Bipolar Disorder Uncovered

BiPolar Explained

BiPolar Explained

Bipolar is a condition that wreaks havoc on those that it affects. If you suffer from Bipolar, chances are that your family suffers right with you. No matter if you are that family member trying to learn to cope or you are the person that has been diagnosed, there is hope out there.

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Married To Mania

This eBook is the key to knowing if you are married to a bipolar spouse, and gives you the keys to what to do about it. Often, being married to a bipolar spouse can be one of the hardest things you go through in your life because emotions in your house can change drastically, and completely without warning. This book gives you the tools to deal with unexpected anger outbursts and guilt that many spouses feel. This book will teach YOU how to deal with feelings of guilt that you may feel towards yourself, even though you have done everything you possibly can to make your marriage work. When you get this eBook, you can order a physical copy of the book and get FREE shipping. Also, you get two bonus eBooks when you order: The Spouse's Guide to Bipolar Disorder Vocabulary, which give you the tools you need to talk to doctors and psychiatrists, and The Bipolar Disorder Rolodex which gives you the latest in bipolar disorder research. It is hard to go through a bipolar marriage without help; now you don't have to.

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Symptoms of Depression and Bipolar Disorder

It is clear that not all individuals with depression or undergoing manic episodes experience every symptom, with severity varying between individuals and over time. With ever increasing numbers of treatment options available for patients with major depression and BPAD, and a growing body of evidence describing their efficacy and safety, clinicians often find it difficult to determine the best and most appropriate evidence-based treatment for each patient. Therefore, European and US consensus guidelines using statistical methods to synthesize and evaluate data from a number of studies (meta-analyses) have been published with recommendations for the treatment of major depression and bipolar disorder.2-4 These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to...

Treatment of bipolar disorder

Lithium can be a very effective treatment for the depression that occurs in bipolar disorder. Antidepressants, including SSRIs, may also be prescribed. Antidepressant medications used to treat the depressive symptoms of bipolar disorder, when taken without a mood-stabilizing medication, can increase the risk of switching into mania or hypomania, or developing rapid cycling, in people with bipolar disorder. Therefore, mood-stabilizing medications are generally required, alone or in combination with antidepressants, to protect patients with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today.

Current treatments of bipolar disorder

Current medications used for the treatment of bipolar disorder are summarized in Table 10. Lithium Since the early 1800s, lithium has been a first-line medication in the treatment of bipolar disorder (manic depression). The mechanism of action by which lithium produces efficacy is unknown. Lithium inhibits production of inositol monophosphate, which plays a role in gene expression.44 Lithium is a well-established treatment for bipolar disorder, being effective in the treatment of both the manic and depressive phases.45'46 It has an approximate response rate of The treatment spectrum for bipolar disorder has broadened since the use of anticonvulsants, such as valproate, carbamazepine, lamotrigine, and gabapentin. Patients with rapid cycling or mixed episode are more likely to benefit Table 10 Current medications commonly used for the treatment of bipolar disorder from treatment with anticonvulsants than patients with other types of bipolar disorder.

Bipolar Disorder

The Epidemiologic Catchment Area study found a 1-year prevalence of 0.1 of bipolar disorder among adults older than 65 living in the community. In light of the 1 2 prevalence of major depression, this finding suggests that about Source. Chen ST, Altshuler LL, Spar JE Bipolar Disorder in Late Life A Review. Journal of Geriatric Psychiatry and Neurology 11 29 35, 1998. Reprinted by permission of Sage Publications, Inc. Source. Chen ST, Altshuler LL, Spar JE Bipolar Disorder in Late Life A Review. Journal of Geriatric Psychiatry and Neurology 11 29 35, 1998. Reprinted by permission of Sage Publications, Inc. 5 -10 of elderly patients with major mood disorder have bipolar disorder. Relatively little research has been published on bipolar disorder in the elderly. Depp and Jeste (2004), in a review, stated, To date, there have been no published large-scale multi-center studies of prevalence, etiology, or clinical features of bipolar disorder in late life, nor have there been any...

