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Bipolar Disorder (6 Hours/ Units)

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Course Objectives:

This course is designed to help you:

1. Define Bipolar Disorder 2. Become familiar with historical influences 3. Identify Bipolar Disorder symptomology 4. Identify and distinguish between various Bipolar Diagnoses 5. Identify causes and associated features 6. Identify and apply effective treatment approaches

Table of Contents:

1. Definitions and History 2. Symptoms and Diagnosis 3. Cultural Considerations 4. Causes and Associated Features 5. Treatment 6. Bipolar Disorder, Mental Illness, and Substance Abuse 7. Client Resources 8. References

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1. Definitions and History Bipolar disorder is a psychiatric diagnosis that describes a category of mood disorders characterized by the presence of one or more episodes of abnormally elevated mood clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes or symptoms, or mixed episodes in which features of both mania and depression are present at the same time. These episodes are usually separated by periods of "normal" mood, but in some individuals, depression and mania may rapidly alternate, known as rapid cycling. Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations. The disorder has been subdivided into bipolar I, bipolar II, cyclothymia, and other types, based on the nature and severity of mood episodes experienced; the range is often described as the bipolar spectrum (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

Data from the United States on lifetime prevalence varies but estimates a rate of around 1 percent for Bipolar I, 0.5 to 1 percent for Bipolar II or cyclothymia, and between 2 and 5 percent for sub threshold cases meeting some but not all criteria. The onset of complete symptoms generally occurs in late adolescence or young adulthood. Diagnosis is based on self-reported experiences, observed behavior, and a number of other clinical factors. Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes.

While genetic variables are influential in developing bipolar disorder, environmental factors are also implicated. Bipolar disorder is often treated with mood stabilizer medications, and other psychiatric medications. Psychotherapy can be effective when the client is stabilized. In serious cases in which there is a risk of harm to oneself or others, a 5150 may be invoked; these cases generally involve severe manic episodes with dangerous behavior or depressive episodes with suicidal ideation. Unfortunately, there are many widespread problems with social stigma, stereotypes and prejudice against individuals with a diagnosis of bipolar disorder.

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Bipolar Disorder is also referred to as manic depression or bipolar affective disorder, the current term "bipolar" is of fairly recent origin and refers to the cycling between high and low episodes (poles). A relationship between mania and melancholia had long been observed, although the basis of the current conceptualization can be traced back to French psychiatrists in the 1850s. The term "manic-depressive illness" or psychosis was coined by German psychiatrist Emil Kraepelin in the late nineteenth century, originally referring to all kinds of mood disorder. German psychiatrist Karl Leonhard split the classification again in 1957, employing the terms unipolar disorder (Major depressive disorder) and bipolar disorder.

History

Varying moods and energy have been a part of the human experience throughout history. The words "melancholia” and "mania" have their etymologies in Ancient Greek. The word melancholia is derived from melas/μελας, meaning "black", and chole/χολη, meaning "bile" or "gall", indicative of the term’s origins in pre-Hippocratic humoral theories (

Within the humoral theories, mania was viewed as arising from an excess of yellow bile, or a mixture of black and yellow bile. The linguistic origins of mania, however, are not so clear-cut. Several etymologies are proposed by the

Angst, J; Selloro, R, September 15, 2000, "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry).

Roman physician Aurelianus including the Greek word ‘ania’, meaning to produce great mental anguish, and ‘manos’, meaning relaxed or loose, which would contextually approximate to an excessive relaxing of the mind or soul (Angst and Marneros 2001). There are at least five other candidates, and part of the confusion surrounding the exact etymology of the word mania is its varied usage in the pre-Hippocratic poetry and mythologies (Angst and Marneros 2001). The concept of a relationship between mania and melancholia can be traced back to at least the 2nd century AD. Soranus of Ephesus (98–177 AD) described mania and melancholia as distinct diseases with separate etiologies; however, he acknowledged that “many others consider melancholia a form of the disease of mania” (Cited in Mondimore 2005 p.49).

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

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

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

Emil Krapelin (1856–1926) refined the concept of psychosis.

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

These concepts were developed by the German psychiatrist Emil Kraepelin (1856–1926), who, using Kahbaum concept of cyclothymia, categorized and

Angst, J; Selloro, R (September 15, 2000, "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry).

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studied the natural course of untreated bipolar patients. He coined the term manic depressive psychosis, after noting that periods of acute illness, manic or depressive, were generally punctuated by relatively symptom-free intervals where the patient was able to function normally.

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

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

Angst, J; Selloro, R, September 15, 2000, "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry).

In 1968, both the newly revised classification systems ICD-8 and DSM-II termed the condition "manic-depressive illness" as biological thinking came to the fore. Bipolar disorder, became popular only recently, and some individuals prefer the older term because it provides a better description of a continually changing multi-dimensional illness.

Angst, J; Selloro, R, September 15, 2000, "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry).

Empirical and theoretical work on bipolar disorder has throughout history "seesawed” between psychological and biological ways of understanding. Despite the work of Kraepelin (1921) emphasizing the psychosocial context, conceptions of bipolar disorder as a genetically based illness dominated the 20th century. Since the 1990s, however, there has been a resurgence of interest and research in to the role of psychosocial processes (Angst, J; Selloro, R,

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September 15, 2000, "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry).

2. Symptoms and Diagnosis Bipolar disorder is a condition in which people experience abnormally elevated (manic or hypomanic) and abnormally depressed states for a period of time in a way that interferes with functioning. Bipolar disorder has been estimated to affect more than 5 million Americans which is approximately 3 out of every 100 adults. It is equally prevalent among both men and women, and exists among all cultures and ethnic groups. Symptoms may vary from person to person. Bipolar disorder can sometimes appear to be unipolar depression. Diagnosing bipolar disorder is difficult, even for mental health professionals. What distinguishes bipolar disorder from unipolar depression is that the affected person also experiences the "highs" of a manic phase (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

Mood Disorders

In 1 year, about 7 percent of Americans suffer from mood disorders, a cluster of mental disorders best recognized by depression or mania (Table 4-1). Mood disorders are outside the bounds of normal fluctuations from sadness to elation. They have potentially severe consequences for morbidity and mortality.

This section covers four mood disorders. As the predominant mood disorder, major depressive disorder (also known as unipolar major depression), garners the greatest attention. It is twice more common in women than in men, a gender difference that is discussed later in this section. The other mood disorders covered below are bipolar disorder, dysthymia, and cyclothymia.

Mood disorders rank among the top 10 causes of worldwide disability (Murray & Lopez, 1996). Unipolar major depression ranks first, and bipolar disorder ranks in the top 10. Moreover, disability and suffering are not limited to the patient. Spouses, children, parents, siblings, and friends

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experience frustration, guilt, anger, financial hardship, and, on occasion, physical abuse in their attempts to assuage or cope with the depressed person’s suffering. Women between the ages of 18 and 45 comprise the majority of those with major depression (Regier et al., 1993).

Depression also has a deleterious impact on the economy, both in diminished productivity and in use of health care resources (Greenberg et al., 1993). In the workplace, depression is a leading cause of absenteeism and diminished productivity. Although only a minority seek professional help to relieve a mood disorder, depressed people are significantly more likely than others to visit a physician for some other reason. Depression-related visits to physicians thus account for a large portion of health care expenditures. Seeking another or a less stigmatized explanation for their difficulties, some depressed patients undergo extensive and expensive diagnostic procedures and then get treated for various other complaints while the mood disorder goes undiagnosed and untreated (Wells et al., 1989).

Complications and Comorbidities

Suicide is the most dreaded complication of major depressive disorders. About 10 to 15 percent of patients formerly hospitalized with depression commit suicide (Angst et al., 1999). Major depressive disorders account for about 20 to 35 percent of all deaths by suicide (Angst et al., 1999). Completed suicide is more common among those with more severe and/or psychotic symptoms, with late onset, with co-existing mental and addictive disorders (Angst et al., 1999), as well as among those who have experienced stressful life events, who have medical illnesses, and who have a family history of suicidal behavior (Blumenthal, 1988). In the United States, men complete suicide four times as often as women; women attempt suicide four times as frequently as do men (Blumenthal, 1988). Recognizing the magnitude of this public health problem, the Surgeon General issued a Call to Action on Suicide in 1999 (see Figure 4-1). Individuals with depression also face an increased risk of death from coronary artery disease (Glassman & Shapiro, 1998).

Mood disorders often coexist, or are comorbid, with other mental and somatic disorders. Anxiety is commonly comorbid with major depression. About one-half of those with a primary diagnosis of major depression also have an anxiety disorder (Barbee, 1998; Regier et al., 1998). The comorbidity of anxiety and depression is so pronounced that it has led to

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theories of similar etiologies, which are discussed below. Substance use disorders are found in 24 to 40 percent of individuals with mood disorders in the United States (Merikangas et al., 1998). Without treatment, substance abuse worsens the course of mood disorders. Other common comorbidities include personality disorders (DSM-IV) and medical illness, especially chronic conditions such as hypertension and arthritis. People with depression have a high prevalence (65 to 71 percent) of any of eight common chronic medical conditions (Wells et al., 1991). The mood disorders also may alter or “scar” personality development.

Figure 4-1. Sugeon General's Call to Action to Prevent Suicide–1999

• Suicide is a serious public health problem

• 31,000 suicides in 1996 • 500,000 people visit emergency rooms due to attempted

suicide

• Suicide rate declined from 12.1 per 100,000 in 1976 to 10.8 per 100,000 in 1996

• Rate in adolescents and young adults almost tripled since 1952

• Rate is 50 percent higher than the homicide rate

• National Strategy for Suicide Prevention: AIM

• Awareness: promote public awareness of suicide as a public health problem

• Intervention: enhance services and programs • Methodology: advance the science of suicide prevention

• Risk factors

• Male gender • Mental disorders, particularly depression and substance

abuse • Prior suicide attempts • Unwillingness to seek help because of stigma • Barriers to accessing mental health treatment • Stressful life event/loss

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• Easy access to lethal methods such as guns

• Protective factors

• Effective and appropriate clinical care for underlying disorders

• Easy access to care • Support from family, community, and health and

mental health care staff

Clinical Depression Versus Normal Sadness People have been plagued by disorders of mood for at least as long as they have been able to record their experiences. One of the earliest terms for depression, “melancholy,” literally meaning “black bile,” dates back to Hippocrates. Since antiquity, dysphoric states outside the range of normal sadness or grief have been recognized, but only within the past 40 years or so have researchers had the means to study the changes in cognition and brain functioning that are associated with severe depressive states.

