Bipolar 2
Bipolar II



Bipolar disorder, also sometimes called manic-depressive disorder, is a mood disorder in which a person experiences episodes of mania without other etilogies to rule out the diagnosis of bipolar disorder. Also, possible, and more commonly known, is to have extreme shifts in mood between depression and manic euphoria.

These "cycles" which vary in speed, can sometimes affect the victim's levels of motivation, energy, and functioning, can be disabling. The DSM lists two main types of bipolar disorder (recognized clinically as Bipolar I and Bipolar II), the former of which features more marked mania, along with possible diagnoses of a "single non-recurring manic episode" which may not be called "bipolar disorder".



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Treatment of disabling bipolar disorder is with mood stabilizers, prominently lithium salts or some anticonvulsants.

Epidemiology
In most populations, bipolar disorder affects around 1% of the population. Bipolar disorder is gender-neutral, affecting both women and men equally. According to psychiatrists, the first episode typically appears in adolescence or early adulthood (mean of 21 years of age) and if recurring or cycling, affects sufferers throughout their life span. Although traditionally thought of as an adult disorder, there is now recognition that children may also suffer from chronic bipolar disorder. (see Bibliography for references.)



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Etiology
A diagnosis of bipolar disorder means the diagnosis of a person having a spontaneous and usually first episode, and they hypothesize that is likely to reoccur with manic or hypomanic symptoms or if diagnosed while manic, depressive symptoms. The causes of a manic episode may also be determinable, leaving the diagnosis of chronic bipolar disorder in doubt. See manic episode or depressive episode.

Episodes linked to stressful events
Scientists assert that recurring (as opposed to singular non-recurring) bipolar disorder may be caused by a combination of biological and psychological factors. Most commonly the onset of this disorder can be linked to stressful life events. According to the "Kindling theory" and possibly assumed, periods of depression, mania, or "mixed" states of manic (euphoric) and depressive symptoms typically recur and may become more frequent, often disrupting work, school, family, and social life. It is possible to see single occurences of depression and mania which do not recur.

The "kindling" theory suggests that persons who are genetically prone toward bipolar disorder experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Then at some point these mood changes occur spontaneously. The person then "becomes bipolar". This might explain why the cause of bipolar disorder is difficult to pinpoint but is somehow related to genetic and/or genetic and enviromental causes. People can also be "prone" to bipolar disorder after substance abuse, or because of a neurological condition or brain damage.

The Kindling Theroy has not been disputed. (as far as we are aware)

Multiple co-occuring explanations
If drug abuse can be linked to bipolar symptoms, they may not recur. Adderall and other drugs and amphetamines (including meth) have been cited as producing mania, even if the drug is not in the bloodstream. For such a patient, the euphoria of the Adderall might not wear off as quickly as it may for others. They may exhibit manic symptoms while on the drug. Some medications have depression as a side effect.

For some people, multiple factors may be valid, including:

stressful events or major life transitions
a family history of psychiatric diagnoses including bipolar disorder, clinical depression, or schizophrenia (This increases a family member's likelihood of having psychiatric symptoms by 10%)
past or present drug use (may complicate diagnoses if present and may lead to misdiagnoses)
Co-occurring conditions
The NIMH states that anxiety disorders and/or obsessive compulsive disorder (mild or severe) may co-occur with or after an episode. Such disorders are not episodic, so they may persist even when one's mood is stable. They may not respond to the medicine(s) that the bipolar disorder does. If thoughts of self-harm exist, the possibility of anxiety-linked obsessive-compulsive disorder should be explored.

Links with creativity
Many artists, musicians, and writers have experienced its mood swings, and some credit the condition with their creativity. However, this disease ruins many lives, and it is associated with a greatly increased risk of suicide. Kay Jamison, who herself is living with bipolar disorder and is considered the leading US expert on the disease, has also written several books that explore this idea. Research indicates that while manic phases may contribute to creativity (see Andreasen, 1988), hypomanic phases, such as those experienced in cyclothymia, actually contribute more (see Richards, 1988). This is perhaps due to the distress and impairment associated with full-blown mania.

Additionally, creativity has been linked to almost every medical conditions affecting the brain, including physical and cognitive disabilities.

Manifestations of bipolar disorder: types of episodes
Bipolar disorder manifests itself in numerous ways, most notably:

Depression: symptoms include a persistent sad mood; loss of interest or pleasure in activities that were once enjoyed; significant changes in body weight; significant changes in appetite; difficulty sleeping or oversleeping; physical slowing or agitation; loss of energy; feelings of worthlessness or inappropriate guilt; difficulty thinking or concentrating; recurrent thoughts of self-harm, death or suicide. (Some people are also diagnosed and treated for obsessive compulsive disorder, anxiety, and/or panic disorder.)
Mania: Abnormally and persistently elevated (high) mood and/or irritability accompanied by at least three of the following symptoms (four if the mood is merely irritable): decreased need for sleep; increased talkativeness; racing thoughts; distractibility; increased goal-directed activity such as shopping, or other tasks carried on in an urgent manner; physical agitation; hypersexuality; excessive involvement in risky activities. The behavior may seem unusual to friends or family, while the person's level of insight may vary, and is higher among those with co-occuring conditions.
Mania is often divided diagnostically into two categories:

full-blown manic episodes, and
hypomania, a less severe form of mania.
Hypomania is often not especially problematic for the person, as he or she typically feels very energetic and in a very good mood. As such, hypomania is often unreported and undiagnosed (this is perhaps the biggest cause of incorrect diagnoses between unipolar and bipolar depression.) Some patients experience only hypomania; in others, hypomania progresses into a full manic state in which the patient has more and more trouble retaining control, and the symptoms become more problematic. For some people, hypomania is an acceptable baseline.