Psychiatric Disorders 601411 Schizophrenia

Depressive disorders Bipolar disorders Major depression (see 6.03 Affective Disorders Depression and Bipolar Disorders) is a chronic disorder that affects 10-25 of females and 5-12 of males. Suicide in 15 of chronic depressives makes it the ninth leading cause of death in the USA. Presenting complaints for depression include depressed or irritable mood, diminished interest or pleasure in daily activities, weight loss, insomnia or hypersomnia, fatigue, diminished concentration, and recurrent thoughts of death. The World Health Organization (WHO) has estimated that approximately 121 million individuals worldwide suffer from depression and that depression will become the primary disease burden worldwide by 2020. In the majority of individuals episodes of depression are acute and self-limiting. The genetics of major depression are not well understood and have focused on functional polymorphisms related to monoaminergic neurotransmission as the majority of effective antidepressants act by...

Disease State Diagnosis

More recently, it has been argued that comorbid mood disorders are sufficiently common in schizophrenic patients to justify a fourth set of characteristic symptoms. Depression and bipolar disorder are highly comorbid in schizophrenia and are one of the key factors contributing to the increased risk for suicide in this disorder. Individuals with schizophrenia attempt suicide more often than people in the general population, and a high percentage, in particular younger adult males, succeeds in the attempt. Controversy remains over whether these mood disorders are in fact a manifestation of the disorder (i.e., share a common etiology), or an epiphenomenon associated with either the disease state or treatment. Regardless of the actual cause, comorbid mood disorders represent a clear risk in treating the schizophrenic patient population and are carefully considered along with the more traditional positive, negative, and cognitive symptoms. Schizophrenia is usually diagnosed in adolescence...

Disease Basis 60321 Causes of Depression

The etiology of depression and BPAD is unknown. Depression is polygenic in nature with both genetic and epigenetic components, making the use of genetically engineered rodents as models for drug discovery precarious.12'13 Moreover, emerging understanding of the biochemical mechanisms is compromised by the fact that most of the drugs used to treat depression and bipolar disorders (e.g., lithium and antidepressants in general) have complex and ill-defined pleiotypic mechanisms of action.12

Catechol Omethyltransferase inhibitors

An increase in the functional monoamines NE, DA, and 5HT can precipitate mania or rapid-cycling in an estimated 20-30 of affectively ill patients. A strong association between velo-cardio-facial syndrome (VCFS) patients diagnosed with rapid-cycling bipolar disorder, and an allele encoding the low enzyme activity catechol-O-methyltransferase variant (COMT L) has been identified.43 Between 85 and 90 of VCFS patients are hemizygous for COMT. There is nearly an equal distribution of L and H alleles in Caucasians. Individuals with low-activity allele (COMT LL) would be

Rates Of Psychiatric Disorders Among People Living With Hiv Infection

The landmark HIV Cost and Services Utilization Study (HCSUS) found that a large, nationally representative probability sample of adults receiving medical care for HIV in the United States in early 1996 (N 2,864 2,017 men, 847 women) reported major depression (36 ), anxiety disorder (16 ), and drug dependence (12 ) (Bing et al., 2001 Galvan et al., 2002), as well as heavy drinking at a rate (8 ) almost twice that found in the general population and high rates of drug use (50 ). The HCSUS study remains the most comprehensive view we have of the prevalence of psychiatric disorders among people living with HIV AIDS, though the study was not designed as a diagnostic assessment of psychiatric disorders among people with HIV AIDS and so rates of psychosis, bipolar disorder, alcohol abuse or dependence, and substance abuse, among others, were not obtained. Disorders of alcohol and other drug (AOD) abuse are differentiated from dependence in the Diagnostic and Statistical Manual of Mental...

Identifying the Molecular Genetic Basis of Behavioral Traits

For a variety of reasons, the promise of interesting new findings has been actualized to a much greater extent for the genetics of medical diseases than for the genetics of psychiatric disorders or behavioral traits, although the recent advances mentioned above are just as pertinent for both fields. While the major genes underlying diseases such as Huntington disease, cystic fibrosis, Duchenne muscular dystrophy, and breast cancer have been located and cloned, a succession of initial positive findings and subsequent failures to replicate those findings have been reported for psychiatric disorders, including schizophrenia, bipolar disorder, and Tourette syndrome.

