient has medical conditions like pregnancy since in certain medical conditions medications pose a risk to the patient.

ECT is often used to treat severe depressive, manic, and mixed episodes since this treatment is very effective for these problems. While in the past electric shocks would cause long term memory problems, this risk is now significantly reduced with modern ECT techniques. Before the patient opts for ETC he should make it a point to discuss the potential benefits and risks of opting for this technique. Hospitalization is generally not required for ECT and the patient receiving this therapy can go home the same day.

Before shocks are given to the patient he will be given a muscle relaxant along with an anaesthetic. His condition will be monitored and he will then be given small amounts of current. This current will be given to his brain and this treatment can go on for many days depending on the severity of the condition.

Side effects of ECT may include:

• Headache
• Muscle soreness
• Heart disturbances
• Short-term confusion
• Memory lapses

Psychosocial interventions
In addition to medication patients are now recommended to opt for psychosocial interventions which include certain forms of psychotherapy. Psychosocial interventions successfully provide the required support and guidance to people with bipolar disorder. This technique also keeps the families of the patient in mind and aims to solve problems or conflicts within the family that arise due to the patient's condition.

Some of the common types of psychosocial interventions include:

Cognitive behavioral therapy- This helps patients understand ways to change inappropriate though patterns such as negative thoughts. Cognitive behavioural therapy also helps patients alter certain behaviours so that they cope with their condition. Coping strategies are often taught to patients in this type of therapy.

Psycho education- This involves teaching patients and their families about the illness. Patients are also educated about possible treatments and the family is taught how to recognize signs of relapse so that patient can benefit from early intervention so that a relapse does not occur. Both the patient and his family are educated about symptoms, ways to cope with the new situation and ways to cope during stressful periods.

Family therapy - This uses various strategies to reduce the level of stress within the family so that the patient's condition is not further aggravated. Through family therapy the therapist will discuss family problems amongst the various family members and he will help them understand that the patient needs their help. The therapist will also attempt to make the patient's family understand that due to this condition the patient may do things that are not liked by the family members, but the patient is not at fault here since he may do these things due to bipolar disorder. The therapist will also educate the family about symptoms, possibility of a relapse, ways to identify a relapse and ways to help the patient cope with his situation.

Interpersonal therapy- This aims to help patients to improve interpersonal relationships within the family and maintain daily routines. This therapy is similar to family therapy but in this therapy the therapist will not only talk to the family but he will also talk to everyone who affects the patient directly like friends, relatives and other people.

Family Therapy for Bipolar Disorder
Patients who are affected with bipolar disorder are usually treated with drugs after an acute episode, and most of these patients find immediate relief from symptoms. Researches indicate that drug therapy is definitely effective on a short term basis but only using drugs is not as effective over the long term. Due to this revelation researchers are trying their level best to find a replacement therapy for drug therapy.

Researchers from the University of North Carolina reviewed and compared results of affected patients enrolled in a program called the family-focused therapy with those patients who had enrolled in a less intensive crisis management program. All of the patients from both these groups had recently had an acute episode and were put on conventional drugs for this condition. The family-focused therapy comprised of a total of 21 sessions that involved educating the patients about the disorder, communication training and helping the patients learn problem-solving skills. Patients of the first group took part in these 21 sessions along with all their immediate family members. The crisis management program on the other hand consisted of only two sessions where family members were educated about this condition along with crisis intervention sessions only when needed. The patients from both the groups underwent the treatments mentioned above for nine months and they were asked to report about their condition for two years.

Results of this experimental program showed that the patients who received 21 sessions of family-focused therapy had fewer relapses and the time gap between each relapse was longer than those patients who were in the crisis management group. As stated above this program concluded that 35 percent patients had fewer relapses that were in the family focused therapy vs. 54 percent who had frequent relapses in the crisis management program, and the time period between each relapse was 73.5 weeks for the family focused group vs. 53.2 weeks for the patients in the crisis management program.

It is important for psychologists to remember that psychosocial interventions cannot be used as a substitute for pharmacotherapy but these therapies need to be used in combination with medications to help patients the most.

Interpersonal and social rhythm therapy (IPSRT)
Interpersonal and social rhythm therapy is based on the principle that bipolar disorder is an illness that occurs when there are disturbances in body rhythms such as seasonal rhythms, social rhythms and circadian rhythms. According to this principle symptoms such as sleep disturbances can be treated by following a healthy daily routine. This principle also believes that once the problem of sleep disturbances is corrected, many related problems tend to subside. Patients affected with this disorder are advised to keep a mood chart that track their various moods and also the activities that they engage in during the day. Patients also complete an interpersonal inventory that allows them to note personal interactions along with triggers, stressors and conflicts that have an effect on their body rhythm. This mood chart is then reviewed during psychotherapy sessions and patients are helped to recognize how certain activities affect their body rhythms. Patients are also taught ways to alter their daily schedule so that their body rhythms are not disturbed and they do not experience any bipolar symptoms.

Interpersonal and social rhythm therapies play a crucial role in improving the quality of long-term prevention of symptoms in patients with bipolar disorder.

In a study that compared two maintenance treatments for bipolar disorder, the researchers concluded that when drug therapy was used in combination with interpersonal and social rhythm therapy, the patient was free from symptoms of depression for a longer period of time. The study also concluded that both these therapies when used with drug therapy were able to keep the majority of affected patients free of manic symptoms.

Bipolar disorder is commonly known as manic depressive disorder and this illness affects between 2- 3 million Americans. This disorder has distinctive characteristics like mood swings, deep depression and mania.

Traditional treatments for the disorder use lithium along with other mood stabilizers, these treatments only work well temporarily and doctors have found that they have only limited long-term success. Due to the disorder's strong genetic base, for many years ever since the discovery of lithium, this disorder was not considered as a condition in which psychotherapy played an important role. In the year 1997, a series of important studies presented during the Second International Conference on Bipolar Disorder suggested a new way to improve the relatively poor long-term success rate with the disease. Dr. Frank along with other highly qualified professionals reported that patients affected with bipolar disorder were susceptible to new episodes of mania and depression when they experienced triggers in their daily lives and disruptions of schedule in their daily life could also cause an episode of mania or depression. These professionals concluded that affected patients who did not experience such disruptions were not victims of new episodes.

The latest available research of Dr. Frank's work in the year 1997 uses techniques that are focused on regularizing the patient's daily routines and improving his interpersonal relations to reduce depressive symptoms so that this in turn improves the quality of remission time experienced by the patient.

IPSRT uses certain questioning styles such as "Clarification" which aims to obviate the patient's biases in talking about interpersonal issues. The "Supportive Listening" style is often therapeutic within itself since it makes the patient feel valued. "Role playing" and "Communication Analysis" are two other highly behavioral based interventions and these styles are invaluable tools in intervening disputes between the patient and another person. The "Encouragement of Affect" allows the patient to experience unwanted affects that may have resulted due to the deployment of the pathogenic defence mechanisms. This questioning style can be used safely within the therapeutic frame and this process allows the patient to acknowledge that an interpersonal issue exists and it also helps the patient to accept it as a part of their treatment.

Cognitive Therapy

Cognitive therapy only controls this disorder and it is not a cure for depression or bipolar disorder. Unlike traditional psychoanalysis, cognitive therapy does not point out the underlying causes of the patient's problem. This therapy merely keeps the problem at bay for as long as possible. Cognitive therapy is usually used in combination with drug therapy. Cognitive therapy is started once the patient is has shown a positive response to medication, and generally this therapy involves between ten to twenty sessions.