Hypomania and mania can both make a person angry, making the mood shift harder to detect as even government guidelines advise that you watch for euphoria. Some people with bipolar disorder will never have full-blown mania; while others will have it rarely.

Mixed state: Symptoms of mania and depression are present at the same time. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and negative thinking, some of which may be automatic (see Automatic Negative Thoughts (ANTs) leading to depression. In a mixed state, depressed mood accompanies manic "activation". Also known as dysphoric mania (from Greek dysphoria: dys, difficulty, phorós, bearer); it does not euphoric characteristics. This is the form most often seen in children.
Diagnostic criteria
According to the DSM-IV-TR (p. 345), the two principal forms of Bipolar disorder are:

Bipolar I disorder, the diagnosis of which requires over the entire course of the individual's life at least one manic (or mixed) state episode which is usually (though not always) accompanied by major depressive episodes.
Bipolar II disorder, which over the course of the individual's life must involve at least one major Depressive episode and must be accompanied by at least one hypomanic episode. There must be no manic episodes. If there were manic episodes, the accurate diagnosis would be Bipolar I.
Therefore, bipolar disorder need not have both severe manic episodes and depressive episodes. In certain cases the sufferer has only episodes of mania. There need be no "cycles" of mania and depression.

This is why certain contemporary psychiatrists avoid from the original name, "manic depression", which suggests that all individuals have both mania and depression. It is unrelated with the notion of equal distribution of cycles of mania and depression, since there need not be any cycles at all-in fact, even when there is one (or more) bout of both mania and depression over the course of an individual's life, the two episodes may be so unrelated to each other temporally and otherwise that this need not constitute a cycle. However, a significant portion of individuals with bipolar experience the classical alternating episodes (cycles) of mania and depression and therefore it is overstating the case to say that the classical alternation "rarely" occurs.

The DSM-IV treats these bipolar disorders as variants of mood disorders (or affective disorders). Other types include major depressive disorder and dysthymic disorder. Bipolar and other mood disorders may have no identifiable medical, traumatic or other external cause (exogenous) or may be due to a medical condition (endogenous). Current psychiatric view no longer labels mood episodes as endogenous or exogenous. The exceptions being a substance induced mood disorder or a mood disorder due to a general medical condition.

In order for a person to be properly diagnosed with bipolar disorders, the mood episodes cannot be due to external medication, drugs or treatment for depression.

Cycles in bipolar disorder
Emil Kraepelin, who first described the illness, included in his original description of manic depression the phenomenon that episodes of acute illness, whether mania or depression, are usually punctuated by relatively symptom-free intervals during which the patient is able to function normally both at work and in social affairs.

The cycles of bipolar disorder may be long or short, and the ups and downs may be of different magnitudes: for instance, a person suffering from bipolar disorder may suffer a protracted mild depression followed by a shorter and intense mania. The manic episodes typically include euphoria, tirelessness, and impulsivity particularly relating to activities; the depressed periods may seem much worse following a manic period from the point of view of the patient.

Severe depression or mania may be accompanied by symptoms of psychosis. These symptoms include hallucinations (hearing, seeing, or otherwise sensing the presence of stimuli that are not there) and delusions (false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's cultural concepts). Psychotic symptoms associated with bipolar disorder typically reflect the extreme mood state at the time.

Domains of bipolar disorder
Mania
Researchers at Duke University have refined Kraepelin-s four classes of mania to include hypomania (featuring mainly euphoria), severe mania (including euphoria, grandiosity, sexual drive, irritability, volatility, psychosis, paranoia, and aggression), extreme mania (most of the displeasures, hardly any of the pleasures), and two forms of mixed mania (where depressive and manic symptoms collide)[2].

Hypomania
Hypomania is not necessarily a pathology, especially if not part of a cycle of mania or depression. Patients rarely, if ever, seek out a psychiatrist complaining of hypomania. Johns Hopkins psychologist John Gartner in The Hypomanic Edge contends that many of America-s greatest visionaries - including Christopher Columbus, Alexander Hamilton, Andrew Carnegie, Louis B Mayer, and Craig Venter (who mapped the human genome) owed their brilliance and drive (and eccentricities) to their hypomanic temperaments.

"Mania lite", however does carry a downside. Trisha Suppes of the University of Texas, Dallas points out that many hypomanic patients have symptoms of irritability (classic -road rage- cases). The DSM, at present, fails to recognize this fact of life. Hypomania can also signal the beginning of a more severe manic episode.

Unfortunately, hypomania has not been well-researched, and much more work needs to be accomplished before psychiatrists can accurately diagnose and treat this overlooked aspect of bipolar disorder. (See Hypomanic Nation.)

Bipolar depression
People with bipolar disorder are depressed far more often than they are manic. According to the Stanley Foundation Bipolar Network, bipolar patients spend three times more days in depression than they do in mania. For bipolar II patients, a study by Hagop Akiskal of the University of California, San Diego revealed this population was depressed 37 times more than they were hypomanic.

A 2003 study by Robert Hirschfeld of the University of Texas, Galveston found bipolar patients fared worse in their depressions than unipolar patients. (See Bipolar Depression.)

Cognition
Numerous studies show that bipolar disorder affects a patient's ability to think and perform mental tasks, even in states of remission. Deborah Yurgelun-Todd of McLean Hospital in Belmont, Massachusetts has argued these deficits should be included as a core feature of bipolar disorder.