At some time or another, virtually all adult human beings will experience a tragic or unexpected loss, romantic heartbreak, or a serious setback and times of profound sadness, grief, or distress. Indeed, something is awry if the usual expressions of sadness do not accompany such situations so common to the human condition—death of a loved one, severe illness, prolonged disability, loss of employment or social status, or a child’s difficulties, for example.

What is now called major depressive disorder, however, differs both quantitatively and qualitatively from normal sadness or grief. Normal states of dysphoria (a negative or aversive mood state) are typically less pervasive and generally run a more time-limited course. Moreover, some of the symptoms of severe depression, such as anhedonia (the inability to experience pleasure), hopelessness, and loss of mood reactivity (the ability to feel a mood uplift in response to something positive) only rarely accompany “normal” sadness. Suicidal thoughts and psychotic symptoms such as delusions or hallucinations virtually always signify a pathological state.

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Nevertheless, many other symptoms commonly associated with depression are experienced during times of stress or bereavement. Among them are sleep disturbances, changes in appetite, poor concentration, and ruminations on sad thoughts and feelings. When a person suffering such distress seeks help, the diagnostician’s task is to differentiate the normal from the pathologic and, when appropriate, to recommend treatment.

Assessment: Diagnosis and Syndrome Severity

The criteria for diagnosing major depressive episode, dysthymia, mania, and cyclothymia are presented in Tables 4-2 through 4-5. Mania is an essential feature of bipolar disorder, which is marked by episodes of mania or mixed episodes of mania and depression. The reliability of the diagnostic criteria for major depressive disorder and bipolar disorder is impressive, with greater than 90 percent agreement reached by independent evaluators (DSM-IV).

Major Depressive Disorder Major depressive disorder features one or more major depressive episodes (see Table 4-2), each of which lasts at least 2 weeks (DSM-IV). Since these episodes are also characteristic of bipolar disorder, the term “major6 depression” refers to both major depressive disorder and the depression of bipolar disorder.

The cardinal symptoms of major depressive disorder are depressed mood and loss of interest or pleasure. Other symptoms vary enormously. For example, insomnia and weight loss are considered to be classic signs, even though many depressed patients gain weight and sleep excessively. Such heterogeneity is partly dealt with by the use of diagnostic subtypes (or course modifiers) with differing presentations and prevalence. For example, a more severe depressive syndrome characterized by a constellation of classical signs and symptoms, called melancholia, is more common among older than among younger people, as are depressions characterized by psychotic features (i.e., delusions and hallucinations) (DSM-IV). In fact, the presentation of psychotic features without concomitant melancholia should always raise suspicion about the accuracy of the diagnosis (vis-à-vis schizophrenia or a related psychotic disorder). The so-called reversed vegetative symptoms (oversleeping, overeating, and weight gain) may be more prevalent in women than men (Nemeroff, 1992). Anxiety symptoms such as panic attacks, phobias, and obsessions also are not uncommon.

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When untreated, a major depressive episode may last, on average, about 9 months. Eighty to 90 percent of individuals will remit within 2 years of the first episode (Kapur & Mann, 1992). Thereafter, at least 50 percent of depressions will recur, and after three or more episodes the odds of recurrence within 3 years increases to 70 to 80 percent if the patient has not had preventive treatment (Thase & Sullivan, 1995). Thus, for many, an initial episode of major depression will evolve over time into the more recurrent illness sometimes referred to as unipolar major depression (Thase & Sullivan, 1995). Each new episode also confers new risks of chronicity, disability, and suicide.

Dysthymia is a chronic form of depression. Its early onset and unrelenting, “smoldering” course are among the features that distinguish it from major depressive disorder (DSM-IV). Dysthymia becomes so intertwined with a person’s self-concept or personality that the individual may be misidentified as “neurotic” (resulting from unresolved early conflicts expressed through unconscious personality defenses or characterologic disorders) (Akiskal, 1985). Indeed, the onset of dysthymia in childhood or adolescence undoubtedly affects personality development and coping styles, particularly prompting passive, avoidant, and dependent “traits.” To avoid the pejorative connotations associated with the terms “neurotic” and “characterologic,” the term “dysthymia” is used in DSM-IV as a descriptive, or atheoretical, diagnosis for a chronic form of depression (see Table 4-3) (DSM-IV). Affecting about 2 percent of the adult population in 1 year, dysthymia is defined by its subsyndromal nature (i.e., fewer than the five persistent symptoms required to diagnose a major depressive episode) and a protracted duration of at least 2 years for adults and 1 year for children. Like other early-onset disorders, dysthymic disorder is associated with higher rates of comorbid substance abuse. People with dysthymia also are susceptible to major depression. When this occurs, their illness is sometimes referred to as “double depression,” that is, the combination of dysthymia and major depression (Keller & Shapiro, 1982). Unlike the superimposed major depressive episode, however, the underlying dysthymia seldom remits spontaneously. Women are twice as likely to be diagnosed with dysthymia as men (Robins & Regier, 1991).

There is no clear consensus as to how many types of bipolar disorder exist. In DSM-IV-TR and ICD-10, bipolar disorder is conceptualized as a

Diagnostic Criteria Summarized

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spectrum of disorders occurring on a continuum. The DSM-IV-TR lists four types of mood disorders which fit into the bipolar categories: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

Bipolar Disorder Bipolar disorder is a recurrent mood disorder featuring one or more episodes of mania or mixed episodes of mania and depression (DSM-IV; Goodwin & Jamison,1990). Bipolar disorder7 is distinct from major depressive disorder by virtue of a history of manic or hypomanic (milder and not psychotic) episodes. Other differences concern the nature of depression in bipolar disorder. Its depressive episodes are typically associated with an earlier age at onset, a greater likelihood of reversed vegetative symptoms, more frequent episodes or recurrences, and a higher familial prevalence (DSM-IV; Goodwin & Jamison, 1990). Another noteworthy difference between bipolar and nonbipolar groups is the differential therapeutic effect of lithium salts, which are more helpful for bipolar disorder (Goodwin & Jamison, 1990).

Mania is derived from a French word that literally means crazed or frenzied. The mood disturbance can range from pure euphoria or elation to irritability to a labile admixture that also includes dysphoria (Table 4-4). Thought content is usually grandiose but also can be paranoid. Grandiosity usually takes the form both of overvalued ideas (e.g., “My book is the best one ever written”) and of frank delusions (e.g., “I have radio transmitters implanted in my head and the Martians are monitoring my thoughts.”) Auditory and visual hallucinations complicate more severe episodes. Speed of thought increases, and ideas typically race through the manic person’s consciousness. Nevertheless, distractibility and poor concentration commonly impair implementation. Judgment also can be severely compromised; spending sprees, offensive or disinhibited behavior, and promiscuity or other objectively reckless behaviors are commonplace. Subjective energy, libido, and activity typically increase but a perceived reduced need for sleep can sap physical reserves. Sleep deprivation also can exacerbate cognitive difficulties and contribute to development of catatonia or a florid, confusional state known as delirious mania. If the manic patient is delirious, paranoid, or catatonic, the behavior is difficult to distinguish from that of a schizophrenic patient. Clinicians are prone to misdiagnose mania as schizophrenia in African Americans (Bell & Mehta, 1981). Most

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people with bipolar disorder have a history of remission and at least satisfactory functioning before onset of the index episode of illness.

In DSM-IV, bipolar depressions are divided into type I (prior mania) and type II (prior hypomanic episodes only). About 1.1 percent of the adult population suffers from the type I form, and 0.6 percent from the type II form (Goodwin & Jamison, 1990; Kessler et al., 1994) (Table 4-5). Episodes of mania occur, on average, every 2 to 4 years, although accelerated mood cycles can occur annually or even more frequently. The type I form of bipolar disorder is about equally common in men and women, unlike major depressive disorder, which is more common in women.

Hypomania, as suggested above, is the subsyndromal counterpart of mania (DSM-IV; Goodwin & Jamison, 1990). By definition, an episode of hypomania is never psychotic nor are hypomanic episodes associated with marked impairments in judgment or performance. In fact, some people with bipolar disorder long for the productive energy and heightened creativity of the hypomanic phase.

Hypomania can be a transitional state (i.e., early in an episode of mania), although at least 50 percent of those who have hypomanic episodes never become manic (Goodwin & Jamison, 1990). Whereas a majority have a history of major depressive episodes (bipolar type II disorder), others become hypomanic only during antidepressant treatment (Goodwin & Jamison, 1990). Despite the relatively mild nature of hypomania, the prognosis for patients with bipolar type II disorder is poorer than that for recurrent (unipolar) major depression, and there is some evidence that the risk of rapid cycling (four or more episodes each year) is greater than with bipolar type I (Coryell et al., 1992). Women are at higher risk for rapid cycling bipolar disorder than men (Coryell et al., 1992). Women with bipolar disorder are also at increased risk for an episode during pregnancy and the months following childbirth (Blehar et al., 1998).