Theories of Depression

The causes of clinically significant depression in the elderly are not known. A genetic vulnerability is strongly suggested by the increased prevalence of depression in the families (particularly first-degree relatives) of affected individuals and is supported by evidence from twin studies (Jansson et al. 2004). Genetic influences tend to be stronger in bipolar disorder than in unipolar mood disorder and in early-onset cases than in late-onset cases. As discussed earlier in this chapter (in the section Substance-Induced Mood Disorder and in Table 3 2), some cases of depression in the elderly appear to be at least partially caused or provoked by medications or other chemical agents and by general medical conditions, such as hypothyroidism and several other chronic medical conditions appear to be risk factors for the development of

Mary Ann Cohen and David Chao

Have comorbid psychiatric disorders that are co-occurring and may be unrelated to HIV (such as schizophrenia or bipolar disorder). The complexity of AIDS psychiatric consultation is illustrated in an article (Freedman et al., 1994) with the title Depression, HIV Dementia, Delirium, Posttraumatic Stress Disorder (or All of the Above).''

Early Childhood Developmental Social and Family History

And other family members as well as discussions about parental drug and alcohol use can follow. Family history also includes information about illness patterns, particularly psychiatric illnesses such as bipolar disorder or schizophrenia. History and chronology of early childhood losses are highly significant and deserve careful interest and documentation. Educational history includes the following questions and is relevant in determination of current level of intellectual and occupational function (1) How far did you go in school '' (2) How did you do in school '' (3) What was school like for you '' (4) Were there any problems with learning ''

Psychopharmacotherapy for Bipolar Depression

For patients with bipolar depression, treatment may be initiated with mood stabilizers alone, and both lithium and lamotrigine have been shown to be effective antidepressants (Young et al. 2004). Dosing of lithium is as per guidelines in the section Psychopharmacotherapy for Bipolar Disorder later in this chapter, and dosing of lamotrigine follows the same guidelines as for young and middle-aged adults. If monotherapy is ineffective, antidepressants may be added, following the principles spelled out earlier, with an important modification. TCAs are the third-line treatment option in bipolar depression because TCAs may be more prone to induce a switch into mania or hypoma-nia than either 1) the SSRIs or other first-line agents (including venlafaxine, duloxetine, and mirtazapine) or 2) MAOIs, the second-line treatment. Although switch rates for elderly patients per se have not been published, Gijs-man et al. (2004) reviewed six clinical trials in middle-aged adults and found a 10 switch...

Antiepileptic Drug Mechanisms

Despite considerable research, the precise mechanism(s) of action of the majority of AEDs is essentially unknown, with the exception of the GABA transaminase inhibitor, vigabatrin, and the selective GABA GAT1 uptake inhibitor, tiagabine, both of which were designed as AEDs based on a defined mechanism of action (Figure 2). While a multiplicity of targets for AEDs have been identified, primarily ion channels, including voltage-gated sodium and calcium channels, GABAa receptors, and, more recently, N-methyl-D-aspartate (NMDA)- and acid (AMPA)-type glutamate receptors3'4 as well as HCN (hyperpolarization-activated, cyclic nucleotide-gated cation) or pacemaker channels,16 many of these represent only a part of a broader spectrum of the activity of different AEDs with the majority of these interactions occurring in the micromolar concentration range. For instance, while sodium valproate can block ion channels and increase GABA levels in brain, its use in the treatment of both epilepsy and...

Unmet Medical Needs

An alternative to this somewhat pessimistic situation is the considerable potential, discovered in the clinic by serendipity, for the use of AEDs in neuropathic pain (see 6.14 Acute and Neuropathic Pain) and BAPD (see 6.03 Affective Disorders Depression and Bipolar Disorders), which has increased interest in advancing AEDs to the clinic as multifactorial therapeutic agents and a renewed focus on understanding the mechanism(s) of action of these agents as anticonvulsants in order to understand the role of aberrant and spontaneous neuronal firing via epileptogenic-like foci in neuropathic pain (neuromas) and BAPD. Like chronic convulsive episodes, outcomes from chronic pain states include cell death, aberrant neuronal sprouting, and neuronal pathway remodeling (see 6.14 Acute and Neuropathic Pain).