Psychosocial interventions on the other hand have the power to increase the success rate of treatment of bipolar disorder but interventions have to be in adjunct to medication. Psycho education has proved to be an effective treatment hence it is used as commonly as general blood testing that is done before the prescription of medication such as mood stabilizers.

Psycho- education can be imparted in various ways. The most common way to impart psycho education is to provide the patient and his family members with written material that they can read when ready. If the therapist feels that the patient is not going to read written information then he can include education as part of therapy. The therapist should keep in mind that while imparting psycho education he should only educate the patient and he should not impose himself on the patient. If the patient feels that he is being imposed upon then he may try to resist the treatment.

Brief family interventions that include psycho education as part of the sessions are very essential in the course of the illness. Psycho education should be preferably included in the first few sessions of therapy. Cognitive behavioral therapy also has shown good results, but its value when not used in conjunction with psycho educational remains to be more precisely determined.

Bipolar Disorder in Children

Bipolar disorder is more likely to affect children whose parents have the disorder. Researches indicate that when one parent has this disorder, the child's risks increase by 15-30% and when both parents have this disorder, the risk to the child increases by 50-75%.

Symptoms of bipolar disorder are usually difficult to diagnose in children, as these symptoms can be mistaken for emotions and behaviors that are common in growing children and adolescents. Symptoms of mania and depression may appear to look like a variety of common behaviours that appear in growing children. When children and adolescents have maniac episodes they are more likely to be irritable and destructive compared to adults who are than to be elated or euphoric. During depressive episodes, the child may complain of headaches, stomach aches, feeling tired and he may also perform poorly at school. During depressive episodes children also display poor communication skills along with extreme sensitivity to rejection or failure.

Since very few studies have been done of the effectiveness and safety of the medications in children and adolescents, the treatment of this disorder in children is based on researches done on treating adults with this disorder. While opting for treatment for children it is very important to search for a doctor who has adequate practical experience in treating this illness in children. The doctor should also allow the patient to work closely with throughout the course of treatment.

Early-Onset Bipolar Disorder
Symptoms of bi polar can be present in a child since infancy or early childhood, or these symptoms may suddenly appear in adolescence or adulthood. Until a few years ago, diagnosis of this disorder was rarely made in childhood. Doctors are now equipped to recognize and treat bipolar disorder in young children through treatment methods such as early intervention and medication. These treatment methods allow children to gain the best possible level of wellness and grow up to enjoy life that is built upon their strengths. Proper treatment of this disorder reduces the negative effects of the illness on the child's life and the lives of those who love him. Families of affected children and adolescents are often surprised when a close one is affected by early-onset and they are open to opting for support.

According to surveys conducted by the American Academy of Child and Adolescent Psychiatry, 3.4 million children and adolescents in USA are affected with this disorder and nearly one third of these patients are affected with depression may experience early onset of bipolar disorder.

How common is bipolar disorder in children?
Although there have not been many surveys conducted on this subject it can be stated that, bipolar disorder affects an estimated 1-2 percent of adults worldwide. It can also be stated that bipolar disorder is more prevalent in children than in adults.

It is suspected that a large number of the children diagnosed with attention-deficit disorder with hyperactivity actually have early-onset this psychiatric disorder instead of and at times along with attention deficit disorder with hyperactivity.

What are the symptoms of bipolar disorder in children?
Bipolar disorder can be diagnosed if there are significant changes in mood and energy. In most adults affected with this disorder, reoccurring states of extreme agitation accompanied by high energy is termed as mania. Similarly in adults reoccurring states of extreme sadness or significant irritability along with by low energy is known as depression.

Most of the times this disorder looks different in children than it does for affected adults. Children affected with bipolar disorder have a continuous mood disturbance that is a mixture of both maniac episodes and depression. This rapid cycling that is often severe between extreme moods produces long lasting irritability in children but the child will also experience a few symptom free episodes periods between these extreme episodes.

Symptoms may include:

• an expansive or irritable mood
• depression
• rapidly changing moods lasting a few hours to a few days
• explosive and destructive rages
• separation anxiety
• inappropriate sexual behavior
• hyperactivity, agitation, and distractibility
• sleep troubles, insomnia, sleeping too much
• bed wetting and night terrors
• strong and frequent cravings, often for sweets and carbohyderates
• excessive involvement in multiple projects and activities
• impaired judgment, impulsivity, racing thoughts, and pressure to keep talking
• Rebellious behaviours
• delusions and hallucinations

Symptoms of bipolar disorder in affected children can be noticed as early as infancy. Many mothers often report that children later diagnosed with bipolar disorder were previously very difficult to settle and slept erratically. Mothers also report that affected children previously seemed extremely clingy and from a very young age they had uncontrollable tantrums or rages that seemed uncalled for. In children affected with this disorder the word "no" often triggered these extreme rages.

Several current studies are also exploring characteristics of affected children and researchers are studying with promising results the safety and effectiveness of adult treatments such as medications in children.

What are the symptoms of bipolar disorder in adolescents?
In adolescents, bipolar disorder usually resembles one or more of the following classical adult presentations of the disorder.

Bipolar I -In this sub type of the disorder, the adolescent will experience alternating episodes of intense episodes of psychotic mania and depression.

Symptoms of mania include:

• elevated, expansive or irritable mood
  
• decreased need for sleep
  
• racing speech and pressure to keep talking
  
• grandiose delusions
  
• excessive involvement in pleasurable but risky activities
  
• increased physical and mental activity
  
• poor judgment
  
• in severe cases, hallucinations
  
• Symptoms of depression include:
  
• pervasive sadness and crying spells
  
• sleeping too much or inability to sleep
  
• agitation and irritability
  
• withdrawal from activities formerly enjoyed
  
• drop in grades and inability to concentrate
  
• thoughts of death and suicide
  
• low energy
  
• significant change in appetite
  
• Periods of relative or complete wellness may also occur between the episodes.

Bipolar II - In this sub type of the disorder, the adolescent will experience episodes of hypomania along with reoccurring episodes of depression. Hypomania is a marked by mainly elevated or irritable mood along with the patient displaying increased physical and mental energy.

Cyclothymia. In this subtype of the disorder adolescents will experience periods of less severe mood swings.

Bipolar Disorder NOS (Not Otherwise Specified) - Doctors usually make this diagnosis only when it is not completely clear which type of bipolar disorder the child is affected with.

For many adolescents a loss or traumatic event in their life triggers the first depressive episode or maniac episode. The episodes that occur later on may occur independently without any obvious stresses but it is possible for these symptoms to worsen with stress. Puberty is a time of risk for children affected with this disorder. In girls the change in the body during puberty may trigger the illness, and symptoms may worsen during the monthly cycle. Once the disorder has emerged these episodes tend to reoccur and worsen without treatment. Studies show that after the first symptoms appear, there is usually a 10 year time gap until treatment begins. Early intervention and treatment can definitely make all the difference in the world during this crucial time of development.

Is substance abuse and addiction related to bipolar disorder?
Majority of the teens who do not get early help for bipolar disorder usually abuse alcohol along with substances like drugs. Parents should keep in mind that if their child or adolescent abuses substances then the child should be evaluated for a mood disorder.

Adolescents who do not experience symptoms until puberty and suddenly experience an onset of symptoms are thought to be especially vulnerable to addiction to drugs or alcohol. Since substances may be readily available to teens, they may use harmful substances to control their mood swings and other problems like insomnia. If addiction develops in adolescents with untreated bipolar disorder then it is very important to treat both the bipolar disorder along with substance abuse.