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

Bipolar I

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diagnosis of Bipolar I disorder but it frequently occurs (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

The following includes a diagnostic criteria summary for Bipolar I Disorder: Bipolar Disorder diagnosis requires at least one Manic or Mixed episode. The following are relevant Bipolar I codes:

• 296.0x Bipolar I Disorder, Single Manic Episode • 296.40 Bipolar I Disorder, Most Recent Episode Hypomanic • 296.4x Bipolar I Disorder, Most Recent Episode Manic • 296.6x Bipolar I Disorder, Most Recent Episode Mixed • 296.5x Bipolar I Disorder, Most Recent Episode Depressed • 296.7 Bipolar I Disorder, Most Recent Episode Unspecified

Bipolar II disorder is characterized by hypomanic episodes rather than actual manic episodes, as well as at least one major depressive episode. There has never been a manic episode or a mixed episode. Hypomanic episodes do not go to the full extremes of mania (i.e. do not usually cause severe social or occupational impairment, and without

Bipolar II

psychosis), and this can make Bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression. For both Bipolar I and II, there are a number of specifiers that indicate the presentation and course of the disorder, including "chronic", "rapid cycling", "catatonic" and "melancholic" (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

The following includes a diagnostic criteria summary for Bipolar II

• Diagnosis of this Bipolar Disorder requires neither a Manic nor a Mixed Episode, but does require at least one episode of hypomania in addition to an episode of Major Depression.

• Presence (or history) of at least one Major Depressive Episodes. • Presence (or history) of at least one Hypomanic Episode. • No history of a Manic or a Mixed Episode. • Other relevant disorders have been ruled out such as Schizoaffective

Disorder and are not superimposed on Schizophrenia,

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Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

• Impairment in social, occupational, or other important areas of functioning

• Specify: Hypomanic: if currently (or most recently) in a Hypomanic Episode Depressed: if currently (or most recently) in a Major Depressive EpisodeSeverity/Psychotic/Remission Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset

Cyclothymic Disorder, formerly known as Cyclothymia, involves a presence or history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. A diagnosis of Cyclothymic Disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994)

The following includes a diagnostic criteria summary for Cyclothymic Disorder:

• Several periods with Hypomanic symptoms for at least two years and the person hasn’t been without these symptoms for more than two months at a time

• Several periods with depressive symptoms that don’t meet criteria for a Major Depressive Episode.

• The time period for children and adolescents is one year • Other disorders have been ruled out such as Schizoaffective

Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

• Symptoms are not due to a medical condition or substance dependence/abuse

• Impairment in social, occupational, or other important areas of functioning.

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Cyclothymia Cyclothymia is marked by manic and depressive states, yet neither are of sufficient intensity nor duration to merit a diagnosis of bipolar disorder or major depressive disorder. The diagnosis of cyclothymia is appropriate if there is a history of hypomania, but no prior episodes of mania or major depression (Table 4-5). Longitudinal followup studies indicate that the risk of bipolar disorder developing in patients with cyclothymia is about 33 percent; although 33 times greater than that for the general population, this rate of risk still is too low to justify viewing cyclothymia as merely an early manifestation of bipolar type I disorder (Howland & Thase, 1993).

Differential Diagnosis Mood disorders are sometimes caused by general medical conditions or medications. Classic examples include the depressive syndromes associated with dominant hemispheric strokes, hypothyroidism, Cushing’s disease, and pancreatic cancer (DSM-IV). Among medications associated with depression, antihypertensives and oral contraceptives are the most frequent examples. Transient depressive syndromes are also common during withdrawal from alcohol and various other drugs of abuse. Mania is not uncommon during high-dose systemic therapy with glucocorticoids and has been associated with intoxication by stimulant and sympathomimetic drugs and with central nervous system (CNS) lupus, CNS human immunodeficiency viral (HIV) infections, and nondominant hemispheric strokes or tumors. Together, mood disorders due to known physiological or medical causes may account for as many as 5 to 15 percent of all treated cases (Quitkin et al., 1993b). They often go unrecognized until after standard therapies have failed.

A challenge to diagnosticians is to balance their search for relatively uncommon disorders with their sensitivity to aspects of the medical history or review of symptoms that might have etiologic significance. For example, the onset of a depressive episode a few weeks or months after the patient has begun taking a new blood-pressure medication should raise the physician’s index of suspicion. Ultimately, occult or covert medical illnesses must always be considered when an apparently clear-cut case of a mood disorder is refractory to standard treatments (Depression Guideline Panel, 1993). Cultural influences on the manifestation and diagnosis of depression are also important for the diagnostician to identify (DSM-IV). As discussed in

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Chapter 2, somatization is especially prevalent in individuals from ethnic minority backgrounds (Lu et al., 1995). Somatization is the expression of mental distress in terms of physical suffering.

Diagnosis is based on the self-reported experiences of an individual as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a clinical assessment. Diagnosis partially depends on both the presence and duration of identified symptoms and behaviors. Assessment is usually completed on an outpatient basis; admission to an inpatient facility is considered if there is a risk to oneself or others. The most widely used criteria for diagnosing bipolar disorder are from the American Psychiatric Association's DSM, the current version being DSM-IV-TR, and the World Health Organization’s ICD-10. The latter criteria are typically used in Europe and other regions while the DSM criteria are used in the USA and other regions, as well as prevailing in research studies (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

An initial assessment may include a physical exam by a physician. Although there are no lab tests which confirm bipolar disorder, there are tests which may exclude medical illnesses such as hypo- or hyperthyroidism, metabolic disturbance, a systemic infection or chronic disease, and syphilis or HIV infection. An EEG may be used to exclude epilepsy, and a CT scan of the head to exclude brain lesions. Clinical investigations are not generally repeated for relapse unless there is a specific medical indication.

Differential diagnosis is crucial since there are several other mental disorders which may involve similar symptoms to bipolar disorder. These include schizophrenia, schizoaffective disorder, drug intoxication, brief drug-induced psychosis, schizophreniform disorder and borderline personality disorder. Both borderline personality and bipolar disorder can involve "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally lasts weeks or months. The term in borderline personality refers to the marked lability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite

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disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute. Some hold that borderline personality disorder represents a subthreshold form of mood disorder, while others maintain the distinctness, though noting they often coexist. (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

Bipolar Disorder Not Otherwise Specified is a catch-all diagnosis that is used to indicate bipolar illness that does not fit into the other diagnostic categories. If an individual clearly seems to be suffering from some type of bipolar disorder but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of Bipolar Disorder NOS (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

Bipolar Disorder, NOS

Specifiers Estimates approximate that bipolar episodes average approximately 0.4 to 0.7 per year, and persist for about three to six months. However, rapid cycling is a specifier that may be applied to any subtype. It is defined as having four or more episodes per year and exists in a significant percentage of the bipolar population. The definition of rapid cycling most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: “at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period”. There are references that describe very rapid or extremely rapid cycling. One definition of extremely rapid cycling is identifying significant shifts in mood within a 24–48-hour period (

3. Cultural Considerations

Kessler, RC; McGonagle, KA; Zhao, S; Nelson, CB; Hughes, M; Eshleman, S; Wittchen, HU; Kendler, KS, 1994, "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States", Archives of General Psychiatry).

Kay Redfield Jamison is a clinical psychologist and Professor of Psychiatry at the Johns Hopkins University School of Medicine. She shares her struggle with bipolar disorder in her book An Unquiet Mind. She also made

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a case for the influence of bipolar disorder on artistic creativity in the book, Touched with Fire (Jamison, Kay Redfield , 1995. An Unquiet Mind: A Memoir of Moods and Madness. New York: Knopf). Many movies include characters with symptoms suggestive of bipolar disorder. The 1993 film Mr. Jones is an example, with Richard Gere playing a character that alternates between manic and depressive episodes, and is eventually hospitalized. In the Australian TV show Stingers, Gary Sweet played the role of a detective who suffered from bipolar and how the symptoms interfered with work. While researching the role, Sweet visited a psychiatrist to learn about bipolar disorder. He said that he left the sessions convinced he was one. TV specials such as the BBC's The Secret Life of the Manic Depressive, MTV's True Life: I'm Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own bipolar disorder, have focused on psychiatric conditions thereby raising public awareness (

4. Causes and Associated Features

Robinson DJ, 2003. Reel Psychiatry: Movie Portrayals of Psychiatric Conditions. Port Huron, Michigan: Rapid Psychler Press).

Cognitive deficits in bipolar disorder are mild and can only be detected by comparing performance in neuropsychological tests between groups of bipolar individuals compared to those without the diagnosis. Bipolar disordered individuals do not perform as well in some tasks compared to controls. However, some patients will actually perform better than controls because of the large variation in test scores. Most individuals are diagnosed with bipolar disorder but who have not experienced major depression or mania for awhile do not demonstrate neuropsychological deficits in test results. By conducting a meta-analysis by averaging outcomes of multiple studies, Robinson et al found that group average results revealed impaired performance on measures of sustained attention, executive function, and memory. It is unknown whether specific cognitive deficits are disorder-specific features of bipolar disorder (Robinson LJ, Thompson JM, Gallagher P, Goswami U, Young AH, Ferrier IN, Moore PB, 2006. A meta-analysis of cognitive deficits in euthymic patients with bipolar disorder. J Affect Disord).

Cognition

Enhanced Creativity

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Several studies suggest that during the manic phase of bipolar disorder, individuals may be more creative. In fact, bipolar disorder is evident in a large number of people involved in the arts. Some research has revealed a significant correlation between creativity and bipolar disorder. Several authors have connected mania to success and accomplishment. A recent study’s findings indicated that greater-than-average striving for goals, and sometimes achieving goals are correlated with mania (Santosa et al. Enhanced creativity in bipolar disorder patients: A controlled study. J Affect Disord. 2006 November 23).