Differential Diagnosis

Mood and anxiety disorders, learning disorders, mental retardation, pervasive developmental disorders, organic mental disorders, and psychotic disorders may all present with impairment of attention, as well as hyperactive impulsive behaviors. The diagnosis of ADHD in DSM-IV-TR requires that the symptoms of inattention cognitive disorganization and impulsivity hyperactivity are not better accounted for by one of the above conditions. Differentiating ADHD from bipolar disorder in childhood is complicated by the low base rate of bipolar disorder and the variability in clinical presentation. Even though there are phenomenological similarities between the two disorders, there is little evidence to suggest that most children with externalizing symptoms are at risk for bipolar disorder. A positive family history of bipolar disorder is especially helpful in diagnosing bipolar disorder in children. In addition, a variety of medical conditions such as epilepsy, Tourette's disorder, thyroid...

Harold W Goforth Mary Ann Cohen and James Murrough

Mood disorders have complex synergistic and catalytic interactions with HIV infection. They are significant factors in nonadherence to risk reduction and to medical care. Mood disorders associated with HIV include illness- and treatment-related depression and mania, responses to diagnoses of HIV, and comorbid primary mood disorders such as major depressive disorder and bipolar disorder. While persons with HIV and AIDS may have potentially no or multiple psychiatric disorders, alterations in mood are frequent concomitants of HIV infection. They have a profound impact on quality of life, level of distress and suffering, as well as direct and indirect effects on morbidity, treatment adherence, and mortality. In this chapter we will describe the significance of each of the mood disorders and their impact on the lives ofpersons with HIV and AIDS and on their families and caregivers. More detailed discussions of the epidemiology and prevalence of mood disorders are found in Chapter 4....

Major Depressive Disorder And Mood Disorders With Depressive Features Due To Hiv And Aids

Major depressive disorder is frequently underdiagnosed and undertreated (Evans et al., 1996-97) in persons with HIV and AIDS. Depression in HIV can be either primary or secondary in nature. When depression develops during the course of HIV infection, it is described typically as a mood disorder due to a medical condition if it is etiologically related to HIV infection, opportunistic disease, antiviral treatments, or comorbid medical conditions. When a person with HIV or AIDS has a longstanding history of depression and or family history of depression or bipolar disorder, however, it is more likely that the diagnosis of major depressive disorder would be supported.

Major Depressive Disorder

Bipolar Disorder As noted in the chapter segment on depression, HIVseropositive individuals are at an increased risk of developing mood disorders across the spectrum of their disease as compared to the general population. Mania can occur at any point along the course of HIV illness, but the occurrence generally clusters into two categories (a) a preexisting bipolar disorder that predated HIV seroconversion or is not directly related to the disease, which can occur at any point during the course of the disease and (b) the late-stage manic syndrome that occurs most commonly but not exclusively in the context of HIV dementia (Lyketsos et al., 1997 Treisman et al., 1998). Primary bipolar disorder is more likely to appear consistent with the usual course of the illness, including euphoric mood, expansiveness, and signs or symptoms of poor judgment. In addition, the presence of a family history of bipolar disorder is more common in this category, and it is less likely to be associated with...

Methods for Locating Genes

Linkage, the oldest of these methods, has been used in genetic studies for many years. Some of the very early psychiatric studies applied this technique to finding gene locations for mental illness by using knowledge of Mendelian patterns of transmission. For example, George Winokur, who was chairman of the department of psychiatry at Iowa for many years and an eminent investigator of bipolar disorder, made the observation that manic-depressive illness and red-green color blindness co-occurred in some families. He also noted that father-to-son transmission rarely occurred in bipolar disorder. This led him to propose that bipolar illness might be linked to the X chromosome. Although this observation has not been consistendy replicated, perhaps because the gene is one of small effect in a polygenic multifactorial disorder, it may point to one of the genes involved in bipolar illness. Candidate gene studies start from the opposite direction. They begin with the theory that a particular...