What role does genetics or family history play in bipolar disorder?
Bipolar disorder tends to have a genetic link, but there are also many environmental factors that influence whether the disorder will affect a particular child. Bipolar disorder can skip generations in certain cases and even and take different forms in various individuals.
The few studies that have been done on this subject vary in the estimate of risk to a given individual but it can be concluded that:

• For the general population, the individual's risk of having a full-blown bipolar disorder is 1 percent.
• Disorders related to bipolar disorder may affect 4-6%.
• When one parent has bipolar disorder, the risk to each of the biological children is l5-30%.
• When both parents have bipolar disorder, the risk to each of the biological children increases by 50-75%.
• The risk in siblings and fraternal twins if one is affected by this disorder is 15-25%.
• The risk in identical twins if one is affected by this disorder is approximately 70%.

Since every generation from World War II, there is a higher possibility and an earlier age of onset of bipolar disorder. On an average, children with bipolar disorder experience their first episode of mania or depression up to 10 years earlier than their parents' generation did. The reason for this is not known.

Historical Perspective
Bipolar disorder has left its mark on history since many famous and accomplished people had symptoms of the illness including famous personalities like:

• Abraham Lincoln
• Winston Churchill
• Theodore Roosevelt
• Goethe
• Balzac
• Handel
• Schumann
• Berlioz
• Tolstoy
• Virginia Woolf
• Hemingway
• Robert Lowell
• Anne Sexton

The biographies of Beethoven, Dickens and Newton reveal severe recurrent mood swings that begin in childhood.

Diagnosing Bipolar Disorder in Children
Children who are not affected with this disorder often have normal episodes when they have difficulty staying still, controlling their impulses, or dealing with daily life frustration. Due to this the Diagnostic and Statistical Manual IV requires that for a diagnosis of bipolar disorder in children the adult criteria must be met. As of now there are no separate criteria for diagnosing children.

Some behaviors by a child however should raise concern in the parents and psychiatrist:

• destructive rages that continue past the age of four
  
• talk of wanting to die or kill themselves
  
• trying to jump out of a moving car

To illustrate how difficult it is to use the DSM-IV to diagnose affected children, the manual states that a episode of mania requires the child to have a "distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least four days." More than 70 percent of affected children have mood and energy shifts several times a day.

How does bipolar disorder differ from other conditions?
Even when a child's behavior is believed to be abnormal, correct diagnosis remains challenging since bipolar disorder in children is usually accompanied by symptoms of other serious psychiatric disorders. In some children, proper treatment for the bipolar disorder reduces or stops the symptoms thought to indicate another diagnosis but in many children, bipolar disorder may be only a part of a more complicated illness that includes neurological, developmental and other components.

Illness that usually occur along with bipolar disorder include:

• reactive attachment disorder (RAD)
• In adolescents, bipolar disorder is often misdiagnosed as:
• borderline personality disorder
• post-traumatic stress disorder (PTSD)
• generalized anxiety disorder (GAD)
• obsessive-compulsive disorder (OCD)
• Tourette's syndrome (TS)
• intermittent explosive disorder
• schizophrenia
• depression
• conduct disorder (CD)
• oppositional-defiant disorder (ODD)
• attention-deficit disorder with hyperactivity (ADHD)
• panic disorder

The need for prompt and proper diagnosis
Tragically, after symptoms first appear in children, years often pass before treatment begins, if ever. Meanwhile, the disorder worsens and the child's functioning at home, school, and in the community is progressively more impaired.

The importance of proper diagnosis cannot be overstated. The results of untreated or improperly treated bipolar disorder can include:

• an unnecessary increase in symptomatic behaviors leading to removal from school, placement in a residential treatment center, hospitalization in a psychiatric hospital, or incarceration in the juvenile justice system
• the development of personality disorders such as narcissistic, antisocial, and borderline personality >
• a worsening of the disorder due to incorrect medications
• drug abuse, accidents, and suicide.

It is important to remember that a diagnosis is not a scientific fact. It is a considered opinion based upon the behavior of the child over time, what is known of the child's family history, the child's response to medications, his or her developmental stage, the current state of scientific knowledge and the training and experience of the doctor making the diagnosis. These factors (and the diagnosis) can change as more information becomes available. Competent professionals can disagree on which diagnosis fits an individual best. Diagnosis is important, however, because it guides treatment decisions and allows the family to put a name to the condition that affects their child. Diagnosis can provide answers to some questions but raises others that are unanswerable given the current state of scientific knowledge.

Parents concerned about their child's behavior, especially suicidal talk and gestures, should have the child immediately evaluated by a professional familiar with the symptoms and treatment of early-onset bipolar disorder.

There is no a blood test or brain scan, as yet, that can establish a diagnosis of bipolar disorder.

Parents who suspect that their child has bipolar disorder (or any psychiatric illness) should take daily notes of their child's mood, behavior, sleep patterns, unusual events, and statements by the child of concern to the parents. Share these notes with the doctor making the evaluation and with the doctor who eventually treats your child. Some parents fax or e-mail a copy of their notes to the doctor before each appointment.

Because children with bipolar disorder can be charming and charismatic during an appointment, they initially may appear to a professional to be functioning well. Therefore, a good evaluation takes at least two appointments and includes a detailed family history.

Good Treatment Plan
A good treatment plan includes medication, close monitoring of symptoms, education about the illness, counseling or psychotherapy for the individual and family, stress reduction, good nutrition, regular sleep and exercise, and participation in a network of support.

The response to medications and treatment varies. Factors that contribute to a better outcome are:

• access to competent medical care
• early diagnosis and treatment
• adherence to medication and treatment plan
• a flexible, low-stress home and school environment
• a supportive network of family and friends
• Factors that complicate treatment are:
• lack of access to competent medical care
• time lag between onset of illness and treatment
• not taking prescribed medications
• stressful and inflexible home and school environment
• the co-occurrence of other diagnoses
• use of substances such as illegal drugs and alcohol

The good news is that with appropriate treatment and support at home and at school, many children with bipolar disorder achieve a marked reduction in the severity, frequency and duration of episodes of illness. With education about their illness (as is provided to children with epilepsy, diabetes, and other chronic conditions) they learn how to manage and monitor their symptoms as they grow older.

The parent's role in treatment
As with other chronic medical conditions such as diabetes, epilepsy, and asthma, children and adolescents with bipolar disorder and their families need to work closely with their doctor and other treatment professionals. Having the entire family involved in the child's treatment plan can usually reduce the frequency, duration, and severity of episodes. It can also help improve the child's ability to function successfully at home, in school, and in the community.
Parents can learn all about bipolar disorder. Read, join support groups, and network with other parents. There are many questions still unanswered about early onset bipolar disorder, but early intervention and treatment can often stabilize mood and restore wellness. You can best manage relapses by prompt intervention at the first re-occurrence of symptoms.
Medication

Few controlled studies have been done on the use of psychiatric medications in children. The U.S. Food and Drug Administration (FDA) has approved only a handful for pediatric use. Psychiatrists must adapt what they know about treating adults to children and adolescents.
Medications used to treat adults are often helpful in stabilizing mood in children. Most doctors start medication immediately upon diagnosis if both parents agree. If one parent disagrees, a short period of watchful waiting and charting of symptoms can be helpful. Treatment should not be postponed for long, however, because of the risk of suicide and school failure.

A symptomatic child should never be left unsupervised. If parental disagreement makes treatment impossible, as may happen in families undergoing divorce, a court order regarding treatment may be necessary.

Other treatments, such as psychotherapy, may not be effective until mood stabilization occurs. In fact, stimulants and antidepressants given without a mood stabilizer (often the result of misdiagnosis) can cause havoc in bipolar children, potentially inducing mania, more frequent cycling, and increases in aggressive outbursts.