By the same token, research by Kay Jamison of Johns Hopkins University and others have attributed high rates of creativity and productivity to individuals with bipolar disorder. (See Brain Damage.)

The Mood Spectrum
Clinical depression and bipolar disorder are classified as separate illnesses, but psychiatry is increasingly viewing them as part of an overlapping spectrum that also includes anxiety and psychosis.

In a 2003 study, Akiskal and Judd re-examined data from the landmark Epidemiological Catchment Area study from two decades before. The original study found that .08 percent of the population surveyed had experienced a lifetime manic episode (the diagnostic threshold for bipolar I) and .05 a hypomanic episode (the diagnostic threshold for bipolar II). But by tabulating survey responses to include criteria below the diagnostic radar, such as one or two symptoms over a short time period, the authors of the study recalculated the data to arrive at an additional 5.1 percent of the population, adding up to a total of 6.4 percent of the entire population who could conceivably be thought of as having bipolar disorder.

There is also a case that clinical (unipolar) depression can be bipolar disorder waiting to happen. In a 2005 study, Jules Angst and his colleagues at Zurich University tracked 406 patients with major mood disorders over a 20-year period. Of 309 patients presenting with depression, 121 (39.2 percent) eventually manifested as bipolar (24.3 percent to bipolar I, 14.9 percent to bipolar II). In all, more than 50 percent of the study population turned out to have bipolar disorder. (See The Mood Spectrum.)

Environmental factors affecting mood in bipolar disorder
In mid-2003, a twin study was published concerning environmental factors and bipolar disorder. The bipolar twin was found to be far more affected by changes in sunlight. Longer nights resulted in mood and sleep-length changes far greater than the healthy twin. Sunny days also did more to improve mood. In fact, natural light in general was found to have a profound positive effect upon the well-being of the bipolar twin.

Paradoxically, in the 2004 publication of a study using Tel Aviv's public psychiatric hospitals, it was found that "Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature". Unipolar depressed patient admission had no such correlation. High temperature points in the month, as well as high temperature months, were found to be correlated with depressive episodes in admissions.

Bipolar disorder and childbirth
For many women with depression or bipolar disorder, the postpartum period is a period of risk for developing illness. Episodes of bipolar disorder that follow childbirth are traditionally called postpartum depression (PD) puerperal psychosis (PP). Ian Jones of the Department of Psychological Medicine in Cardiff is researching this area.

Dual diagnosis
Bipolar disorder is often complicated by co-occurring alcohol or substance abuse. Traditionally this has been viewed as an attempt by patients to self-medicate the condition. More recently, some have doubted if this is an entirely accurate description. Cannabis in particular can alleviate symptoms of depression and may also have a mood stabilizing component in bipolar disorders, but the random titration of drug abusers usually does do more harm than good. There is growing evidence, however, that carefully titrated dosage of delta-9-THC tincture, taken sublingually, may prove of some benefit when taken with other mood stabilizer medications. In some cases, the substance abuse seems to begin before the onset of bipolar disorder, which is difficult to reconcile with the idea of self-medication (at least initially). Nicotine addiction is very common in people with bipolar disorder, and in the view of some, may be an active precursor to mature onset of both bipolar affective disorder and other forms of clinical depression in general.

Drugs like adderall, Ritalin or any stimulant can produce mania, but often times this is not actually bipolar disorder, but a singular manic episode. This is valid according to the DSM.

Treatment of bipolar disorder
There is no cure for bipolar disorder; the emphasis is on management of the symptoms. A variety of medications are used to treat bipolar disorder; many people with bipolar disorder require multiple medications (sometimes up to five). Some people with bipolar disorder add to or replace their Western medication with herbal or holistic options. Still, even with optimal medication treatment, many people with the illness have some residual symptoms. Cognitive therapy may work to lessen the severity of mood swings by recognizing and managing triggering symptoms or events.

Principles
Medications called mood stabilizers are be used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are sometimes also treated with antidepressants, although this carries a risk of inducing mania (especially when no mood stabilizer is also prescribed).

In severe cases where the mania or the depression is severe enough to cause psychosis (and recently sometimes in less severe cases as well, although this remains controversial), antipsychotic drugs may also be used. A new class of atypical antipsychotics are also popular. The FDA has only approved them for acute episodes, if at all. Like most doctors, psychiatrists use medication for "off-label" uses, though this carries more risk of unexpected side effects.

Some people have reported that antipsychotics cause mania, panic attacks, or psychosis. Any agitation should be reported to the doctor immediately.

Medications work differently in each person, and it takes considerable time to determine in any particular case whether a given drug is effective at all, since bipolar disorder is sometimes episodic, and patients may experience remissions and periods of normal functioning (which may last years) whether or not they receive treatment. For this reason, neither patients nor their doctors should expect immediate relief, although extreme mania will seem to dissapate quickly. Dr. John Burrows says that patients should not expect full stabilization for at least 3-4 weeks.

Compliance with medications can be a major problem, because some people becoming manic lose insight, or the awareness of having an illness, and they therefore discontinue medications. They may suddenly find themselves initiating multiple projects often being scattered and ineffective, or may go on a spending spree or take a poorly planned trip landing them in an unfamiliar location without cash. The manic periods, euphoric as they may be, may seem or be disastrous because of the impulsiveness and irrationality that comes with them.