Integrating Cbt And Ipt In

This similarity in therapist behavior supports the feasibility of a merged intervention. We have successfully integrated behavioral and cognitive techniques in two other IPT projects, one targeting bipolar disorder (Frank, Swartz, & Kupfer, 2000) and one that addresses comorbid panic and depression (Cyranowski et al., 2004). Thus, in developing CGT, we began with standard grief-focused IPT and developed some CBT-informed modifications, drawing especially upon Foa's approach to PTSD (Jaycox, Zoellner, & Foa, 2002 Zoellner, Fitzgibbons, & Foa, 2001).

Treatment Of Psychiatric Disorders In The Context Of

Specific considerations should be given to patients with HIV and severe, chronic mental illness. Approximately 2.6 of persons in the United States meet the criteria (based on duration, disability, and diagnosis) for severe mental illness (SMI) in a given year (Kessler et al., 1996). Most individuals with SMI have schizophrenia, bipolar disorder, and major depressive disorder (MDD), requiring extended or frequent hospitaliza-tions (Regier et al., 1990). Schizophrenia and bipolar disorder impair a person's ability to perceive HIV risk, modify behavior, and participate in treatment. Adequate consideration and treatment of the specific symptoms in individual patients will maximize their adherence to a comprehensive treatment plan.

Psychiatric Comorbidity And Sequelae

Non-substance-related Axis I disorders are also common among cocaine addicts. The rates for current depressive disorders vary between 11 and 55 (Carroll et al., 1994 Griffin, Weiss, Mirin, & Lange, 1989 Haller, Knisely, Dawson, & Schnoll, 1993), whereas those for lifetime depression range from 40 to 60 (Kleinman et al., 1990). Bipolar depression appears to be over-represented among cocaine users. In a large, community-based sample, 42.1 of cocaine abusers were found to have bipolar disorder (Karam, Yabroudi, & Melhem, 2002). Because of the specific actions and effects of cocaine, it is sometimes difficult to determine whether depression is independent of cocaine use or the result of chronic self-administration. However, depression that predates drug use or persists beyond the 1-2 weeks characteristic of cocaine withdrawal may indicate a coexisting disorder. Also, if a cocaine abuser becomes acutely depressed or suicidal after ingesting only very small amounts of the drug, a...

Sleep Disturbance In

Less need for sleep and difficulty falling asleep are common symptoms of mania. In individuals living with HIV, mania may represent exacerbation of a preexisting bipolar disorder, may be part of the organic manic syndrome that can be seen in the context of advanced HIV infection, or may be associated with treatment with steroids or zidovudine (Della Penna and Triesman, 2005). Identification and treatment of the underlying cause of the organic mania and treatment of the mania itself with mood stabilizers or an-tipsychotics may resolve the insomnia, although hypnotics can be added if necessary.

Treatment Of Dually Diagnosed Patients A Heterogeneous Population

However, providing group treatments tailored to patients with some degree of diagnostic homogeneity (e.g., patients with bipolar disorder and SUDs) can be a difficult strategy to implement if one is unable to recruit a large enough clinical population for these groups. Similarly, even within diagnostically homogeneous groups, considerable heterogeneity in illness severity and functioning may still exist. Ries, Sloan, and Miller (1997) have suggested a conceptual approach that divides dually diagnosed patients into four major subgroups, according to the severity (i.e., major or minor) of each disorder. Although this is a somewhat crude way to classify patients, it may be helpful in developing an outpatient group treatment program for dually diagnosed patients.