No one medication works in all children. The family should expect a trial-and-error process lasting weeks, months, or longer as doctors try several medications alone and in combination before they find the best treatment for your child. It is important not to become discouraged during the initial treatment phase. Two or more mood stabilizers, plus additional medications for symptoms that remain, are often necessary to achieve and maintain stability.

Parents often find it hard to accept that their child has a chronic condition that may require treatment with several medications. It is important to remember that untreated bipolar disorder has a fatality rate of 18 percent or more (from suicide), equal to or greater than that for many serious physical illnesses. The untreated disorder carries the risk of drug and alcohol addiction, damaged relationships, school failure, and difficulty finding and holding jobs. The risks of not treating are substantial and must be measured against the unknown risks of using medications whose safety and efficacy have been established in adults, but not yet in children.

Effective treatment depends on appropriate diagnosis of bipolar disorder in children and adolescents. There is some evidence that using antidepressant medication to treat depression in a person who has bipolar disorder may induce manic symptoms if it is taken without a mood stabilizer. In addition, using stimulant medications to treat attention deficit hyperactivity disorder (ADHD) or ADHD-like symptoms in a child with bipolar disorder may worsen manic symptoms. While it can be hard to determine which young patients will become manic, there is a greater likelihood among children and adolescents who have a family history of bipolar disorder. If manic symptoms develop or markedly worsen during antidepressant or stimulant use, a physician should be consulted immediately, and diagnosis and treatment for bipolar disorder should be considered.

In addition to seeing a child psychiatrist, the treatment plan for a child with bipolar disorder usually includes regular therapy sessions with a licensed clinical social worker, a licensed psychologist, or a psychiatrist who provides psychotherapy. Cognitive behavioral therapy, interpersonal therapy, and multi-family support groups are an essential part of treatment for children and adolescents with bipolar disorder. A support group for the child or adolescent with the disorder can also be beneficial, although few exist.

Therapeutic Parenting
Parents of children with bipolar disorder have discovered numerous techniques that the Child Adolescent Bipolar Foundation (CABF) refers to as therapeutic parenting. These techniques help calm their children when they are symptomatic and can help prevent and contain relapses. Such techniques include:

• practicing and teaching their child relaxation techniques
• using firm restraint holds to contain rages
• prioritizing battles and letting go of less important matters
• reducing stress in the home, including learning and using good listening and communication skills
• using music and sound, lighting, water, and massage to assist the child with waking, falling asleep, and relaxation
• becoming an advocate for stress reduction and other accommodations at school
• helping the child anticipate and avoid, or prepare for stressful situations by developing coping strategies beforehand
• engaging the child's creativity through activities that express and channel their gifts and strengths
• providing routine structure and a great deal of freedom within limits
• removing objects from the home (or locking them in a safe place) that could be used to harm self or others during a rage, especially guns; keeping medications in a locked cabinet or bo.x

What are the educational needs of a child with bipolar disorder?
A diagnosis of bipolar disorder means the child has a significant health impairment (such as diabetes, epilepsy, or leukemia) that requires ongoing medical management. The child needs and is entitled to accommodations in school to benefit from his or her education. Bipolar disorder and the medications used to treat it can affect a child's school attendance, alertness and concentration, sensitivity to light, noise and stress, motivation, and energy available for learning. The child's functioning can vary greatly at different times throughout the day, season, and school year.

The special education staff, parents and professionals should meet as a team to determine the child's educational needs. An evaluation including psychoeducational testing will be done by the school (some families arrange for more extensive private testing). The educational needs of a particular child with bipolar disorder vary depending on the frequency, severity and duration of episodes of illness. These factors are difficult to predict in an individual case. Transitions to new teachers and new schools, return to school from vacations and absences, and changing to new medications are common times of increased symptoms for children with bipolar disorder. Medication side effects that can be troublesome at school include increased thirst and urination, excessive sleepiness or agitation, and interference with concentration. Weight gain, fatigue, and a tendency to become easily overheated and dehydrated impact a child's participation in gym and regular classes.

These factors and any others that affect the child's education must be identified. A plan called an IEP (Individual Education Plan) will be written to accommodate the child's needs. The IEP should include accommodations for periods when the child is relatively well (when a less intense level of services may suffice), and accommodations available to the child in the event of relapse. Specific accommodations should be backed up by a letter or phone call from the child's doctor to the director of special education in the school district. Some parents find it necessary to hire a lawyer to obtain the accommodations and services that federal law requires public schools to provide for children with similar health impairments.

Examples of accommodations helpful to children and adolescents with bipolar disorder include:

• preschool special education testing and services
• small class size (with children of similar intelligence) or self-contained classroom with other emotionally fragile (not behavior disorder") children for part or all of the day
• one-on-one or shared special education aide to assist child in class
• back-and-forth notebook between home and school to assist communication
• homework reduced or excused and deadlines extended when energy is low
• late start to school day if fatigued in morning
• recorded books as alternative to self-reading when concentration is low
• designation of a "safe place" at school where child can retreat when overwhelmed
• designation of a staff member to whom the child can go as needed
• unlimited access to bathroom
• unlimited access to drinking water
• art therapy and music therapy
• extended time on tests
• use of calculator for math
• extra set of books at home
• use of keyboard or dictation for writing assignments
• regular sessions with a social worker or school psychologist
• social skills groups and peer support groups
• annual in-service training for teachers by child's treatment professionals (sponsored by school)
• enriched art, music, or other areas of particular strength
• curriculum that engages creativity and reduces boredom (for highly creative children)
• tutoring during extended absences
• goals set each week with rewards for achievement
• summer services such as day camps and special education summer school
• placement in a day hospital treatment program for periods of acute illness that can be managed without inpatient hospitalization
• placement in a therapeutic day school during extended relapses or to provide a period of extra support after hospitalization and before returning to regular school
• placement in a residential treatment center during extended periods of illness if a therapeutic day school near the family's home is not available or is unable to meet the child's needs

Quick reference
What is bipolar disorder?
Bipolar disorder, also known as manic depression, is a mood disorder characterized by extreme shifts in mood, from depressive lows to manic highs.

What are the different types of bipolar disorder?
The American Psychiatric Association's Diagnostic and Statistical Manual Fourth Edition (DSM-IV) has divided bipolar disorder into two types, Bipolar I, the more severe form, and Bipolar II, the "milder" form. In addition, the DSM-IV lists as separate disorders "Cyclothymia," which could be described as an even milder version of bipolar, and schizoaffective disorder, which borders on schizophrenia.

What are the symptoms of bipolar I?
Bipolar I requires only the presence of a single manic episode, though just about all people with bipolar I experience major depressive episodes, as well. The DSM describes a manic episode as "a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week" (or requiring hospitalization). In addition, the DSM requires at least four of the following seven symptoms (three if merely irritable): 1) Inflated self-esteem or grandiosity, 2) decreased need for sleep, 3) More talkative than usual, 4) Flight of ideas, racing thoughts 5) Distractibility, 6) Increase in goal-setting activity or psychomotor agitation 7) Excessive involvement in pleasurable activities (such as buying sprees, sexual indiscretions, or foolish business investments).

The DSM goes on to say that the symptoms must be severe enough to interfere with work or social relations or necessitate hospitalization to prevent harm to one's self or others. Those manic highs must be a lot of fun. Not really. People on manic highs are out of control, and people out of control quickly get into trouble. Ruined careers, personal bankruptcy, and wrecked relationships are par for the course, and hospitalization, incarceration, and homelessness are far too common. Moreover the intoxicating high of mania (euphoria) can turn on itself into a raging agitation (dysphoria) that creates a state of internal hell. Also, most people in a manic episode experience at least one psychotic symptom (such as delusional thoughts or hallucinations). Finally, there are "mixed" states where one is literally both manic and depressed.