Epidemiology

The lifetime prevalence of bipolar disorder type I, which includes at least a lifetime manic episode, has generally been estimated at 2%. A reanalysis of data from the National Epidemiological Catchment Area Survey in the United States, however, suggested that 0.8 percent experience a manic episode at least once (the diagnostic threshold for bipolar I) and 0.5 a hypomanic episode (the diagnostic threshold for bipolar II or cyclothymia). Including sub-threshold diagnostic criteria, such as one or two symptoms over a short time-period, an additional 5.1 percent of the population, adding up to a total of 6.4 percent, were classed as having a bipolar spectrum disorder. A more recent analysis of data from a second US National Comorbidity Survey found that 1% met lifetime prevalence criteria for bipolar 1, 1.1% for bipolar II, and 2.4% for subthreshold symptoms. There are conceptual and methodological limitations and variations in the findings. Prevalence studies of bipolar disorder are typically carried out by lay interviewers who follow fully structured/fixed interview schemes; responses to single items from such interviews may suffer limited validity. In addition, diagnosis and prevalence rates are dependent on whether a categorical or spectrum approach is used. Concerns have arisen about the potential for both under diagnosis and over diagnosis (

Although major depressive disorder and bipolar disorder are currently classified as separate disorders, some researchers increasingly view them as part of an overlapping spectrum that also includes anxiety and psychosis. According to Hagop Akiskal, M.D., at the one end of the spectrum is bipolar type schizoaffective disorder, and at the other end is recurrent unipolar

Judd, Lewis L.; Hagop S. Akiskal, January 2003. "The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases". Journal of Affective Disorders).

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depression, with the anxiety disorders present across the spectrum. Also included in this view are premenstrual dysphoric disorder, postpartum depression, and postpartum psychosis. This view helps to explain why many people who have the illness do not have first-degree relatives with clear-cut "bipolar disorder", but who have family members with a history of these other disorders (Akiskal HS, Bourgeois ML, Angst J, Post R, MollerHJ, Hirschfeld RMA: Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disorders).

Bipolar disorder in children has generally been considered very rare. The diagnosis itself is even controversial. However, onset prior to age 10 has been found in an estimated 0.3% to 0.5% of bipolar patients, although some figures suggest higher rates. Nevertheless, findings indicate that the number of

Children and Adolescents

American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, and continues to increase. The data suggests that doctors had been more aggressively applying the diagnosis to children, rather than that the incidence of the disorder has increased. The study calculated the number of psychiatric visits increased from 20,000 in 1994 to 800,000 in 2003, or 1% of the population under age 20. Assumptions regarding behavior, particularly in regard to diagnosing bipolar disorder, ADHD, and mania in children and adolescents, have raised questions regarding unnecessary treatment. A recent congressional investigation revealed that several research psychiatrists promoting the diagnosis and the use of unapproved antipsychotic drugs in children had been receiving millions of dollars in fees from pharmaceutical companies, much of which they did not disclose in their financial reporting (American Academy of Child and Adolescent Psychiatry, 1997. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder)

Late adolescence and early adulthood are typically when the onset of bipolar disorder tends to peak. Since this is a significant developmental time period, social and vocational development can be disrupted (American Academy of Child and Adolescent Psychiatry, 1997. Practice Parameters for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder).

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The causes of bipolar disorder are likely to vary. Despite the fact that twin studies have mostly included small sample sizes, they have provided a substantial genetic contribution and environmental influence. For Bipolar I, the concordance rates in modern studies are approximately 40% in monozygotic twins (same genes), compared to 0 to 10% in dizygotic twins. A combination of bipolar I, II and cyclothymia produced concordance rates of 42% versus 11%, with a relatively lower ratio for bipolar II that likely reflects heterogeneity. The overall heritability of the bipolar spectrum has been put at 0.71. There is overlap with unipolar depression and if this is also counted in the co-twin the concordance with bipolar disorder rises to 67% (Mz) and 19% (Dz). The relatively low concordance between dizygotic twins brought up together suggests that shared family environmental effects are limited, although the ability to detect them has been limited by small sample sizes. (Manic-depressive illness FK Goodwin, KR Jamison - 1990 - Oxford University Press New York).

Possible Causes

Genetic Influences

Genetic influences are thought to be important in bipolar disorder Genetic studies have suggested many “chromosomal regions and candidate genes appearing to relate to the development of bipolar disorder”, but the results are not consistent and often not replicated. Although the first genetic linkage finding for mania was in 1969, the linkage studies have been inconsistent. Genetic linkage studies may be followed by fine mapping searching for the phenomenon of linkage disequilibrium with a single gene, then DNA sequencing; using this approach causative DNA base pair changes have been reported for the genes P2RX7and TPH. Recent meta-analyses of linkage studies detected either no significant genome-wide findings or, using a different methodology, only two genome-wide significant peaks, on chromosome 6q and on 8q21. Genome-wide

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association studies have also not brought a consistent focus, each has identified new loci, while none of the previously identified loci were replicated. Findings did include a single nucleotide polymorphism in DGKH; a locus in a gene-rich region of high linkage disequilibrium (LD) on chromosome 16p12; and a single nucleotide polymorphism in MYO5B. A comparison of these studies, combined with a new study, suggested an association with ANK3 and CACNA1C, thought to be related to calcium and sodium voltage-gated ion channels. Diverse findings point strongly to heterogeneity, with different genes being implicated in different families. Numerous specific studies find various specific links. Advanced parental age has been linked to a somewhat increased chance of bipolar disorder in offspring, consistent with a hypothesis of increased new genetic mutations. A review seeking to identify the more consistent findings suggested several genes related to serotonin (SLC6A4 and TPH2), dopamine (DRD4 and SLC6A3), glutamate (DAOA and DTNBP1), and cell growth and/or maintenance pathways (NRG1, DISC1 and BDNF), although noting a high risk of false positives in the published literature. It was also suggested that individual genes are likely to have only a small effect and to be involved in some aspect related to the disorder (and a broad range of "normal" human behavior) rather than the disorder (Kato, T., 2007. "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neurosci 61).

Some long-term studies indicate that children who later receive a diagnosis of bipolar disorder may show subtle early traits such as subthreshold cyclical mood abnormalities, full major depressive episodes, and possibly ADHD with mood fluctuation. There may be hypersensitivity and irritability. There is some disagreement whether the experiences are necessarily fluctuating or may be chronic.

Childhood Indicators

Environmental Factors

Evidence suggests that environmental factors play a significant role in the development and course of bipolar disorder, and that individual psychosocial variables may interact with genetic dispositions. There is fairly consistent evidence from prospective studies that recent life events and interpersonal relationships contribute to the likelihood of onsets and recurrences of bipolar mood episodes, as they do for onsets and recurrences of unipolar depression. There have been repeated findings that between a third and a half of adults

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diagnosed with bipolar disorder report traumatic/abusive experiences in childhood, which is associated on average with earlier onset, a worse course, and more co-occurring disorders such as PTSD. The total number of reported stressful events in childhood is higher in those with an adult diagnosis of bipolar spectrum disorder compared to those without, particularly events stemming from a harsh environment rather than from the child's own behavior. Early experiences of adversity and conflict are likely to make subsequent developmental challenges in adolescence more difficult, and are likely a potentiating factor in those at risk of developing bipolar disorder (Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994).

Neurological Considerations

Hyperintensities above) are 2.5 times more likely to occur in

(bright areas on MRI scans

bipolar disorder Researchers hypothesize that abnormalities in the structure and/or function of certain brain circuits could underlie bipolar and other mood disorders. Some studies have found anatomical differences in areas such as the amygdala, prefrontal cortex and hippocampus. However, despite 25 years of research involving more than 7000 MRI scans, studies continue to report conflicting findings and there remains considerable debate over the neuroscientific findings. Two fairly consistent abnormalities found in a meta-analysis of 98 MRI or CT neuroimaging studies were that groups with bipolar disorder had lateral ventricles which were on average 17% larger than control groups, and were 2.5 times more likely to have deep white matter hyperintensities. Given the size of the meta-analysis, it was concluded that the relatively small number of significant findings was perhaps surprising, and that there may be genuinely limited structural change in bipolar disorder, or perhaps heterogeneity has obscured other differences. In addition, it was noted that averaged associations found at the level of

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multiple studies may not exist for an individual. (Kato, T., 2007. "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neurosci) The "kindling" theory asserts that people who are genetically predisposed toward bipolar disorder can experience a series of stressful events, each of which lowers the threshold at which mood changes occur. Eventually, a mood episode can start (and become recurrent) by itself. There is evidence of hypothalamic-pituitary-adrenal axis (HPA axis) abnormalities in bipolar disorder due to stress (Kato, T., 2007. "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neurosci).

Recent research in Japan hypothesizes that dysfunctional mitochondria in the brain may play a role (Stork & Renshaw, 2005).

Other recent research in implicates issues with a sodium ATPes pump, causing cyclical periods of poor neuron firing (depression) and hyper sensitive neuron firing (mania). This may only apply for type one, but type two apparently results from a large confluence of factors.

It has been suggested that a hypersensitivity of the melatonin receptors in the eye could be a reliable indicator of bipolar disorder, in studies called a trait marker, as it is not dependent on state (mood, time, etc). In small studies, patients diagnosed as bipolar reliably showed a melatonin-receptor hypersensitivity to light during sleep, causing a rapid drop in sleep time melatonin levels compared to controls. Another study showed that drug-free, recovered, bipolar patients exhibited no hypersensitivity to light. It has also been shown in humans that

Melatonin

valproic acid, a mood stabilizer, increases transcription of melatonin receptors and decreases eye melatonin-receptor sensitivity in healthy volunteers while low-dose lithium, another mood stabilizer, in healthy volunteers, decreases sensitivity to light when sleeping, but doesn't alter melatonin synthesis. The extent to which melatonin alterations may be a cause or effect of bipolar disorder are not fully known. (Kato, T., 2007. "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neurosci)

Psychological studies of bipolar disorder have examined the development of a wide range of both the core symptoms of psychomotor activation and

Psychological Processes

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related clusterings of depression/anxiety, increased hedonic tone, irritability/aggression and sometimes psychosis. The existing evidence has been described as patchy in terms of quality but converging in a consistent manner. The findings suggest that the period leading up to mania is often characterized by depression and anxiety at first, with isolated sub-clinical symptoms of mania such as increased energy and racing thoughts. The latter increase and lead to increased activity levels, the more so if there is disruption in circadian rhythms or goal attainment events. There is some indication that once mania has begun to develop, social stressors, including criticism from significant others, can further contribute. There are also indications that individuals may hold certain beliefs about themselves, their internal states, and their social world (including striving to meet high standards despite it causing distress) that may make them vulnerable during changing mood states in the face of relevant life events. In addition, subtle frontal-temporal and sub cortical difficulties in some individuals, related to planning, emotional regulation and attentional control, may play a role. Symptoms are often subthreshold and likely continuous with normal experience. Once (hypo)mania has developed, there is an overall increase in activation levels and impulsivity. Negative social reactions or advice may be taken less notice of, and a person may be more caught up in their own thoughts and interpretations, often along a theme of feeling criticized. There is some suggestion that the mood variation in bipolar disorder may not be cyclical as often assumed, nor completely random, but results from a complex interaction between internal and external variables unfolding over time; there is mixed evidence as to whether relevant life events are found more often in early than later episodes. Many sufferers report inexplicably varied cyclical patterns (Kato, T., 2007. "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neurosci).