Other Psychiatric Populations

In non-SPMI populations, integrated treatment models have also been developed for other patient subpopulations with psychiatric disorders and SUDs such as bipolar disorder (Weiss et al., 2000), personality disorders (Ball, 1998 Linehan et al., 2002), and anxiety disorders such as PTSD (Brady, Dansky, Back, Foa, & Carroll, 2001 Najavits, Weiss, Shaw, & Muenz, 1998), obsessive-compulsive disorder (Fals-Stewart & Schafer, 1992), and social phobia (Randall, Thomas, & Thevos, 2001). With the exception of social phobia, for which integrated CBT for social phobia and alcohol use disorders has yielded worse anxiety and drinking outcomes compared to group CBT geared toward alcohol relapse prevention alone (Randall et al., 2001), preliminary evidence suggests that these new treatments are generating some positive results.

Specific Treatment Modalities

Relapse prevention therapy (RPT), developed by Marlatt and Gordon (1985), is a form of CBT that focuses on understanding the process of relapse in order to prevent it. RPT can be used as an adjunctive therapy or as a treatment in and of itself. When modified to address dually diagnosed individuals, preventing relapse from both disorders is emphasized. For example, RPT modified for patients with co-occurring bipolar disorder and SUDs (Weiss, Najavits, & Greenfield, 1999 Weiss et al., 2000) teaches patients about triggers for both substance use and bipolar disorder (e.g., erratic sleep behaviors, associating with the wrong people, nonadherence to one's medication regimen).

Pharmacotherapy Targeting Substance Dependence in Dually Diagnosed Populations

Although pharmacotherapies aimed specifically at decreasing alcohol or drug use (e.g., naltrexone, disulfiram) can be efficacious in improving SUD outcomes in non-dually-diagnosed populations, the literature on the use of these medications in dually diagnosed populations is quite thin. Concerns that disulfiram may cause or exacerbate psychosis (Mueser, Noordsy, Fox, & Wolfe, 2003) have contributed to a reluctance to prescribe it in patients with SPMI (Kingsbury & Salzman, 1990). While there have been no controlled studies of disulfiram in populations with alcohol dependence and SPMI, there have been a few published case reports (Brenner, Karper, & Krystal, 1994) and case series (Kofoed, Kania, Walsh, & Atkinson, 1986 Mueser et al., 2003) describing its tolerability and potential benefit for improving alcohol outcomes and hospital-ization rates for those who remain in treatment. Additionally, there is preliminary evidence that naltrexone may improve drinking outcomes in...

Pathological Gambling and Other Behavioral Addictions

The association of ICDs with mood disorders has led to their grouping as an affective spectrum disorder (McElroy et al., 1996). Many people with ICDs report that the pleasurable yet problematic behaviors alleviate negative emotional states. Because the behaviors are risky and self-destructive, the question has been raised whether ICDs reflect subclinical mania or cyclothymia. The elevated rates of co-occurrence between ICDs and depression, and bipolar disorder support their inclusion within an affective spectrum, as do early reports of treatment response to SRIs, mood stabilizers, and electroconvulsive therapy (McElroy, Hudson, Pope, Keck, & White, 1991 McElroy et al., 1996). However, as has been suggested with SUDs, depression in ICDs may be distinct from primary or uncomplicated depression for example, depression in ICDs may represent a response to shame and embarrassment (Grant & Kim, 2002a). In addition, rates of co-occurrence of ICDs and bipolar disorder may not be as high...

Delirium Dementia Amnestic Disorder And Other Cognitive Disorders

In DSM-III-R, delirium, dementia, amnestic disorder, and other cognitive disorders were included in a section called organic mental disorders, which contained disorders that were due to either a general medical condition or substance use. In DSM-IV, the term organic was eliminated because of the implication that disorders not included in that section (e.g., schizophrenia, bipolar disorder) did not have an organic component. In fact, virtually all mental disorders have both psychological and biological components, and to designate some disorders as organic and the remaining disorders as nonorganic reflected a reductionistic mind-body dualism that is at odds with our understanding of the multifactorial nature of the etiological underpinnings of disorders.