What are the symptoms of bipolar II?
The DSM requires that in order to be diagnosed as Bipolar II the patient should show symptoms or have history of at least one major depressive episode along with having symptoms or a history of at least one hypomanic episode. Hypomania can be described as "mild" mania, that have the same symptoms, but where these symptoms are not serious enough to interfere with work or the social life of a person, although they are clearly observable by others.

One can also define a person with hypomania as the "life of the party" with "salesperson of the month" productivity. Since because everything seems so perfect in this state, people experiencing these episodes are completely oblivious to the fact that there is anything wrong, and they usually fail to ask for help. Since this state does not last forever, after a while there is a crash into depression or an escalation into experiencing mania. People with bipolar I often experience hypomania before experiencing mania.

There are some patients who seem to benefit from the constant state of hypomania. This is mainly because since they are successful they don't come to the attention of the psychiatric profession. A well known authority on bipolar disorder, Kay Jamison PhD in 2002 described Teddy Roosevelt as hypomanic on a mild day. Bill Clinton is also considered to be a walking hypomania poster boy.

What are the symptoms of cyclothymia?
Cyclothymia can be defined as "bipolar light," that is characterized by mind mood swings from hypomania to mild depression.

What are the symptoms of schizoaffective disorder?
The DSM lists this psychiatric disorder under "Schizophrenia and Other Psychotic Disorders," but many experts suggest that even though bipolar and schizophrenia are totally different disorders they have certain similar or overlapping symptoms. Schizoaffective disorder lies between bipolar and schizophrenia and it is characterized by mania and depression as well as psychosis such as delusions, hallucinations, incoherent speech or other symptoms of schizophrenia.

I have my up moods and down moods, my bad days and good. Does this mean I have bipolar?

Mood swings for most people are normal, as moods are affected by the emotional mindset of a person that include elation, grief, and anger. When a patient's behavior begins to affect his work and social relations or is easily noticed by others, then the person may have a problem.

The depressive side of Bipolar Disorder
Mania usually gets all the attention since the person seems agitated and very energetic, but most people do not realize that bipolar patients are actually depressed three times more than they experience maniac episodes. The depressed phase of the illness is more dangerous than the maniac side since the depressive side results in more hospitalizations compared to the manic side. Depression in bipolar disorder accounts for nearly all of related suicides and one in five of these suicides goes undiagnosed.

Is bipolar depression different than unipolar depression?
Bipolar depression has been little studied and the depressive side of this disorder until very recently was not taken very seriously by researchers and clinicians. Based on the available data it can be concluded that many people with bipolar disorder suffer from "atypical" depression rather than "melancholic" depression that is characterized by eating or sleeping too much along with other symptoms such as sensitivity to rejection, and leaden paralysis.

Rapid-cycling.
The DSM's standard of rapid cycling is that the patient must experience at least four episodes over a period of one year. Rapid-cyclers usually change form one mood to the other and then back to the original mood at far shorter intervals, sometimes several times a day and at times even many times an hour. In rare cases rapid cyclers can change moods in the space of minutes. Since most of the patients who experience who rapid-cycle represent a moving target, and due to the instability of their mental condition, this group of individuals are much more difficult to treat, with extremely high rates of failure. Women affected with this disorder are more likely to be rapid-cyclers compared to men.

Bipolar consists of various episodes that affect the patient's moods and at times there are long periods of remission between episodes. In a chronic disorder such as schizophrenia the patient's cognition is affected in such a way that it progressively worsens. Lately many experts believe that in bipolar disorder even between episodes, many patients experience subtle cognitive deficits that can worsen over time.

Although the brain has numerous ways of repairing itself, brain imaging studies and studies of post-mortem brains indicate smaller volumes in certain segments of the brain and larger volumes in other bipolar patients, which may affect their ability to learn, ability to remember and function normally. Some of the medications that are prescribed for bipolar disorder have been found to prevent further deterioration and in some cases even reverse the damage. Studies conducted on rats have shown that two bipolar medicines, lithium and Depakote, can successfully make new brain cells to grow and a study on humans found that the medicine lithium produced similar results.

People with bipolar tend to suffer from at least one other mental illness, as well, including anxiety and panic, and alcohol and substance dependence. According to one major study 61 percent of people that are affected with bipolar are also affected with substance dependence disorder for a lifetime.

People with bipolar and a substance dependence problem
The Substance Abuse and Mental Health Services Administration advises psychiatrists to treat both these illnesses at the same time, ideally in a comprehensive setting in the same facility or at the minimum with different health care providers working together.

Does bipolar affect other areas of the body?
Yes, unfortunately. People with bipolar usually die seven years before those in the general population and this number is not related to suicide. Most of the research on the mind-body connection relates to depression, but we can apply much of those findings to bipolar. The risk of heart disease is doubled in people with depression, and a previous depression is often the greatest risk factor for heart disease and other ills, over smoking, drinking, high blood sugar, and previous heart attacks. Depression has also been connected to diabetes, bone loss, stroke, irritable bowel syndrome, and possibly cancer.

How serious a problem is bipolar?
The Stanley Bipolar Foundation Network, which admittedly gets the sickest patients in its clinics, recently released this data: 85.1 percent had been hospitalized in the past, on average three times. The rate of suicide attempts was 50.3 percent. A third were currently married, another third single, and the rest were separated, divorced, or widowed. Despite the fact that approximately 90 percent had high school diplomas and a third had completed college, almost 65 percent were unemployed and 40 percent were on welfare or disability. According to Mark Bauer in 2001 when he spoke at a conference, up to 50 percent of bipolar patients remain ill for long periods in their life.

The good news is we can dramatically improve our chances by being compliant with our medications, and making lifestyle choices that contribute to our mental and physical well-being.

The demographics of bipolar?
Approximately one to two percent of the population suffers from bipolar, but some experts push the figure up to as high as five percent by adopting softer criteria for the illness. Equal numbers of men and women suffer from the illness. People tend to have their first episode in their late teens or early twenties, though they may have experienced some of the symptoms much earlier.

Can children get bipolar?
Yes, and sad to say it appears to be far more frequent than in the past. Moreover, studies are finding that bipolar children are sicker than bipolar adults. A bipolar child can rage out of control for hours on end and literally hold his family hostage. Because the illness on the surface appears similar to ADHD or conduct disorder, children are usually misdiagnosed - often by psychiatrists who refuse to believe that kids can get bipolar - and are treated with the wrong drugs that make their condition worse.
So how do you tell a bipolar child from one who has ADHD or conduct disorder?
Only by careful observation and long conversations with the parents. As opposed to those with ADHD or conduct disorder, for example, bipolar children tend to be risk-seeking and grandiose, with nonstop flight of thoughts.

How controversial is the topic of bipolar in children?
Very. Fortunately, the problem has been recognized, psychiatrists are waking up to the situation, and a lot of new research is underway. Much of the controversy centers on whether we should be giving children meds that are intended for adults, but a lot of this comes from people who deny mental illness exists in the first place and who are opposed to all forms of psychiatry.

What causes bipolar?
We don't really know, though we do know that genes predispose people to the illness, and that stress can trigger an episode. One possibility is there is an overabundance of the excitatory neurotransmitter glutamate in the synapse (the space between two neurons) due to cortisol, which is secreted as part of the "flight or fight" reaction to stress. The glia - the "other" brain cell - is thought to clear excess glutamate from the synapse, but bipolar patients have a shortage of glia. Glutamate in turn generates calcium which flows through an ion channel penetrating the cell membrane and into the neuron and activates calcium-dependent enzymes inside.