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Increased Risk May Stem From Variation in Gene On/Off Switch

Protein produced by PBRM1 gene Source: UCSC Genome Browser

Researchers, for the first time, have pinpointed a genetic hotspot that confers risk for both bipolar disorder and depression. People with either of these mood disorders were significantly more likely to have risk versions of genes at this site than healthy controls. One of the genes, which codes for part of a cell's machinery that tells genes when to turn on and off, was also found to be over-expressed in the executive hub of bipolar patients' brains, making it a prime suspect. The results add to mounting evidence that major mental disorders overlap at the molecular level.

"People who carry the risk versions may differ in some dimension of brain development that may increase risk for mood disorders later in life," explained Francis McMahon, M.D., of the NIMH Mood and Anxiety Disorders Program, who led the study.

McMahon and an international team of investigators, supported, in part by NIMH, report on the findings of their genome-wide meta-analysis online January 17, 2010 in the journal Nature Genetics

Background

.

Major mood disorders affect 20 percent of the population and are among the leading causes of disability worldwide. It's long been known that bipolar disorder and unipolar depression often run together in the same families, hinting at some shared lineage. Yet, until now, no common genes or chromosomal locations had been identified.

McMahon and colleagues analyzed data from five different genome-wide association studies (GWAS) totaling more than 13,600 people, and

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confirmed their results in 3 additional independent samples totaling 4,677 people.

Findings of This Study

Genetic variations on Chromosome 3 were significantly associated with both mood disorders. The suspect gene, called PBRM1, codes for a protein critical for chromatin remodeling, a key process in regulating gene expression. A neighboring gene is involved in the proliferation of brain stem cells.

The researchers pinpointed a "protective" version of the PBRM1 gene that is carried by 41 percent of healthy controls, but only 38 percent of people with bipolar and unipolar depression. The risk version was found in 62 percent of mood disorder cases and 59 percent of controls. The researchers also showed that PBRM1 is expressed more in the prefrontal cortex of people with bipolar disorder than in controls.

Significance

Since mood disorders likely involve altered gene expression during brain development and in response to stress, PBRM1's profile makes it a good potential candidate gene. This first genetic evidence of unipolar/bipolar overlap is also the first significant genome-wide association with any psychiatric illness in the Chromosome 3p region.

However, the findings underscore limitations of the GWAS approach, which looks for connections to gene versions that are common in the population. Having one copy of this risk variant increases vulnerability for developing a mood disorder by a modest 15 percent. Why do some people with this variant — and presumably other, yet to be discovered, shared risk genes — develop bipolar disorder while others develop unipolar depression or remain healthy? Environmental influences and epigenetic factors may be involved, suggest the researchers, who note that "genetic association findings so far seem to account for little of the inherited risk for mood disorders."

"Our results support the growing view that there aren't common genes with large effects that confer increased risk for mood disorders," said McMahon. "If there were, in this largest sample to date, we would have found them. The disorders likely involve many genes with small effects — and different

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genes in different families — complicating the search. Rarer genes with large effects may also exist."

What's Next?

Ultimately, findings such as these may lead to identification of common biological pathways that may play a role in both unipolar and bipolar illness and suggest strategies for better treatment, said McMahon. The results add to other evidence of overlap that is spurring a new NIMH initiative to make sense of research findings that don't fit neatly into current diagnostic categories. See: Genes and Circuitry, Not Just Clinical Observation, to Guide Classification for Research.

Bipolar disorder and unipolar depression often run in the same families, as this pedigree diagram illustrates. The new study is the first to trace both illnesses to a shared chromosomal hotspot.

Source: NIMH Genetics Initiative Bipolar Disorder Consortium

5. Treatment

There are a number of pharmacological and psychotherapeutic techniques used for Bipolar Disorder. Individuals may use self-help and pursue a personal recovery journey. Hospitalization may occur, especially with manic episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still

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occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups.

Medication

Sodium valproate is a common mood stabilizer Common treatment is a mood stabilizer medication such as Lithium Carbonate or Lamotrigine. There is an evidence based review which shows these two drugs are the most effective. Lamotrigine has been found to be best for preventing depression; these two drugs comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is lithium, while almost as widely used is sodium valproate, also used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder, and lamotrigine, which is the first anticonvulsant shown to be of benefit in bipolar depression (Kato, T., 2007. "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neurosci). Treatment of the agitation in acute manic episodes has often required the use of antipsychotic medications, such as Quetiapine, Olanzapine and Chlorpromazine. More recently, Olanzapine and Quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder. A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.

The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use triggering manic, hypomanic or mixed episodes, especially if no mood stabilizer is used. However, most mood stabilizers are of limited effectiveness in depressive episodes. Rapid cycling can be induced or made worse by antidepressants, unless there is adjunctive treatment with a mood stabilizer. One large-scale

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study found that depression in bipolar disorder responds no better to an antidepressant with mood stabilizer than it does to a mood stabilizer alone. Recent research indicates that triacetyluridine may help improve symptoms of bipolar disorder. Topamax (generic name topiramate) is an anticonvulsant often prescribed as a mood stabilizer. It is an off-label use when used to treat bipolar disorder.

Psychotherapy is intended to alleviate symptoms, recognizing episode triggers, reduce negative expressed emotion in relationships, recognize

Psychosocial

prodromal symptoms before full-blown recurrence, and, practice the factors that lead to maintenance of remission. Cognitive behavioral therapy, family-focused therapy, and psychoeducation have the most evidence for efficacy in regard to relapse prevention, while interpersonal and social rhythm therapy and cognitive-behavioral therapy appear the most effective in regard to residual depressive symptoms. Most studies have been based only on bipolar I, however, and treatment during the acute phase can be a particular challenge. Some clinicians emphasize the need to talk with individuals experiencing mania, to develop a therapeutic alliance in support of recovery.

A good prognosis for Bipolar Disorder results from good treatment which requires an accurate diagnosis. Because bipolar disorder continues to have a high rate of both under-diagnosis and misdiagnosis, it is often to receive timely and competent treatment. Although bipolar disorder can be a disabling medical condition, many individuals with bipolar disorder can live a high functioning lives. Frequently medication is necessary in order to achieve this. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.

Prognosis

Prognosis is impacted by several factors, many of which are within one’s control. Such factors may include: appropriate medications and corresponding dosages; comprehensive knowledge of the disease and its effects; a positive relationship with a competent medical doctor and therapist; and good physical health, which includes exercise, nutrition, and a regulated stress level. There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in

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conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes (Goodwin FK, Jamison KR, 2007. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press).

A 20-year study on bipolar I and II revealed that functioning varied over time along a spectrum from good to fair to poor. During periods of major depression or mania (in BPI), functioning was on average poor, with depression being more persistently associated with disability than mania. Functioning between episodes was on average good - more or less normal. Sub threshold symptoms were generally still substantially impairing, however, except for hypomania (below or above threshold) which was associated with improved functioning . Another study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately 2-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States." Episodes of abnormality are associated with distress and disruption, and an elevated risk of suicide, especially during depressive episodes (

Functioning

Goodwin FK, Jamison KR, 2007. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press).

A study from first admission for mania or mixed episode (representing the hospitalized and therefore most severe cases) found that 50% achieved syndromal recovery (no longer meeting criteria for the diagnosis) within six weeks and 98% within two years. 72% achieved symptomatic recovery (no symptoms at all) and 43% achieved functional recovery (regaining of prior occupational and residential status). However, 40% went on to experience a new episode of mania or depression within 2 years of syndromal recovery, and 19% switched phases without recovery.

Recovery

The following behaviors can lead to depressive or manic recurrence:

Recurrence

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• Discontinuing or lowering one's dose of medication, without consulting one's physician.

• Being under or over medicated. Generally, taking a lower dosage of a mood stabilizer can lead to relapse into mania. Taking a lower dosage of an antidepressant, may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania.

• An inconsistent sleep schedule can destabilize the illness. Too much sleep (possibly caused by medication) can lead to depression, while too little sleep can lead to mixed states or mania.

• Caffeine can cause destabilization of mood toward irritability, dysphoria, and mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can have effects ranging from anti-depressant to mania-inducing.

• Inadequate stress management and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress still causes relapse.

• Often bipolar individuals are subject to self-medication, the most common drugs being alcohol, and marijuana. Sometimes they may also turn to hard drugs, which can cause the condition to worsen. Studies show that tobacco smoking induces a calming effect on most bipolar people, and a very high percentage suffering from the disorder smoke.

(

Recurrence can be managed by the sufferer with the help of a close friend, based on the occurrence of idiosyncratic prodromal events. This theorizes that a close friend may notice which moods, activities, behaviors, thinking processes, or thoughts typically occur at the outset of bipolar episodes. They can then take planned steps to slow or reverse the onset of illness, or take action to prevent the episode from being damaging. These sensitivity triggers show some similarity to traits of a highly sensitive person (

Goodwin FK, Jamison KR, 2007. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press).

Goodwin FK, Jamison KR, 2007. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press).

Mortality

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"Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD. The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder." (Goodwin FK, Jamison KR, 2007. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press).