Behaviors and Medical History That May Lead to Kidney Failure

Lithium is widely used for the treatment of bipolar disorder. When it damages the kidneys (which it can do if the level of lithium in the blood gets too high), urine flow increases (sometimes to over a gallon a day). Protein may not appear in the urine at the early stages. Blood creatinine concentration will rise. Alternative medications, such as valproic acid, are available for the treatment of bipolar disorder, but may damage the liver. Dieter Bacchus was an employee of city government. He developed bipolar disorder at the age of 21 and was started on lithium at age 24. His lithium and creatinine levels were checked regularly. By age 35, his serum creatinine concentration was noted as above normal, 1.8 mg per dl (normal is less than 1.5 mg per dl). By age 40, two glomerular filtration rate (GFR) determinations were 5.2 and 9.0 ml per min (normal is more than 100 ml per min). His lithium dosage was finally reduced, and by 1989 his GFR increased to 41.5 ml per min. He had no symptoms...

Salt and Water Deficit

Other individuals drink fluids compulsively. This is not connected with chronic kidney disease, except that the occurrence of both compulsive water drinking and chronic kidney disease in the same person makes hyponatremia very likely. This occurrence is greater than one would predict from chance alone, because neuropsychiatric disorders, including bipolar disorders and compulsive taking of laxatives, can both lead to the development of kidney disease (see Chapter 2), and compulsive water drinking can be associated with either of these disorders.

How Are Mood Disorders Treated

Mood stabilizers are primarily used to treat bipolar disorder. As the name suggests, they abort the activity of the emotional roller coaster and even out the mood swings so that the emotional temperature fluctuates mildly around the zero point. Because bipolar disorder is a very debilitating illness, mood stabilizers are a godsend to people who previously used to swing between mania and depression. Because being high can be subjectively fun for a person with mania, people with this condition sometimes dislike mood stabilizers because they get rid of the highs. Usually, however, people with mania eventually develop insight about the destructive effects of manic episodes. For example, the gifted poet Robert Lowell, who suffered from severe bipolar illness, spoke gratefiilly about the benefits of taking lithium after it became available in the early 1970s. One of his friends described Lowell's remarkable improvement on lithium

New Research Areas

The monoamine hypothesis of depression has been the cornerstone of antidepressant treatment for several decades.52 However, many questions remain unanswered as to the underlying pathophysiology of affective disorders and if monoamines themselves are responsible for regulating unipolar and bipolar depressives states. It is clear, as stated earlier, that the etiology of depression and bipolar disorder is still unknown. Arguably, however, the clinical and preclinical data supporting the monoamine hypothesis are beyond question. With this in mind, the fact remains that the clinical response is delayed several weeks following administration of monoaminergic antidepressant agents, suggesting that other mechanisms may well be involved in the efficacy of these agents. It has long been suggested that alterations in gene expression may be a contributing factor for the delayed clinical response, thereby resulting in changes in signal transduction mechanisms (Figure 1).35> 44'53 Several...


HPA axis hyperactivity is found in bipolar disorder related to depression and mixed states. Patients with bipolar disorder also have cognitive difficulties and endocrine disturbances may contribute to such dysfunction. Antiglucorticoid therapies are novel treatments of mood disorder. Preliminary data in psychotic depression suggest that mifepristone (RU-486), a glucocorticoid receptor antagonist (91), has antidepressant and salutary cognitive effects in a matter of days. The positive effects of mifepristone in severe bipolar depression in a parallel, double-blind, placebo-controlled experiment were recently reported with improvement in two-thirds of patients in the medium- and high-dose groups within 7 days.71 The other major treatment for psychotic major depression is a combination of antidepressants and antipsychotics, which improve symptoms in roughly 60 of cases.72 However, side effects from mifepristone are very low compared to these combinations of drugs.73 The glucocorticoid...

Mood Disorders

The mood disorders section begins with the criteria for mood episodes (major depressive episode, manic episode, hypomanic episode, mixed episode), which are the building blocks for the episodic mood disorders. The codable mood disorders come next and are divided into the depressive disorders (i.e., major depressive disorder and dysthymic disorder, described in Chapter 26) and the bipolar disorders (i.e., bipolar I disorder, bipolar II disorder, and cyclothymic disorder, described in Chapter 28). Finally, the many specifiers that provide important treatment-relevant information close this section. Several so-called subthreshold mood disorders (i.e., they are characterized by depression but fall short of meeting the diagnostic criteria for either major depressive disorder or dysthymic disorder) are included in DSM-IV-TR appendix B, for Criteria Sets and Axes Provided for Further Study. These include minor depressive disorder, brief recurrent depressive disorder, mixed anxiety depressive...