There are other ion channels that may be over stimulated in response to various neurotransmitters. In addition, researchers are also looking at the neurotransmitter dopamine, with is involved in pleasure and reward. There is also some evidence that vitamin or mineral deficiencies may play a role. In all likelihood, several processes are occurring at once, and not necessarily the same ones individual to individual.

I think my client may be bipolar. What is my first stop?
If they are in a life-threatening situation, or if they may be a danger to others, they must go to an emergency room of their local hospital. Otherwise, you should refer them to a psychiatrist.

Why a psychiatrist?
First, because medications are the cornerstone of bipolar treatment, and only medical doctors such as psychiatrists can prescribe medications, unlike a psychologist who specializes in therapy. Second, because of their training and experience, psychiatrists are far more likely to give a correct diagnosis than going to your family doctor.

What should they expect from a psychiatric examination?
They can expect questions ranging from how you are feeling to how you are faring at work and at home to any family history of mental illness, if any. All the while, the psychiatrist will be probing for unusual behavior, such as spending sprees or talking too fast. Unfortunately, it takes bipolar I patients six years and bipolar II patients more than 11 years between first contact with the medical system and a correct diagnoses.

When a client sees a psychiatrist they should focus on all those times they didn't feel their normal self or too much like their normal self. They might want to go back over those times in your life they would rather forget - such as embarrassing themselves in public or attacking their spouse or walking off their job or getting arrested - or where they were unusually productive - working 20-hour days, cleaning the house in the middle of the night, writing a term paper in three hours - and try to remember what you were feeling during the time and the times that led up to these events. If they felt that they were smarter than the rest of the world, describe it. If they were incapacitating, describe how hard it was to get out of bed. If possible, try to write down everything they can recall in order to organize their thoughts.

How is bipolar treated?
Ideally, by a combination of different medications, psychotherapies, natural treatments and lifestyle choices. No one treatment, therapy, or lifestyle choice on its own is likely to get the job done. A number of them working as complements to each other ensures the best chance of success.

Clinical States and Course Specifiers: Implications for Treatment
There is increasing evidence that the symptoms of bipolar disorder, particularly the presence of rapid cycling or mixed states, may have major clinical implications. Bipolar disorder can manifest with a variety of clinical presentations along the course of the patient's lifetime. Mixed states along with rapid cycling and psychosis may occur as a phases of the disorder. Rapid cycling and psychotic features may also be permanent and be part of a sub type of the disorder. These factors may influence the use of different medications and combinations of medications at different periods during the treatment of bipolar disorder. There is significant evidence that mono therapy along with a mood stabilizer over a long period of time benefits only a minority of patients. Hence, classifying the bipolar disorder into specific subtypes, like mixed states, rapid cycling and or psychosis, at different points in the course of the illness may allow more specific choice of successful treatment.

Commonly Asked Questions

What about sexual dysfunction?
Viagra may help, for women as well as men.

What about the other side effects?
There are many medicines available to treat tremors and spasms, and it is also possible to find wakefulness agents to handle sedation. Many times by simply lowering the dose or changing to a different medicine the problem at hand can be solved. If the patient experiences any side effects then he should discuss about the side effects with his psychiatrist, so they can work on a solution. Patients should also be aware that good lifestyle choices can reduce potential side effects.

Tell me about benzodiazepines.
Benzodiazepines include diazepam, lorazepam, and clonazepam. The main purpose of these drugs is to relieve anxiety and to reduce sleep problems, but they can be very effective in quickly reducing the patient from a state of manic and they can also be used as an additional medicine to control maniac episodes. The main drawback of these medicines is they can be addictive, causing severe withdrawal symptoms, as well as having a depressive effect if stopped suddenly hence they are usually prescribed to patients on a short-term basis or on an as-needed basis.

What about pregnancy and breastfeeding?
Always check with a doctor or psychiatrist. In general, antidepressants are considered safe through all phases of pregnancy and breastfeeding. Mood stabilizers like lithium can cause an heart defect in the first trimester, while the risk of spina bifida is considered to be very hight to be take mood stabilizers like Depakote or Tegretol during the first trimester. Of the antipsychotics, Haldol, the most studied, can be used safely during pregnancy. Frederick Goodwin MD at a 2001 conference stated that because of the risk of postpartum mania in pregnant women it is very important for expectant mothers to resume taking their medicines well before giving birth. Alternatives to taking bipolar medicines include opting for a omega-3 fatty acids and light therapy. ECT is considered as the last option. Three bipolar medicines that should be avoided taking while breastfeeding include Lithium, Lamictal and antipsychotics.

Can you mix alcohol with Bipolar medications?
Caffeine and nicotine are other drugs you should seriously consider eliminating or cutting back on.

How do clients know if they are taking the correct medications?
The short answer is they don't. The APA and other groups have come up with treatment guidelines and treatment algorithms, based on expert consensus, to guide clinicians through a range of options. The state of Texas, in its pioneering bipolar algorithm, for example, recommends either lithium or Depakote or Zyprexa for treating mania, and various two-med combinations if the result is less than satisfactory until we graduate to three-med combinations in stage five. The reason lithium, Depakote, and Zyprexa are mentioned as first choices is because they are the most studied, and until Lamictal joined the list in June 2003 and Risperdal in Dec 2003 the only ones FDA-approved to treat bipolar (the rest are prescribed "off-label, but with FDA approval expected for most).

But because every individual is unique and no two cases of bipolar are the same, they are basically a guinea pig. Very rarely do one's first meds work like a charm, and the process of finding the combination that works best can involve months and even years of heartbreak and frustration. This sounds very discouraging.

Only if one believes that they should sit back and let their medications do all the work. Smart lifestyle choices and various coping techniques can make a world of difference. Medications treatment can also be combined with psychotherapy to great effect.

How does cognitive therapy work?
Cognitive therapy - also called cognitive behavioral therapy - works to change erroneous thoughts (such as "It's the end of the world.") into more positive ones (such as, "Let's find a solution.") Once one is thinking and behaving in a positive way - such as working toward a solution than bewailing the end of the world - one actually begins feeling better. The therapy applies equally well to depression and mania. The therapy typically lasts 10 to 20 sessions, and involves active participation and homework. Various studies have found cognitive therapy to be as effective as antidepressant treatment. One major study found that a type of cognitive therapy combined with an antidepressant produced better results that either therapy or antidepressant treatment alone.

What about other types of psychotherapy?
Before you engage in therapy that involves working on painful issues or suppressed memories, it is very important that your mood be stabilized, as otherwise these therapies can cause your condition to deteriorate. Some therapists take a dim view of medications, and their opinions on the subject are the last thing you need to be exposed to while you are still recovering and vulnerable. Having said that, if your boss is making you unhappy and your family is causing you stress, simply taking meds or doing cognitive therapy is not going to change these situations. These represent very dangerous triggers that need to be addressed. Therapy that can help you resolve these issues may literally save your life.

What about ECT?
Electro-convulsive therapy, also known as shock treatment, has been used successfully to treat both depression and mania, but because of risk of short-term memory loss - and in rare cases long-term memory loss - is regarded as a treatment of last resort, except if the patient's condition puts him or her in a life-threatening situation where achieving a quick response is vital. Patients are typically given a course of several or more ECTs spaced over several weeks. Treatment involves being given anaesthesia and muscle relaxants. Electrodes are placed to one side or both sides of the skull and a current is switched on. The treatment is controversial, though much of the opposition comes from groups opposed to all forms of psychiatry. Unfortunately, the psychiatric profession has been less than honest about problems like memory loss, and neglects to mention that relapses of the disorder are common which will require the patient to undergo additional "booster" treatments.