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

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

Family Psychoeducation

Other Clinical Models for Psychoeducational Multifamily Groups

As the effectiveness of the Family Psychoeducation approaches to the treatment of schizophrenia has become established, interest has developed in extending these models to other conditions. That has led to the development of several newer approaches designed for consumers with specific diagnoses or for specific situations, such as when a given consumer has no family available or family involvement is complicated by a history of trauma within the family. The design of these newer models has proceeded with the same method as was done in working with people who experience schizophrenia: specific aspects have been designed to ameliorate phenomena that have been shown to influence outcome in previous research. That is, they are rooted in empirical findings, rather than theory, and those findings range over the entire body of psychiatric and psychological research, including both biological and psychosocial studies. Though they do not have the depth of

35

outcome study results that has been shown for the models for people who experience schizophrenia, evidence is accumulating that they are just as effective. The practitioner who sets out to apply these models should review the available literature, since at the time of this writing many of these models were being tested, but results were not yet published.

Included here are brief summaries of descriptions of psychoeducational multifamily group treatment approaches for people with several common diagnoses as well as a model for ameliorating the effects of chronic medical illness on the family. The practitioner interested in applying these newer methods should consult the volumes in which they are described fully and seek training from qualified trainers.

Multifamily Groups for Bipolar Illness

David A. Moltz, M.D. Margaret Newmark, M.S.W.

The psychoeducational multifamily group model must be significantly modified for people who experience a bipolar disorder. The symptoms, course and family responses have been shown to be different than in schizophrenia, and recent biological research has highlighted major differences in brain function between the disorders. A key finding is that family “expressed emotion” (defined earlier in text as behaviors perceived by the consumer as being critical and/or lacking warmth/support) affects relapse, but there is an even greater biological contribution to relapse than in schizophrenia. For instance, Miklowitz and his colleagues found that family psychoeducation, in the form of single-family behavioral management, reduced relapses markedly, but from nearly 90% to about 50%, as opposed to the 40% to 15% reduction observed for consumers with schizophrenia. Thus, biological and psychosocial factors seem to be more evenly weighted in determining course of illness in bipolar disorder; nevertheless, family psychoeducation remains a powerful treatment in preventing relapse and improving longer-term outcomes.

A Model for Bipolar Disorder

This model, developed by Moltz, Newmark, McFarlane and associates, was first implemented at a public mental health center in the South Bronx of New York City and later at a community mental health center in coastal Maine. It has been effective in both settings. Only one other group has

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published a report of psychoeducational multifamily group approach. Anderson and associates compared a family process multifamily group to a psychoeducational multifamily group for short-term treatment of hospitalized consumers with affective disorders. One of the few significant differences between the groups was that those attending the psychoeducational group reported greater satisfaction than those attending the process group. Therefore, whether or not the psychoeducational format had measurable clinical advantages, it was more valued by family members. For further information please refer to the references in Chapter 12.

The key elements of this model are the same as in the approach for consumers with schizophrenia. Each is modified in important ways to match the clinical and psychosocial problems encountered in bipolar disorder.

The materials cited in Chapter 12 contain information regarding the use of single family groups for individuals with bipolar disorder.

Joining

• Initial joining sessions are held separately for the consumer and the family.

• Individual and family sessions have similar structure, since the individual with bipolar illness is usually able to participate fully.

• Meetings with the consumer and the other family members are often carried out separately during the acute phase of illness, but usually together if joining occurs after the manic phase is over and family meetings with the consumer are less likely to be emotionally intense.

Content

The content of the joining sessions is modified to reflect the specific impact of bipolar illness on the family. It includes:

• Extensive discussion of the history of symptoms and course of illness • Identifying precipitants and prodromal signs • Emphasis on differing attitudes and attributions • Discussion of inter-episode functioning, that is to say, “how is life

between episodes?”

Conjoint sessions

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After several sessions with the family and the consumer meeting separately, they are seen together for one or more conjoint sessions facilitated by the two practitioners who will be co-facilitating the group. These conjoint sessions allow the family to come together as a unit prior to the multifamily group, while the separate sessions allow each party to express their concerns without constraints and thereby diminishes conflict during the joinings.

Educational workshop

The structure and format of the bipolar workshop are similar to the schizophrenia workshop except that the consumer is included. Content is determined by the specific characteristics of the illness and includes:

• Symptoms of manic and depressed episodes, differences from normal highs and lows

• The issue of will-power • The question of the “real” personality • The impact of acute episodes on the family • The long term impact of the illness on the family • Theories of etiology of the illness • Short and long-term treatment strategies

Ongoing group meetings

The structure of the multifamily group meetings is essentially the same as the schizophrenia model.

Challenges to group formation and maintenance

Several issues related to specific characteristics of bipolar illness have presented challenges to group formation and process:

• Diagnostic ambiguity • Maintaining the group structure • Co-occurring conditions, especially substance abuse in consumer and

other family members.

Outcomes

In general, consumers reported that:

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• they were less angry over time; • they had less debilitating episodes when they did occur; • they were better able to manage symptoms and episodes; • they experienced fewer hospitalizations; and • they were more able to appreciate their family’s experience.

Family members reported:

• increased confidence in their ability to cope with the illness; • increased confidence in the consumer’s ability to manage the illness;

and • benefits from the program even if the consumer did not attend.

Practitioners reported:

• it took about two years to master the techniques; • they learned to see their role more as consultant than therapist; • they better appreciated family’s and consumer’s experience of illness

and efforts to cope with it; and • each person’s struggle with illness is different.

Multifamily Group Treatment For Major Depressive Disorder

Gabor Keitner, M.D. Ivan W. Miller, Ph.D. Laura M. Drury, M.S.W. William H. Norman, Ph.D. Christine E. Ryan, Ph.D. David A. Solomon, M.D.

To date, the only previous multifamily group treatment for consumers who experience depression has been the model developed by Anderson (1986). This multifamily approach has been used at the University of Pittsburgh for many years, however the only empirical data collected on this model is a comparison of participants’ satisfaction with the group. This study indicated that consumers and families were very satisfied with the treatment and believed that they obtained significant benefits. However, despite the fact that this intervention has been incorporated into several long-term studies of depression, there has been no study of the potential effects of this multifamily treatment on outcome or course of illness in major depression. Such studies are underway now and preliminary results are promising.

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Conducting multifamily group treatment for people with depression

Consumers with mood disorders participated in psychoeducational multifamily groups in a 5-year federally-sponsored research study. Consumers with unipolar and bipolar illness were combined in order to ensure a critical mass of consumers and families, and also because we felt that there was a significant overlap in the themes of remission and relapse between unipolar and bipolar forms of mood disorders. In addition, both unipolar and bipolar consumers had a common experience in the depressive phase of the illness and it was assumed that a certain percentage of unipolar consumers may eventually experience an episode of mania.

Much of the following material was drawn from previous descriptions of psychoeducational groups.

Overview of goals and structure

• Helping consumers and family members become knowledgeable about the signs and symptoms of depression and mania;

• Promoting relationships and increasing understanding of the effects of the illness by sharing information, support and members' perspectives on family interactions;

• Consumers and family members gain insights and learn new coping strategies in dealing with different phases of the consumer's illness; and

• Consumers and families have a better understanding of how they can work with each other and with mental health professionals to deal with the illness.

Family and group composition

A core feature of this program is that both the consumer and family members attend the sessions. All family members of the household over the age of 12 are expected to attend. A minimum of four families seems to be necessary to insure adequate activity and group discussion. Groups of five to six families, or twelve to fourteen people, are optimal. Groups typically include consumers with both bipolar disorder and others with major depression.

Practitioners

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Two co-leaders are needed. The leaders deal with any consumers or family members who become upset during a session. Leaders should be experienced in working with consumers, their families, and also in group process and therapy. They should know about current issues and treatments of major depression and bipolar illness, including the biopsychosocial model of mood disorders.

Clinical procedures

The group leaders (practitioners) should meet before each session to discuss the content of the session and the division of tasks between them. They should also meet immediately after the session to review and assess group members and plan future agendas and strategies. This debriefing is especially important if a crisis occurred during the group session with either a consumer or a family member.

Screening session

This is an individual meeting between the consumer, family member(s) and one of the two co-leaders. It serves to:

• Introduce the consumer and family to the therapist; • Provide an opportunity to assess the family's and consumer's

knowledge about mood disorders, coping skills and methods of dealing with the illness;

• Build an alliance between the therapist consumer, and family; and • Let the therapist assess the appropriateness of the family and the

consumer for the psychoeducational group.

Structure of psychoeducation groups

Please refer to the references in Chapter 12 for specific information about the structure of these groups.

Conclusion

The optimal treatment of depression has yet to be defined. Pharmacotherapy, psychotherapy, family therapy, and group therapy all play a role for some consumers at some point in the illness. The multifamily group format is a welcome addition to the currently available treatments for depression. The

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role of the family is significant in determining the course of the depression and its response to treatments.

Multifamily Psychoeducational Treatment of Borderline Personality Disorder

Cynthia Berkowitz, M.D. John Gunderson, M.D.

The development of psychoeducational multifamily treatment of borderline personality disorder (BPD) is prompted by four factors:

• the need for novel psychosocial interventions in this disorder, • the success of psychoeducational multifamily treatment of

schizophrenia, • the need for more effective family interventions in this disorder, and • the emergence of a deficit model of BPD.

Dialectical Behavioral Therapy has been developed by Marsha Linehan and colleagues as a disorder specific treatment of BPD, focusing on the diminution of the self-destructive behavior that is the major cause of morbidity in BPD. It is the only psychosocial treatment of this disorder that has been subjected to a controlled outcome study. Linehan has established the effectiveness of this cognitive-behavioral treatment of BPD.

Practitioners who treat individuals with BPD know that the recurrent crises that mark the course of the illness often occur in response to interactions between the individual with BPD and relatives. This pattern strongly suggests that a treatment targeted at altering the family environment could positively influence the course of the disorder. The findings of Young and Gunderson, (1995) suggest that adolescents with BPD saw themselves as being significantly more alienated than did adolescents with other disorders. Their research found that alienation in the family environment is a useful target for intervention and indicates that psychoeducation may be able to diminish feelings of alienation.