Disease State

Insomnia is difficulty in falling asleep, remaining asleep, early morning awakening, and or sleep that is nonrestorative, all of which may lead to daytime consequences including fatigue, impaired cognition, irritability, mood disorders, and anxiety. It is among the most common of clinical complaints and can either be persistent or transient. A diagnosis of persistent insomnia should be aggressively managed due to significant attendant health concerns, e.g., depression and suicide, and precipitation of manic episodes in bipolar disorder.28 Insomnia is a cardinal symptom in depression and anxiety with treatment of the underlying psychiatric disorder frequently relieving the sleep disorder.

Somatic Treatments

Adolescents and adults with autistic disorder often exhibit symptoms in a cyclic manner and so there is much interest in how these individuals might respond to agents typically used in bipolar disorder. A single open trial of lithium revealed no significant improvement in symptoms in individuals with autistic disorder without bipolar disorder.


Considerable data indicate that a subgroup of hyperactive children show high rates of delinquency and substance abuse during adolescence, and this continues into adulthood. However, it is likely because of the comorbidity with CD or bipolar disorder that higher rates of substance abuse are found in adolescents with ADHD

Secondary Mania

Secondary manic syndromes due to late-stage disease are not common but can have disastrous consequences for the patient when they do occur. In a chart review, Lyketsos and colleagues (1993) reported that manic syndromes affected approximately 8 of the examined population across a 17-month period. These patients were less likely to have a family history of bipolar disorder but more likely to have concurrent dementia than patients with manic episodes early in the non-AIDS stage of their disease. This link has been substantiated by other retrospective and small case-control studies (Kieburtz et al., 1991 Mijch et al., 1999). Ellen and colleagues (1999) identified mania in 1.2 of HIV-seropositive patients and in 4.3 of those with AIDS-defining illness, findings suggestive of increased rates during the course of disease progression.


Individual's history the 12-month comorbidity prevalence rate of these disorders was also quite high. For example, the NCS estimated that over 33 of those with bipolar disorder would experience an SUD within 12 months, followed by nearly 20 of those with major depression and 15 of those with an anxiety disorder.

Protective Factors

Experience gathered from individual and group psychotherapy of suicidal persons with HIV infection indicates that several factors can protect an individual from a premature self-inflicted death and from self-destructive behaviors. Protective factors include a taking-charge attitude rather than passivity, an adequate understanding of illness, denial that does not interfere with adherence with medical treatment, increasing social support via networking, and optimism (Alfonso and Cohen, 1997 Rosengard and Folkman, 1997 Cohen, 1998, 1999). There is very little research that systematically addresses the protective factors that prevent development of suicidal behavior in persons with HIV infection. Studies of nonsuicidal persons with psychiatric disorders and unknown HIV serostatus and clinical interviews of HIV-positive, long-term survivors can be used, however, to highlight possible psychosocial variables that may ultimately prevent the development of suicidal and self-destructive...

What Is Cg Treatment

A novel component of CGT entails a focus on long-term personal goals and discussion of ways to achieve them. This segment is a component of the restoration-focus strategy in CGT. Motivation to go on living can be a problem for individuals with CG. We have documented suicidal ideation in more than half of the individuals with CG whom we have treated, and nearly a third have either made a suicide attempt or engaged in indirect self-destructive behavior. in addition, a kind of reluctance to give up grieving is often seen in CG. The person with CG often fears that grief is all that is left of the relationship to the deceased and if he or she has less grief, then he or she risks losing the deceased forever. Survivor guilt about still being alive and free to enjoy the world may also be present. There may be reticence to develop a close relationship because of fear of being hurt again by its loss. Some people are convinced that no one can understand them, or they feel resentment because they...