Keep in mind that the middle of a raging depression is not the time to be making decisions about ECT. People with their bipolar in remission should do their research now and make their decision accordingly, while they have their wits about them.
Alternative or complementary treatments for bipolar
Yes. These include omega-3 fatty acids, vitamin and mineral supplements, and acupuncture.
Omega-3 fatty acids

Omega-3 is found in deepwater fish such as salmon and in flax. One study found that countries with low fish consumption coincided with high depression rates. A pilot study using omega-3 in conjunction with normal meds found the substance to be effective in treating bipolar. Until we know more, it is advised that omega-3 be considered as a complement to, rather than as a replacement for, one's normal medications.

Vitamins and mineral supplements
Unfortunately, much of the food we eat comes from soil depleted of nutrients. The raw materials for producing neurotransmitters are nutrients. A deficiency of vitamin B6, for instance, may affect how serotonin is synthesized. In lieu of precise knowledge of one's individual deficiencies, all-purpose supplement combinations may be an option. One pilot study found a certain supplement combination dramatically improved symptoms in bipolar patients. Larger studies are planned. Use under a doctor's supervision. It is advisable to use supplements as a complement to medications rather than as a replacement.

Acupuncture
A pilot study comparing depression treatment (where the needles were placed at specific "depression" points) to sham treatment (the needles were randomly applied) found those in the depression treatment group experienced a 42 percent reduction in symptoms compared to 22 percent for the controls, with virtually no side effects. A larger study is underway, as is an acupuncture study using bipolar patients.

Lifestyle choices
These include diet, exercise, sleep, avoiding stress, and religious or spiritual practice.

Diet
Diet is crucial to good mood. When choosing a healthy diet, there are no right or wrong choices, though in general high fat, high sugar, and high carbohydrate diets should be avoided, and junk foods, caffeine and alcohol restricted. Folate (from leafy green vegetables) deficiency and high sugar intake have been linked to depression. Carbohydrates get processed into sugar, which can boost serotonin but also induce mood-busting sugar crashes. Chocolate can act as a tasty antidepressant, with an endorphin-like effect, but can also set one up for a sugar crash. Paradoxically, eating too much sugar can lower blood sugar levels in some people, which results in further unhealthy cravings. Be mindful about switching to NutraSweet, however. One small study of patients with depression found they had severe reactions to its working chemical, aspartame.

Exercise
Numerous studies have found aerobic exercise works as effectively as antidepressants. Generally, the last thing you want to do when you're depressed is exercise, but even a five minute walk can help. Exercise not only promotes regular sleep and eating but it also increases energy levels, generates beneficial endorphins, boosts serotonin levels and it may even stimulate new brain cell growth.

Sleep
Too little or too much sleep affects just about everyone with a mood disorder. For those with bipolar, missing a night's sleep can trigger a manic episode. A major key to establishing good sleep hygiene is going to bed and waking up at a regular hour. For those who continue to experience difficulties, psychotherapy can help, as well as sleeping pills and wakefulness agents.

Avoiding stress
Stress is toxic to anyone with a mood disorder, so every effort needs to be made to reduce stressful situations from one's life and develop appropriate skills for coping. This may involve major life decisions regarding work and personal relationships. Numerous psychotherapies can help people work through difficult job and relationship situations so that stress is less of a factor in one's life. Therapy can also teach a range of coping skills. Other coping strategies include exercise, meditation, yoga, and relaxation exercises.

Religious or spiritual practice
A multitude of studies have found those who are religious or spiritual live longer, are healthier, recover from illnesses quicker, and are less depressed. Much of this undoubtedly has to do with the support one gets from one's religious community, as well as the more healthy lifestyles these people tend to lead, not to mention the comfort that belief in a higher power can bring. In addition, the exercises and practices associated with religion and spirituality such as meditation, prayer, and yoga have positive benefits on mental and physical health. Scientists also speculate the immune system and other biological processes may be enhanced by religious or spiritual practice. Finally, don't rule out pure God-power.

Support groups
A major study found that online support groups have a positive impact on depression. Face to face support groups have a similar benefit. At a support group, you meet people who have walked in your shoes, who have unique insights into the illness that they are all too happy to share, and are willing to be with you in a time of crisis. In lieu of a support group, family support and support from trusted friends is crucial.

Journaling
Many people with bipolar keep a mood journal or a daily diary of their ups and downs. Mood journals can help you spot patterns to your episodes, as well as a depression or mania in the making.
Coping day to day
Over time, you will develop your own personal bag of tricks. These can range from keeping a journal to taking some time out for yourself to do volunteer work. In general, any project that makes it worth your while to get out of bed or any activity that helps motivate you to get out of the house and be with other people should be regarded as beneficial.

Feeling suicidal
Get help immediately. Treat this as a crisis every bit as life-threatening as a heart attack, which it is. Every year, one million people worldwide die by their own hand, most as a result of depression or bipolar. The true figure is probably many times higher, disguised as death by accident or death by risky behavior. Contact a trusted friend or family member. In the US, the national suicide hotline is 1 800 SUICIDE. Just as someone with a heart attack goes to the emergency room, that is where you should be, unless someone competent has decided you are not in danger.

Suicidal crisis
Have a good support network in place, people you can contact at a moment's notice. Have a good relationship with your doctor, therapist or psychiatrist, as you may need to call him or her in the middle of the night. Commit the national suicide hotline to memory, if you live in the US, and have local hotline numbers handy.

Plan
Majority of the suicides related to depression occur during the first three depressive episodes and before the patient understand that an episode of suicidal thinking is temporary. The likelihood that the patient will actually act on impulsive suicidal thoughts drops significantly after they realize that this phase will pass away. To prevent suicide it is important for the patient to have a plan of action ready before depression and thoughts of suicide occur. Some people find it helpful to develop an action plan that includes warning signs the patient should watch out for and steps to take if the patient feels that he is slipping into suicidal thoughts. The Plan for Life of the patient may include:

• Contact information for your doctor, psychiatrist, and therapist, including back-up phone numbers (emergency services, pager and cell phone)
• Contact information for friends and family.
• A description of medical diagnosis, not just your depression but any medical problems you may have. Include information about any medications you are taking.
• Health insurance information
• Contact information for a local suicide hotline
• Contact information for your support group.

Educate those you trust about your condition before it becomes a crisis so they can be prepared if they are called upon to help. Provide key support people with your plan so they can act quickly, if needed. Carry a copy of your plan with you at all times so you can refer to it or pass it along to someone else who might be helping you in a time of crisis. With all the phone numbers in one place, it will be easier for someone to help.

How to fight suicidal thoughts
Keep a journal to write down your thoughts. Each day, write about your hopes for the future and the people you value in your life. Read what you've written when you need to remind yourself why your own life is important.
Go out with friends and family. When we are well, we enjoy spending time with friends and family. When we're depressed, it becomes more difficult, but it is still important. Visiting or allowing visits by family and friends who are caring and can understand may help you feel better

Patients should avoid drugs and alcohol since most deaths by suicide result from sudden unstoppable impulses. Patients are advised to stay away from intoxicating substances since drugs and alcohol contribute to irrational and uncontrollable impulses. Drugs and alcohol also interfere with medications prescribed for depression and these substances cause the prescribed medications to be useless.

Learn to recognize the earliest warning signs of a suicidal episode. There are often subtle warning signs your body will give you when an episode is developing. As you learn to manage your illness, you will learn how to be sensitive to them. This is a signal to treat yourself with the utmost care, as opposed to becoming angry or disgusted with yourself.