Based on studies of the role of expressed emotion (EE) in BPD by Jill Hooley as well as by John Vuchetich, (the latter study in association with development of the current treatment), we hypothesize that EE in the family may be a risk factor for worsening psychosocial functioning in the individual with BPD.

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Rationale for psychoeducational multifamily treatment of BPD

The following principles borrow heavily from the previous work of Anderson, Hogarty, Falloon, Leff and McFarlane in the development of psychoeducational treatment but also incorporate emerging concepts of BPD, particularly the functional deficit model.

• BPD is characterized by functional deficits of (i) affect and impulse dyscontrol, (ii) intolerance of aloneness and (iii) dichotomous thinking. If individuals with BPD have functional deficits in their ability to cope, it follows that they would benefit from an environment that could help them cope with those deficits.

• The functional deficits above may render individuals with BPD handicapped but not disabled. This means that they can be held accountable for their actions but that change for them occurs very slowly and with great difficulty.

• BPD is an enduring disorder characterized by recurrent crises. The specific goal of the treatment is to diminish crises rather than to cure the disorder. We hypothesize that stress in the family environment may significantly influence the course of the disorder.

• Families can influence the course of illness in that they can either diminish the stresses that cause relapses or inadvertently create them. Families are asked specifically to make the home environment calmer and to reduce the stress the consumer who experiences BPD is subjected to.

• Living with an ill relative has stressful consequences for the family. A major goal of the current treatment is to diminish stress within the family.

• Family members will want to use education to change their behavior if they believe they can help an ill family member by doing so.

• Stress within the family may have at its root alienation between the individual with BPD and the family. Psychoeducational treatment moves parents away from issues of their possible causal role in the occurrence of the illness and away from blaming and criticizing the individual with BPD.

The role of the multifamily group in treatment of BPD

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The mechanisms of the multifamily group directly address the particular problems facing the families of individuals with BPD, including the need for:

• improved clarity of communication and directness; • diminished hostility; and • diminished over-involvement.

Structure of psychoeducational multifamily group treatment

The same three-stage structure used in the treatment of people with schizophrenia can be applied to people with borderline personality disorder. In this model, family psycoeducational treatment begins with a joining phase followed by an educational workshop. Families then join a multifamily group for an extended period of biweekly treatment. Again, the details of conducting the joining sessions, educational workshop and multifamily group sessions are described in the references listed in Chapter 12.

Treatment outcome

The psychoeducational multifamily group treatment of BPD is currently under study in a project involving two multifamily groups. Each of the families consisted of a mother or two parents with a daughter having BPD. Data is currently available for only eight of the participating families:

• 66.7 percent felt that the multifamily group helped them to modulate angry feelings

• 66.7 percent felt less burdened • All participating families felt that the group improved their

communication with their daughters (75 percent felt that the improvement was “very great” )

• All participating families felt that the treatment improved their knowledge of the disorder

• 91.6% of parents felt that the treatment had helped them to set limits • All of the participating families felt supported by the group

Conclusion

While the evidence supporting its effectiveness for people who experience borderline personality disorder is preliminary, the data available suggests

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that consumers are experiencing improved communication and diminished hostility within their families.

Multifamily Behavioral Treatment of Obsessive Compulsive Disorder

Barbara Van Noppen, M.S.W. Gail Steketee, Ph.D.

Education about consumers with obsessive compulsive disorder (OCD) and the reduction of critical responses to behavioral symptoms are important family factors in the course of illness and possibly in treatment outcome for OCD. Clinical investigation of family members’ responses to OCD symptoms and of their impact on the symptoms can lead to the development of family behavioral interventions that may help both the consumer and the family. Multifamily behavioral treatment (MFBT) includes consumers and their significant others in a 20-session intervention (12 weekly and 6 monthly sessions) over a period of 9 months. Preliminary findings revealed efficacy of MFBT comparable to standard individual behavioral therapy. Furthermore, reductions in the symptoms experienced by consumers with obsessive compulsive disorder who completed MFBT have been maintained at one-year follow-up.

Multifamily behavioral treatment (MFBT)

MFBT, compared to single-family behavioral therapy, offers the opportunity for reduction in perceived isolation, enriched opportunities for problem solving and emotional distancing, enabling family members to respond in a less personalized way to the symptoms. A sense of community and social support often develops through the course of the MFBT, as families share stories with one another. There is a lessening in feelings of shame and stigma, which encourages family members to take a larger role in treatment and join with the consumer to combat the symptoms of obsessive compulsive disorder. The presence of other families with similar problems provides an opportunity for consumers and families to learn effective negotiation of agreements and to adopt symptom management strategies modeled by other members of the group. Additional potential benefits of multifamily intervention are reduced therapist burnout and greater cost-effectiveness of treatment.

A recent uncontrolled trial by Van Noppen and colleagues examined the effects of MFBT for 19 consumers and family members treated in 4 groups.

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Consumers experienced significant reductions in obsessive compulsive symptom severity and similar reduction in scores on a measure of family functioning. Among MFBT consumers, 47% made clinically significant improvements (reliably changed and scoring in the non-clinical range on OCD symptoms) at post-test, and 58% achieved this status at 1-year follow-up. Results from MFBT were comparable to those achieved by individual behavior therapy. Overall, the multifamily intervention was quite effective, although some consumers did not show strong gains and there is clearly room for improvement.

Features and procedures of MFBT

MFBT is similar to methods described by McFarlane and Falloon, but uses interventions specifically aimed at reducing obsessive-compulsive symptoms and changing dysfunctional patterns of communication. This family group treatment incorporates psychoeducation, communication and problem-solving skills training, clarifying boundaries, social learning and in vivo rehearsal of new behaviors. There is also in-group observation of exposure and response prevention with therapist and participant modeling.

• 4-6 families (no more than 16 total participants is recommended), including consumer and others who have daily contact with the consumer. Co-leaders are optimal; at least one leader should have an advanced degree in social work, psychology or certified counseling and experience in clinical work with individuals, families and groups.

• Sessions are 2 hours long and typically meet in the late afternoon or early evening.

The key clinical procedures include:

• Each consumer and family has a pre-treatment screening by phone with the therapist(s) to determine appropriateness for the group and readiness for treatment; following this, two intake sessions are scheduled;

• At the intake sessions, 1 1/2 hours each, pretreatment forms are completed, symptom severity and family response styles determined, goals of the group and behavioral therapy principles are discussed, and pre-treatment concerns and questions are addressed;

• Treatment is comprised of 12 weekly sessions and 6 monthly group follow-up sessions, providing:

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o education about OCD and reading of self-help material; o education about families and OCD; o in vivo exposure and response prevention plus homework and

self-monitoring; o homework discussion with family group feedback and problem-

solving; and o behavioral contracting among family members and

communication skills training.

Conclusion

MFBT appears to be a good alternative to labor-intensive individual behavioral treatment. Recent research findings suggest that MFBT may especially help consumers who experience obsessive compulsive disorder and have not benefited from standard individual treatment and who are living with family members. MFBT incorporates family members into behavioral treatment by teaching family members and consumers to negotiate contracts. The goal of this treatment is to encourage anxiety reduction for the consumer, to educate and model reasonable interactive responses within families, and to remove family members from the consumer’s compulsions in a supportive manner.

Rates of Bipolar Diagnosis in Youth Rapidly Climbing, Treatment Patterns Similar to Adults NIMH Perspective on Diagnosing and Treating Bipolar Disorder in Children

The number of visits to a doctor's office that resulted in a diagnosis of bipolar disorder in children and adolescents has increased by 40 times over the last decade, reported researchers funded in part by the National Institutes of Health (NIH). Over the same time period, the number of visits by adults resulting in a bipolar disorder diagnosis almost doubled. The cause of these increases is unclear. Medication prescription patterns for the two groups were similar. The study was published in the September 2007 issue of the Archives of General Psychiatry

Mark Olfson, M.D., M.P.H., of New York State Psychiatric Institute of Columbia University, along with National Institute of Mental Health (NIMH) researcher Gonzalo Laje, M.D., and their colleagues examined 10 years of data from the National Ambulatory Medical Care Survey (NAMCS), an annual, nationwide survey of visits to doctors' offices over a one-week period, conducted by the National Center for Health Statistics.

.

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The researchers estimated that in the United States from 1994-1995, the number of office visits resulting in a diagnosis of bipolar disorder for youths ages 19 and younger was 25 out of every 100,000 people. By 2002-2003, the number had jumped to 1,003 office visits resulting in bipolar diagnoses per 100,000 people. In contrast, for adults ages 20 and older, 905 office visits per 100,000 people resulted in a bipolar disorder diagnosis in 1994-1995; a decade later the number had risen to 1,679 per 100,000 people.

While the increase in bipolar diagnoses in youth far outpaces the increase in diagnosis among adults, the researchers are cautious about interpreting these data as an actual rise in the number of people who have the illness (prevalence) or the number of new cases each year (incidence).

"It is likely that this impressive increase reflects a recent tendency to over-diagnose bipolar disorder in young people, a correction of historical under recognition, or a combination of these trends. Clearly, we need to learn more about what criteria physicians in the community are actually using to diagnose bipolar disorder in children and adolescents and how physicians are arriving at decisions concerning clinical management," said Dr. Olfson.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

attention-deficit hyperactivity disorder (ADHD)

provides general guidelines that can help doctors identify bipolar disorder in young patients. However, some studies show that youths with symptoms of mania (over-excited, elated mood)—one of the classic signs of bipolar disorder—often do not meet the full criteria for a diagnosis of bipolar disorder. Other disorders, such as

, may have symptoms that overlap, so some of these conditions may be mistaken for bipolar disorder as well. For example, in a study conducted in 2001, nearly one-half of bipolar diagnoses in adolescent inpatients made by community clinicians were later re-classified as other mental disorders.

Doctors also face tough questions when deciding on proper treatment for young people. Guidelines for treating adults with bipolar disorder are well-documented by research, but few studies have looked at the safety and effectiveness of psychiatric medications for treating children and adolescents with the disorder. Despite this limited evidence, the researchers found similar treatment patterns for both age groups in terms of use of psychotherapy and prescription medications.