Depression does not respond instantaneously to resumed medication, typically taking 2-6 weeks to respond. Mania may disappear slowly, or it may become depression. Other reasons cited by individuals for discontinuing medication are side effects, expense, and the stigma of having a psychiatric disorder. In a relatively small number of cases stipulated by law (varying by locality but typically, according to the law, only when a patient poses a threat to himself or others), patients who do not agree with their psychiatric diagnosis and treatment can legally be required to have treatment without their consent. Throughout North America and the United Kingdom, involuntary treatment or detention laws exist for severe cases of bipolar disorder and other mental illnesses. In some cases, the burden of proof favors the psychiatrist.

Prognosis
While bipolar disorder can be one of the most severe and devastating medical conditions, fortunately many individuals with bipolar disorder can also live full and mostly happy lives with correct management of their condition. Compared to patients with schizophrenia, persons with bipolar disorder are more likely to have periods of normal functioning in the absence of medication. Although schizophrenic patients may have remissions with relatively high levels of functioning, schizophrenic patients tend to suffer some impairment during these intervals in contrast to persons with bipolar disorder who often appear completely healthy when they are between mood swings.

Lithium salts
The use of lithium salts as a treatment of bipolar disorder was first discovered by Dr. John Cade.

Lithium salts have long been used as a first-line treatment for bipolar disorder. In ancient times, doctors would send their mentally ill patients to drink from "alkali springs" as a treatment. They did not know it, but they were really prescribing lithium, which was present in high concentration in the waters. The therapeutic effect of lithium salts appears to be entirely due to the lithium ion, Li. The two lithium salts used for bipolar therapy are lithium carbonate (mostly) and lithium citrate (sometimes). Approved for the treatment of acute mania in 1970 by the FDA, lithium has been an effective mood-stabilizing medication for many people with bipolar disorder. Lithium is also noted for reducing the risk of suicide. Although lithium is among the most effective mood stabilizers, most persons taking it experience side effects similar to the effects of ingesting too much table salt, such as high blood pressure, water retention, and constipation. Regular blood testing is required when taking lithium to determine the correct lithium levels since the therapeutic dose is close to the toxic dose.

The mechanism of lithium salt treatment is believed to work as follows: some symptoms of bipolar disorder appear to be caused by the enzyme inositol monophosphatase (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. It is involved in signal transduction and is believed to create an imbalance in neurotransmitters in bipolar patients. The lithium ion is believed to produce a mood stabilizing effect by inhibiting IMPase by substituting for one of two magnesium ions in IMPase's active site, slowing down this enzyme.

Lithium orotate is used as an alternative treatment to lithium carbonate by some sufferers of bipolar disorder, mainly because it is available without a doctor's prescription. It is sometimes sold as "organic lithium" by nutritionists, as well as under a wide variety of brand names. There seems to be little evidence for its use in clinical treatment in preference to lithium carbonate. Self-treatment without medical monitoring is potentially dangerous.

Anticonvulsant mood stabilizers
Anticonvulsant medications, particularly valproate and carbamazepine, have been used as alternatives or adjuncts to lithium in many cases. Valproate (Depakote and Depakene) was FDA approved for the treatment of acute mania in 1995, and is now considered by many to be the first line of therapy for bipolar disorder. It is preferable to lithium because its side effect profile seems to be less severe, compliance with the medication is better, and fewer breakthrough manic episodes occur. However, valproate is not as effective as lithium in preventing or managing depressive episodes, so patients taking valproate may also need an SSRI or other antidepressant as an adjunct medicinal therapy. Some research suggests that different combinations of lithium and anticonvulsants may be helpful. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, have been studied to determine their efficacy as mood stabilizers in bipolar disorder. Lamotrigine is particularly promising, as there is evidence it acts as a mood stabilizer and particularly helps bipolar persons with severe depression. Topiramate has not done well in clinical trials, which may be because it seems to help a few patients very much but most not at all. Unfortunately, there are several controlled studies that show that gabapentin is very effective for certain types of epilepsy and has a mild side effect profile but is ineffective for bipolar disorder. Nevertheless, many psychiatrists continue to prescribe topiramate and gabapentin for bipolar disorder, although this is becoming increasingly controversial.

According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients taking valproate should be monitored carefully by a physician. It should be noted, however, that the therapeutic dose for a patient taking valproate for epilepsy is very different than the therapeutic dose of valproate for an individual with bipolar disorder.

Atypical antipsychotic drugs
The newer atypical antipsychotic drugs such as risperidone, quetiapine, and olanzapine are often used in acutely manic patients, because these medications have a rapid onset of psychomotor inhibition, which may be lifesaving in the case of a violent or psychotic patient. Parenteral and orally disintegrating (in particular, Zyprexa Zydis) forms are favoured in emergency room settings. [7] These drugs can also be used as adjunctives to lithium or anticonvulsants in refractory bipolar disorder and in prevention of mania recurrence. In light of recent evidence, olanzapine (Zyprexa) has been FDA approved as an effective monotherapy for the maintenance of bipolar disorder.[8] A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be just as effective and safe as Lithium in prophylaxis.[9]

Marijuana
Although the use of marijuana for the treatment of bipolar disorder is seldom mentioned by proponents of medical marijuana, there is anecdotal evidence that its use can alleviate the mood swings associated with the disease. The euphoriant effect of marijuana may be useful for mood elevation during the depressive phase, while the manic phase may be moderated by the tranquilizing effects of the drug.

Omega-3 fatty acids
Omega-3 fatty acids are also used as an alternative or additional treatment for bipolar disorder. Omega-3 fatty acids are polyunsaturated fatty acids which can be found in wild salmon, flaxseed and walnuts. To receive a significant dose, however, omega-3 fatty acids must usually be taken in the form of a fish oil supplement. An initial clinical trial by Stoll et. al. which produced strongly positive results . It has been hypothesized that the therapeutic ingredient in omega-3 fatty acid preparations is eicosapentaenoic acid (EPA) and that supplements should be high in this compound to be beneficial.