Talk about suicide. Your ability to explore the feelings, thoughts, and reactions associated with depression can provide valuable perspective and reassurance to your friend or loved one who may be depressed. Talking about suicide does not plant the idea in someone's head. Not everyone who thinks of suicide attempts it. For many, it's a passing thought that lessens over time. For a significant number of people, however, the hopelessness and exaggerated anxiety brought on by untreated or under-treated depression may create suicidal thoughts that they cannot easily manage on their own. For this reason, take any mention of suicide seriously.
Recognizing warning signs

Sometimes even health care professionals have difficulty determining how close a person may be to attempting suicide. If you sense there is a problem, ask the person direct questions and point out behavior patterns that concern you. Remind the person that you care about them and are concerned. Talking about suicide with someone will not plant the idea in his or her head. If you believe that immediate self-harm is possible, have them sign a no suicide contract and take the person to a hospital emergency room immediately.

NO SUICIDE CONTRACT
I, __________________________PROMISE (COMMIT) THAT
I WILL NOT KILL, HARM OR INJURE MYSELF IN ANY MANNER WITHOUT FIRST TALKING TO MY THERAPIST, DOCTOR, PSYCHIATRIST OR WITH SOME RESPONSIBLE, CARING AND SUPPORTIVE PERSON THAT I HAVE PREVIOUSLY DESIGNATED.
FURTHERMORE, SHOULD I BECOME DEPRESSED OR FEEL HOPELESS AT ANY TIME OF DAY OR NIGHT, I WILL CONTACT SOMEONE WITH WHOM I CAN TALK.
I ACKNOWLEDGE THAT I HAVE RECEIVED TELEPHONE NUMBERS, NAMES AND ADDRESSES OF PROFESSIONAL PERSONS AND ORGANIZATIONS THAT CAN BE REACHED 24 HOURS A DAY.
IMPORTANT PEOPLE IN MY LIFE WITH WHOM I CAN TALK AND WILL CONTACT ARE:
NAME RELATIONSHIP PHONE #

Doctor

Therapist

Psychiatrist

Suicide Hotline 1-800-SUICIDE
(1-800-784-2433)











SIGNATURE
DATE
TIME


WITNESS
DATE
TITLE


 

Feelings of despair and hopelessness
Often times, people with depression talk about extreme, feelings of hopelessness, despair and self-doubt with those closest to them. The more extreme these feelings grow, and the more often they are described as "unbearable," the more likely it is that the idea of suicide may enter the person's mind

Taking care of business
When a person is "winding up his or her affairs" and making preparations for the family's welfare after he or she is gone, it is a good chance they are considering self-harm or suicide.

Rehearsing suicide
Rehearsing suicide or discussing specific methods of suicide repeatedly are also indications of a person planning to commit suicide. Even if the person's suicidal intention do not appear to be permanent such steps taken for preparation makes it much easier for the individual to give in to a sudden uncontrollable impulse.

Drug or alcohol abuse
A person with worsening depression may abuse drugs or alcohol. These substances can worsen symptoms of depression or mania, decrease the effectiveness of medication, enhance impulsive behavior, and severely cloud judgment.

Beginning to feel better
It may sound strange, but a person with depression may be most likely to attempt suicide just when he or she seems to have passed an episode's low point and be on the way to recovery. Experts believe there is an association between early recovery and increased likelihood of suicide. As depression begins to lift, a person's energy and planning capabilities may return before the suicidal thoughts disappear, enhancing the chances of an attempt. Studies show that the period six to twelve months after hospitalization is when patients are most likely to consider or reconsider suicide.

Express empathy and concern
Severe depression is usually accompanied by a self-absorbed, uncommunicative, withdrawn state of mind. When you try to help, you may be met by an individual's reluctance to discuss what he or she is feeling. At such times, it is important to acknowledge the reality of the pain and hopelessness he or she is experiencing. Describe specific behaviors and events that trouble you. If you can explain particular ways a persons' behavior has changed, this may help to get communication started. Try to help him or her overcome feelings of guilt. Compounding the lack of interest in communication may be guilt or shame over having suicidal thoughts. If there has already been a suicide attempt, guilt over both the attempt and its failure can make the problem worse. It is important to reassure the individual that there is nothing shameful about what they are thinking and feeling. Keep stressing that thoughts of hopelessness, guilt, and even suicide are all symptoms of a treatable medical condition and reinforce the person's good. Stress that the person's life is important to others Emphasize in specific terms the ways in which the person's suicide would be devastating to others. Share (if possible) stories and pictures of past events with friends and loved ones.

Anger
The person may express anger and feel betrayal by your attempt to prevent their suicide.

Always be supportive
A person who has thought about or attempted suicide will most likely have feelings of guilt and shame. Be supportive and assure the person that their actions were caused by an illness that can be treated.

It is not uncommon for friends and family members to experience stress or symptoms of depression when dealing with a suicidal person. They can only help the person through their own treatment with encouragement and support. They cannot get better for them. They should not focus all of their energy on the one person, ask friends and family to join them in providing support and keep to their normal routine as much as possible. They should pay attention to their own feelings and seek help if they need it. Responding to an emergency situation

If someone is threatening to commit suicide; if someone has let you know they are close to acting on a suicidal impulse, or if you strongly believe he or she is close to a suicidal act, these steps can help you manage the crisis.

Take the person seriously. Stay calm, but don't under-react.
Involve other people. Don't try to handle the crisis alone or jeopardize your own health or safety. Call 911, if necessary. Contact the person's doctor, the police, a crisis intervention team, or others who are trained to help.
Express concern. Give concrete examples of what leads you to believe the person is close to suicide.

Listen attentively. Maintain eye contact. Use body language such as moving close to the person or holding his or her hand, if appropriate.

Ask direct questions. Find out if the person has a specific plan for suicide. Determine, if you can, what method of suicide is being considered.

Acknowledge the person's feelings. Be understanding, not judgmental or argumentative. Do not relieve the person of responsibility for his or her actions.

Offer reassurance. Stress that suicide is a permanent solution to a temporary problem, reminding the person that there is help and things will get better.

Don't promise confidentiality. (you may want to remind the client about your confidentiality agreement: that you will only break confidentiality if your client is in danger of hurting themselves or others) You may need to speak to the person's doctor in order to protect the person from him or herself.

Make sure guns and old medications are not available.

If possible, don't leave the person alone until you are sure they are in the hands of competent professionals. If you have to leave, make sure a friend or family member can stay with the person until they can receive help.

It is pointless to disregard the full destructive power of bipolar, and because of it some people may have to considerably scale back their expectations in life. On the positive side, you have survived one of the most malevolent forces on the planet, and you are a much stronger person as a result, in closer touch with your own humanity.
Alcohol and recreational drugs with medications
Yes, doing so can be very harmful. Always talk to a doctor, psychiatrist or psychologist before mixing alcohol or illegal substances with prescription medications. Also, ask the pharmacist for the package insert from medications to learn about the drug interactions and side effects of the medication. Make sure to know how alcohol or illegal substances are going to interact with specific medications. Educating oneself could save a life.

Side effects from medications
Side effects of many medications include dry mouth, nausea, constipation, drowsiness, weight gain, weight loss or sexual dysfunction in patients of both sexes. Some side effects may be temporary while others can be permanent. Make sure your patient discusses any concerns he has before he receives a prescription.
There are a few things one can do to help relieve some side effects, including (all of these must be discussed with the client's psychiatrist or medical doctor prior to exercising these suggestions):

• Changing the time you take your medication.
• Taking your medication with or with/out food.
• Keep to your daily routine. Eat healthy meals, get regular exercise, and get plenty of rest.
• Drink plenty of water.
• Stay as physically active as you can. Even light exercise such as walking can help minimize physical effects of stress.
• Never stop taking medication or alter the dose without consulting the doctor.

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