However, although there are a number of clinical trials with encouraging results, and widespread anecdotal reports of efficacy, attempts to confirm the hypothesized beneficial effects of omega-3 fatty acids in several larger double-blind clinical trials have so far produced unconclusive results.

Psychotherapy
Certain types of psychotherapy or psychosocial interventions, generally used in combination with medication, often can provide tremendous additional benefit. These include cognitive-behavioral therapy, interpersonal and social rhythm therapy, family systems therapy, and psychoeducation.

Electroconvulsive therapy
Electroconvulsive therapy (ECT) is sometimes used to treat severe bipolar depression in cases where other treatments have failed. Although it has proved to be a highly effective treatment, doctors are reluctant to use it except as a treatment of last resort because of the side-effects and possible complications of ECT, particularly when repeated treatments ("maintenance ECT") are needed.

Alternative treatments
Complementary non-Western treatments, such as acupuncture and orthomolecular therapy, are used by people with bipolar disorder, and some research shows that some of them may have some scientific merit.

Treatment issues
Nearly all bipolar treatment studies have involved treating patients in the acute (initial) mania stage, where overmedication is often justified in removing a patient from danger. Much less is known, however, about long-term treatment, where relapse prevention and full remission are the main treatment goals.

Virtually nothing is known about treating hypomania. Conceivably patients in hypomania, if otherwise stable, could be treated with reduced medication doses, various forms of talking therapy, or relaxation exercises, but there are no studies to guide patients and psychiatrists. On one hand, mild hypomania may be a legitimate baseline for some patients. For others, hypomania may signal the beginning of a cycle into more severe mania, necessitating immediate intervention.

Until recently, depression was largely overlooked in bipolar disorder. The anticonvulsant medication, lamotrigine is often used for treating bipolar depression, particularly where other drugs have failed and the patient's disorder has a strong depressive component. New clinical trials are finding that certain new-generation antipsychotics such as olanzapine and quetiapine show some beneficial effect in treating bipolar depression. Lithium also has a mild antidepressant effect.

Because there is a danger of antidepressant medications such as SSRIs switching bipolar patients into mania, these medications are used with caution, nearly always with an antimania agent[12].

Research findings
Heritability
Bipolar disorder appears to run in families. The rate of suicide is higher in people who have bipolar disorder than in the general population. In fact, people with bipolar disorder are about twice as likely to commit suicide as those suffering from major depression (12% to 6%).

The rate of prevalence of bipolar disorder is roughly equal in men and women. Lifetime risk of bipolar I disorder is often quoted as around 1%, but when bipolar II is included the true rate may be around 4%.

More than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a heritable component. Studies seeking to identify the genetic basis of bipolar disorder indicate that susceptibility stems from multiple genes. Scientists are continuing their search for these genes using advanced genetic analytic methods and large samples of families affected by the illness. The researchers are hopeful that identification of susceptibility genes for bipolar disorder, and the brain proteins they code for, will make it possible to develop better treatments and preventive interventions targeted at the underlying illness process.

Recent genetic research
Bipolar disorder is considered to be a result of complex interactions between genes and environment. The monozygotic concordance rate for the disorder is 70%. This means that if a person has the disorder, an identical twin has a 70% likelihood of having the disorder as well. Dizygotic twins have a 23% concordance rate. Children of a bipolar parent have a 50% chance of developing schizophrenia, schizoaffective or bipolar disorder. First degree relatives are seven times more likely to develop the condition than the general population.

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

Medical imaging
Researchers are using advanced brain imaging techniques to examine brain function and structure in people with bipolar disorder, particularly using the functional MRI. An important area of imaging research focuses on identifying and characterizing networks of interconnected nerve cells in the brain, interactions among which form the basis for normal and abnormal behaviors. Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Better understanding of the neural circuits involved in regulating mood states may influence the development of new and better treatments, and may ultimately aid in diagnosis.

Personality types
An evolving literature exists concerning the nature of personality and temperament in bipolar disorder patients, compared to major depressive disorder (unipolar) patients and non-sufferers. Such differences may be diagnostically relevant. Using MBTI continuum scores, bipolar patients were significantly more extroverted, intuitive and perceiving, and less introverted, sensing, and judging than were unipolar patients. This suggests that there might be a correlation between the Jungian extraverted intuiting process and bipolar disorder.

Research into new treatments
In late 2003, researchers at McLean Hospital found tentative evidence of improvements in mood during EP-MRSI imaging, and attempts are being made to develop this into a form which can be evaluated as a possible treatment.

It has been hypothesized that bipolar disorder may be the result of poor membrane conduction in the brain and that one possible cause may be a deficiency in omega-3 fatty acids. Following an encouraging small-scale study conducted by Andrew Stoll at Harvard University's McLean Hospital, the Stanley Foundation is sponsoring research regarding the beneficial claims, and several large scale trials of treatment using omega-3 fatty acids are under way.

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

In 2005 two double blind placebo controlled studies were underway at Harvard University and University of Calgary to determine if the trends noted in several open label trials using a mineral, vitamin and amino acid supplement called E.M. Power would continue to demonstrate effectiveness. In preliminary studies, as many as 70% of patients taking the supplements were free of symptoms after slowly having withdrawn from psychotropic medications.

For immediate management of mania, left coloric vestibular stimulation has proven effective in dramatically and rapidly stopping mania for up to 24 hours. Currently there are only case reports, and there has been no organized research on use of the procedure for acute mania.

Another avenue for treatment that has, at times been curative for resolving manic psychosis is by treating an underlying infections such as Lyme disease. Results in these cases suggest that the term bipolar disorder may not accurately represent the actual biological disorders which meet the DSM-IV requirement for a bipolar disorder. For an unknown number of patients, the problem may be a kind of immune mediated disorder provoked by Lyme disease (Toxoplasmosis, Bornea virus), or any or a number of other chronic infections, including something as common as the flu.

Bipolar disorder, talent and famous people
Many famous people are believed to have been affected by bipolar disorder, based on evidence in their own writings and contemporaneous accounts by those who knew them. Bipolar disorder is found in disproportionate numbers in people with creative talent such as artists, musicians, authors, poets, and scientists, and it has been speculated that the mechanisms which cause the disorder may be related to those responsible for creativity in these persons. (Many of the historical creative talents commonly cited as bipolar were "diagnosed" retrospectively after their deaths and thus the diagnoses are unverifiable; however, in cases diagnosed in recent decades there does seem to be at least some correlation between bipolar disorder and creativity.) The possible explanation for this is that hypomanic phases of the illness allow for heightened concentration on activities and the manic phases allow for around-the-clock work with minimal need for sleep. See list of people believed to have been affected by bipolar disorder.

Sources
Material from public domain text copied from http:www.nimh.nih.gov/publicat/manic.cfm which states: "All material in this fact sheet is in the public domain and may be copied or reproduced without permission from the Institute. Citation of the source is appreciated."
1, 2, 3 and 4 Links and references showing that gabapentin (Neurontin) is an inappropriate and ineffective medication for bipolar disorder.
Suicide rate of persons with bipolar disorder
References
^ Link and reference involving kindling theory
^ Hakkarainen R, et al. (2003). Seasonal changes, sleep length and circadian preference among twins with bipolar disorder. BMC Psychiatry 3 (1), 6.
^ Shapira A, et al. (2004). Admission rates of bipolar depressed patients increase during spring/summer and correlate with maximal environmental temperature. Bipolar Disorder Feb;6 (1), 90-3.
^ Baldessarini RJ, et al. (2003). Lithium treatment and suicide risk in major affective disorders: update and new findings. J Clin Psychiatry 64 (Suppl 5), 44-52.
^ 1 and 2 Links and references showing the promise of lamotrigine (Lamictal) in the treatment of bipolar depression.
^ Osher Y, Bersudsky Y, Belmaker RH. Omega-3 eicosapentaenoic acid in bipolar depression: report of a small open-label study. J Clin Psychiatry. 2005;66(6):726-9. PMID 15960565
^ Stoll AL, Severus WE, Freeman MP et al. (1999), Omega 3 fatty acids in bipolar disorder. A preliminary double-blind, placebo-controlled trial. Arch Gen Psychiatry 56(5):407-412.
^ Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. PMID 15939837
^ Barrett TB, Hauger RL, Kennedy JL, Sadovnick AD, Remick RA, Keck PE, McElroy SL, Alexander M, Shaw SH, Kelsoe JR. Evidence that a single nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is associated with bipolar disorder. Mol Psychiatry. 2003 May;8(5):546-57.
Further reading
Classic works on this subject include

Manic-depressive insanity and paranoia by Emil Kraepelin., 1921. ISBN 0405074417 (English translation of the original German from the earlier Eighth Edition of Kraepelin's textbook - now outdated, but a work of major historical importance).
Manic-Depressive Illness by Frederick K. Goodwin and Kay Redfield Jamison. ISBN 0195039343 (The standard, very lengthy, medical reference on bipolar disorder.)
Touched With Fire: Manic-Depressive Illness and the Artistic Temperament by Kay Redfield Jamison (The Free Press: Macmillian, Inc., New York, 1993) 1996 reprint: ISBN 068483183X
An Unquiet Mind: A Memoir of Moods and Madness by Kay Redfield Jamison (Knopf, New York, 1995) (An excellent autobiographical work about what it's like to have bipolar disorder, by the woman who is also one of the medical world's experts on it.) ISBN 0330346512
Mind Over Mood: Cognitive Treatment Therapy Manual for Clients by Christine Padesky, Dennis Greenberger. ISBN 0898621283
Bipolar Disorder: A guide for patients and families by Francis Mondimore M.D., 1999. ISBN 0801861179 (A detailed in-depth book covering all aspects of bipolar disorder: history, causes, treatments, etc.)

PsychEducation.org (home)
The HCL-32 is a screening tool for researchers trying to find people with bipolar disorder. This is one of the better "complete but simple" lists of manic-side symptoms. It's a good "fine-tooth comb" when people want to inventory all possible hypomanic symptoms, usually in the context of asking "do I really have bipolar disorder?" (Download pdf of symptom list only)
Remember, however, that this is not exactly the right question. As at the Harvard bipolar clinic, we should instead be asking "how much bipolarity might you have?" In that clinic's Bipolarity Index, you'll note that hypomania or mania only account for up to 1/5th of the possible score; the other 4/5th's of the total 100 points possible come from other factors such as family history, age of onset of depression, course of the depressions since, and response to medications.
Thus you should not look at the HCL as a "yes or no" tool for detecting bipolar disorder. It's simply a handy way to check what should be checked when looking for hypomania or mania -- which is just one part of the story. Okay, with that reminder, here we go.
At different times in their life everyone experiences changes or swings in energy, activity and mood ("highs and lows" or "ups and downs"). The aim of this questionnaire is to assess the characteristics of the "high" periods.
1. First of all, how are you feeling today compared to your usual state?

Much worse than usual Worse than usual A little worse than usual Neither better nor worse than usual
A little better than usual Better than usual Much better than usual

2. Compared to other people, my level of activity energy and mood: (Not how you feel today, but how you are on average)

is always rather stable and even is generally higher is generally lower repeatedly shows periods of ups and downs

3. Please try to remember a period when you were in a "high" state (while not using drugs or alcohol). In such a state:

1. I need less sleep
2. I feel more energetic and more active
3. I am more self-confident
4. I enjoy my work more
5. I am more sociable (make more phone calls, go out more)
6. I want to travel and/or do travel more
7. I tend to drive faster or take more risks when driving
8. I spend more money/too much money
9. I take more risks in my daily life (in my work and/or other activities)
10. I am physically more active (sport etc.)
11. I plan more activities or projects.
12. I have more ideas, I am more creative
13. I am less shy or inhibited
14. I wear more colourful and more extravagant clothes/make-up
15. I want to meet or actually do meet more people
16. I am more interested in sex, and/or have increased sexual desire
17. I am more flirtatious and/or am more sexually active
18. I talk more
19. I think faster
20. I make more jokes or puns when I am talking
21. I am more easily distracted
22. I engage in lots of new things
23. My thoughts jump from topic to topic
24. I do things more quickly and/or more easily
25. I am more impatient and/or get irritable more easily
26. I can be exhausting or irritating for others
27. I get into more quarrels
28. My mood is higher, more optimistic
29. I drink more coffee
30. I smoke more cigarettes
31. I drink more alcohol
32. I take more drugs (sedatives, anti-anxiety pills, stimulants)

The remaining questions ask how these "highs" affect your life (positively or negatively); other people's reactions to them; how long they last; whether you've had one recently; and how much of the last year has been spent in such a state.

If you are considering suicide...
From the American Association of Suicidology - http://www.suicidology.org/

Quote:
IF YOU ARE CONSIDERING SUICIDE

The last thing that most people expect is that they will run out of reasons to live. But if you are experiencing suicidal thoughts, you need to know that you’re not alone. By some estimates, as many as one in six people will become seriously suicidal at some point in their lives. Fortunately, most people do not act on their suicidal thoughts – crises pass and problems are solved. But sometimes thoughts lead to self-harm.

Some Important Facts AAS Would Like to Share with You

Suicidal thinking is usually associated with problems that can be treated. Clinical depression, anxiety disorders, chemical dependency, and other disorders produce profound emotional distress. They also interfere with effective problem-solving. But you need to know that new treatments are available, and studies show that the vast majority of people who receive appropriate treatment improve or recover completely. Even if you have received treatment before, you should know that different treatments work better for different people in different situations. Several tries are sometimes necessary before the right combination is found.

If you are unable to think of solutions other than suicide, it is not that solutions don’t exist, only that you are currently unable to see them. Therapists and counselors (and sometimes friends) can help you to see solutions that otherwise are not apparent to you.

Suicidal crises are almost always temporary. Although it might seem as if your unhappiness will never end, it is important to realize that crises are usually time-limited. Solutions are found, feelings change, unexpected positive events occur. Suicide is sometimes referred to as “a permanent solution to a temporary problem.” Don’t let suicide rob you of better times that will come you way when you allow more time to pass.

Problems are seldom as great as they appear at first glance. Job loss, financial problems, loss of important people in our lives – all such stressful events can seem catastrophic at the time they are happening. Then, month or years later, they usually look smaller and more manageable. Sometimes, imagining ourselves “five years down the road” can help us to see that a problem that currently seems catastrophic will pass and that we will survive.

Reasons for living can help sustain a person in pain. A famous psychologist once conducted a study of Nazi concentration camp survivors, and found that those who survived almost always reported strong beliefs about what was important in life. You, too, might be able to strengthen your connection with life if you consider what has sustained you through hard times in the past. Family ties, religion, love of art or nature, and dreams for the future are just a few of the many aspects of life that provide meaning and gratification, but which we can lose sight of due to emotional distress.

Do not keep suicidal thoughts to yourself! Help is available for you, whether through a friend, therapist, or member of the clergy. Find someone you trust and let them know how bad things are. This can be your first step on the road to healing.

Telephone Numbers for More Information on Receiving Help

National Mental Health Association 703-684-7722
Anxiety Disorders Association of America 301-231-9350
American Psychological Association 202-336-5500
American Psychiatric Association 202-682-6000
Depressive and Manic-Depressive Association 312-642-0049
National Alliance for the Mentally Ill 703-524-7600
National Suicide Prevention Lifeline 800-273-TALK
(800-273-8255)

What a great article. I agree with most of it. I was diagnosed about 16 years ago bi-polar, took a few years to get the right meds, but my combo has worked so well over the past 14 years, that I have kept jobs, relationships, my kids talk to me, and I have a few great groups of supportive friends.
I am in a little bit of a bind today however. I sent my prescriptions to the mail in pharmacy (being the first of the year I have to meet an insurance deductable) so the 90 day scripts for the meds I take weren't covered and they wouldn't mail them without an approval from me. Well, they kept leaving messages on my home phone, which I don't check and never tried my cell...so by the time I recieved the Letter in the mail informing me they were holding onto my scripts until they were authorized, I was already out of my meds!
I was told I would recieve them by the end of the week ( I now have been off them for 4 days, that will make 9 days).
I called my dr's office, explaining to them what happened and that I was already feeling like an electric current was running through my normally serene body, they agreed to call in 4 days worth to the local pharmacy.
When I landed at the pharmacy..they refuse to fill it...saying I could go to jail for it.
I believe in peace, love and joy. Serenity, bliss and happiness, so no I didn't threaten, though I did try to reason wiht the pharmasist.
She still refused to give me 4 days worth. I did not pull the mental illness card (which could have been fun, but sadistic).
SO
After all that,,,,I am trying to find out what kind of withdrawl symptoms I can expect to experience until the "pills come in the mail".
I have been on Tegretol and Paxil for over 15 years.
Every day, working in New York and Hawaii, I had my pills...
this is the first time I have not been able to get them.
The electrical charge is strongest when I am sitting still... I am going to ask the Divine to assist me in this as I seem to be quite helpless tonight..
Any ideas?

I read it and I think it is very informative. Thanks to you I have an idea of what I am dealing with I have Bipolar disorder level 1. I am not on meds at all. But I seem to be doing pretty well. But my moods however is a different story.

Self-Defeating Beliefs and irrational thinking
1. Emotional perfectionism: " I should always feel happy, confident and in control of my emotions"

2. Emotophobia: "I should never feel angry, anxious, inadequate, jealous or vulnerable."

3. conflict phobia: " people who love each other should not fight"

4. entitlement: "people should be the way I expect them to be."

5. low frustration tolerance: "I should never feel frustrated,
life should be easy"

6. performance perfectionism: "I must never fail or make a mistake"

7. perceived perfectionism: "people will not love and accept me as
a flawed and vulnerable human being"

8. fear of failure: "my worthwhileness depends on my achivements,
(or my intelligence, or status or attractiveness)."

9. fear of disapproval or criticism: "I need everybody's approval to be
worthwhile"

10. fear of rejection or being alone: "If I am alone, then I'm bound to feel miserable and unfulfilled. If I am not loved life is not worth living."

These are self-defeating beliefs and might be part of our self esteem and
linked to co-dependant behavior.
Each one of these beliefs is irrational thinking and are some common cognitive distortions. They include the 10 types of stinkng thinking.

1. all or nothing thinking: "I am either a success or a failure" " the world is either black or white"

2. Mind reading: "They probably think that I am incompetent," "I just know that he or she disapproves" Don't jump to conclusions.

3. emotional reasoning: "Because I feel inadequate. I am inadequate"
"What I feel therefore I am."

4. Personalizations: "That comment wasn't just random, it must have been directed toward me."

5. Overgeneralization: "Everything I do turns out wrong. It doesn't matter what my choices are, I always fall flat."

6. Catastrophizing: "If If I go to the party there will be terrible consequences", " I better not try because I might fail and that would be awful!"

7. Should statements: "I should visit my family everytime they want me to." " You should do this or that"

8. Control Fallacies: "If I'm not in complete control all fo the time, I will go out of control" "I must be in control of all of the contingencies in my life."

9. Comparing: "I am not as competant as my co-workers or supervisors." "Compared to others there is clearly something flawed about me."

10. Heavens reward fallacy: "If I do everything perfectly here, then I will be rewarded later," I have to muddle through this life maybe things will be better latter."

11. Disqualifying the positive: "This success experience was only a fluke', "The compliment that I received was unwarrented"

12. Perfectionism: "I must do everything perfectly or I will be criticized and a failure."
"An adequate job is akin to a failure"

13. Selective abstraction: The rest of the information doesn't matter. This is a salient point" "I must focus on the negative details
while I ignore and filter out all of the positive aspects of a situation. and obcess about it"

14. Externalization of self worth: "my worth is dependant upon what others think of me" "They think therefore I am"

15. Fallacy of change: "You should change your behavior because I want you to."They sould act differently because I expect them to."

16. Fallacy of worrying: " If I worry enough it will be resolved." "One cannot be too concerned"

17. Fallacy of ignoring: "If you isnore it, maybe it will go away." If I don't pay attention then I will not be held responcible"

18. Fallacy of fairness: "Life should be fair, people should be fair."

19. Being right: I must prove that I am right because being wrong is unthinkable." To be wrong is to be a bad person."

20. Fallacy of attachment. "I can't live without a man." "If I was in an intimate relationship all of my problems will be solved." "You can only be attached by being intimate with them."

Helpful, any other self defeating articles?

This overview "101" was exactly what I was looking for. Many thanks.
After being diagnosed as a typical only child at 8, depressed after my husband & child died, then clinically depressed while caring for my Alzheimer's-suffering dad (all of which were treated with lots of drugs but not, in my opinion, successfully), I was told that all that was wrong & that all my life I was dealing with a bi-polar condition. I've been treated with low doses of neurotin (had to stop because of side effects, speech probs) now topamax (milder side effect of skin prickling, mainly around mouth). The change this medication has had on my life has amazed me & leaves me convinced that I finally have a proper diagnosis.
I was already on cymbalta from my MD for statin pain, which the psychiatrist says will moderate the topamax & prevent my tipping over into mania. To my knowledge I've never had a manic episode. Do I now have to worry about this "mood stabilizer" becoming an upper? & is this the way these 2 drugs interact? My pharmacist says no.
Anyone who's been there, please advise.

hi jude,
have you noticed any mental fogging with the topamax?
there are other mood stabilizers if this is not working for you.
bizi
welcome to the forums.

Nope, no fogging that I've noticed. No feedback suggesting any.
Thanks so much for what you've posted. No wonder my psych recommended that I come here. Your welcome is also appreciated.