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Of the medications studied, mood stabilizers, including lithium—which was the only medication approved at the time of the study by the U.S. Food and Drug Administration for treating bipolar disorder in children—were prescribed in two-thirds of the visits by youth and adults. Anticonvulsant medications, such as valproate (Depakote) and carbamazepine (Tegretol), were the most frequently prescribed type of mood stabilizers in both groups.

Doctors prescribed antidepressant medications in slightly over one-third of visits by youth and adults. Antidepressant medications include the older classes of antidepressant medications, such as tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs); selective serontonin reuptake inhibitors, such as fluoxetine (Prozac) and paroxetine (Paxil); and also newer types of antidepressants, including venlafaxine (Effexor). In both age groups, about one-third of the visits where antidepressant medications were prescribed did not include prescription of a mood stabilizer. This trend raises concerns, considering an earlier NIMH-funded study (Thase & Sachs, 2000) which reported that treating adults who have bipolar disorder with an antidepressant in the absence of a mood stabilizer may put them at risk of switching to mania. Also, a recent NIMH study showed that for depressed adults with bipolar disorder who are taking a mood stabilizer, adding an antidepressant medication was no more effective in managing bipolar symptoms than a placebo (sugar pill).

Roughly the same percentage of youth and adult bipolar visits included a prescription for an antipsychotic medication, although young patients were more likely to be prescribed one of the newer, atypical antipsychotic medications, such as aripiprazole (Abilify) or olanzapine (Zyprexa), than other types of antipsychotics. This finding suggests that doctors may be basing their treatment choices for bipolar youth on prescribing practices for adults with the disorder.

However, one main difference between youth and adult treatment was that children and teens were more likely than adults to be prescribed a stimulant medication—usually prescribed for treating ADHD—and adults were more likely than youth to be prescribed benzodiazepines, a type of medication used to treat anxiety disorders. More than half of all diagnosed youths and adults were prescribed a combination of medications. Given the relative lack of studies on appropriate treatments for youth with bipolar disorder, the researchers noted the urgent need for more research on the safety and

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effectiveness of medication treatments that are commonly prescribed to this age group.

The study had several important limitations. For example, the survey relied on the judgment of the treating physicians, rather than an independent assessment. As a result, the researchers' findings reveal more about patterns in diagnosis among office-based doctors than about definitive numbers of people affected by the illness. Another limitation is that the survey recorded the number of office visits instead of the number of individual patients, so some people may have been counted more than once.

"A forty-fold increase in the diagnosis of bipolar disorder in children and adolescents is worrisome," said NIMH Director Thomas R. Insel, M.D. "We do not know how much of this increase reflects earlier under-diagnosis, current over-diagnosis, possibly a true increase in prevalence of this illness, or some combination of these factors. However, these new results confirm what we are hearing increasingly from families who tell us about disabling, sometimes dangerous psychiatric symptoms in their children. This report reminds us of the need for research that validates the diagnosis of bipolar disorder and other disorders in children and the importance of developing treatments that are safe, effective, and feasible for use in primary care."

"This research, performed at a National Center on Minority Health and Health Disparities Center of Excellence, underscores the need to fully engage the community with their health care providers to better understand the actual prevalence of bipolar disease in children and adolescents," said John Ruffin, Ph.D., Director of NCMHD.

Additional study authors were Carmen Moreno, M.D., and Carlos Blanco, M.D., Ph.D., of New York State Psychiatric Institute/College of Physicians and Surgeons of Columbia University; Andrew B. Schmidt, C.S.W., of New York State Psychiatric Institute; and Huiping Jiang, Ph.D., of Columbia University.

The study was funded by the NIMH Intramural Research Program, National Institute on Drug Abuse (NIDA), NCMHD, the Agency for Healthcare Research and Quality (AHRQ), the Alicia Koplowitz Foundation, and the New York State Psychiatric Institute.

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NIMH Perspective on Diagnosing and Treating Bipolar Disorder in Children

A recently published research paper (September 2007, Archives of General Psychiatry

• Were physicians under-diagnosing bipolar disorder in the past?

) reported a 40-fold increase in the rate of diagnosing bipolar disorder in youth over the past decade. This paper raises several important questions:

• Are they over-diagnosing currently? • Are more children developing behavioral disorders than in the past?

It is unclear exactly what is causing this increase, but current evidence suggests a combination of each of these and possibly other factors. The following is intended to discuss the paper's findings within the broader context of what we know about the diagnosis and treatment of bipolar disorder in children and adolescents.

It is important to note that the paper's findings were based on data from a survey conducted annually by the National Center for Health Statistics. The survey comprises a one-page form that asks a nationally representative sample of private practice doctors to describe certain characteristics of each patient visit, including children and adults, over a one-week period. Neither the survey nor the paper provides information regarding:

• how common bipolar disorder is (prevalence) within the community; • the annual rate at which new cases are reported (incidence). • practices of other mental health providers, such as psychologists,

clinical social workers, and mental health counselors; • practices of physicians who work for the Federal government (such as

the Veterans Administration); or • practices of non-office based health settings where people with

bipolar disorder may receive mental health care, such as community mental health centers and hospital clinics.

The survey recorded the number of office visits instead of the number of individual patients, so some people may have been counted more than once. Because the survey was conducted only over one week, it was not possible to study the length and progress of treatment. In addition, information on the doses of some medications was not available. Finally, while a 40-fold increase seems large, the base rate (25 bipolar diagnoses per 100,000 people)

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suggests that the diagnosis was rarely used in 1994-1995. The recent rate of 1,003 bipolar diagnoses per 100,000 people is indeed much higher than the 1994-1995 rate, but still well below the rate of bipolar disorder for adults (1,679 bipolar diagnoses per 100,000 people).

How do physicians currently diagnose bipolar disorder in children? The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) lists criteria to define bipolar disorder in children. These criteria are based on how the disorder typically appears in adults and have not changed over the past decade.1 Research indicates that there are children whose symptoms clearly meet these criteria, as well as a much larger group of children who show some but not all symptoms. It is in this latter group, who frequently show excessive irritability and impulsivity, where there is disagreement as to whether these are symptoms of bipolar disorder or of a broader spectrum of mood disturbances. Such mood disturbances may have been diagnosed differently or may not have come to a physician's attention a decade ago.

Co-occurring disorders can also make diagnosis more difficult. As many as 60 percent of children diagnosed with bipolar disorder in most studies also have attention deficit hyperactivity disorder (ADHD),2,3

Recent research has demonstrated that many adult mental disorders begin in childhood. The NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial found that about 65 percent of adults with bipolar disorder describe the onset of symptoms before age 19,

raising questions about whether the current diagnostic criteria are specific enough to distinguish symptoms of bipolar disorder from symptoms of other related illnesses in children.

4 suggesting that the disorder may have been insufficiently recognized in the past. It is not yet clear, however, that all of the children currently diagnosed with bipolar disorder will grow up to be adults with bipolar disorder.

A current NIMH supported study is following a group of children and adolescents diagnosed with bipolar disorder to determine the course of their symptoms over time. In this and other research studies for which having bipolar disorder is a requirement, only a small fraction of children referred for participation actually meet criteria for the disorder. It seems likely therefore, that many of the children and adolescents in the community diagnosed as having bipolar disorder do not have the same illness as adults

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with bipolar disorder. In this sense, the diagnosis may be over-used or mis-used in children. This is not to say that these children and their families are not in distress. While these children may not all have bipolar disorder, it appears that physicians are reporting a true increase in the number of children and adolescents presenting with severe behavioral problems, including irritability, aggression, and erratic moods.

NIMH is committed to the development of biological tests that can help validate the diagnosis of bipolar disorder in children. Recent research advances showed that electroencephalograms (EEGs) and magnetic resonance imaging (MRI) studies of the brain can reveal differences between bipolar disorder and related behavioral syndromes which cause some of the same symptoms in children as bipolar disorder causes. In addition, recent studies have identified novel candidate genes that may increase risk for adults with bipolar disorder.5,6

Whatever the issues are in diagnosis, the

NIMH researchers also recently found that parents of children diagnosed with bipolar disorder appear more likely to themselves have bipolar disorder, compared with the parents of children with severe irritability but without the classic mood episodes of bipolar disorder. This suggests that genetics should ultimately prove helpful for validating bipolar diagnoses in children.

Archives

More research is needed to determine the safety and effectiveness of the many medications currently used to treat bipolar disorder in youth, as well as to identify other types of appropriate treatment. Several NIMH-funded clinical trials seek to accomplish this goal, including the

paper also described widespread prescribing of medications not FDA-approved for children diagnosed with bipolar disorder. Currently, there are no antidepressants approved by the FDA for treating bipolar disorder in children and adolescents, and only one approved atypical antipsychotic, risperidone (Risperdal).

Treatment of Early Age Mania study, involving children (ages 6-15) who have mania, which is comparing the effectiveness of three medications commonly used to treat bipolar disorder in adults. An additional study is focusing on teens (ages 13-17) diagnosed with bipolar disorder to examine the effectiveness of family-focused therapy (FFT) in conjunction with medication treatment. Another promising area of study lies in the ongoing trials of early diagnosis and interventions for children at risk for developing bipolar disorder because of a strong family history.

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The apparent inaccurate use of the bipolar diagnosis and questions about the safety and effectiveness of medications being prescribed to young children raise real concerns. These concerns need to be balanced by recognizing that psychiatric illnesses can cause disabling and sometimes dangerous symptoms during a critical period of physical and cognitive development, with many potential long-term effects for a child's future. Parents and physicians concerned about the risk of treatment need to consider the risks of not treating children who may have impulsive behaviors that can threaten themselves or others and make it difficult or impossible for the child to function well at home, at school or with peers. Children currently in treatment should not discontinue medication without consulting a physician.

Information on current trends in mental health care can help to highlight specific areas for further research and to assess ongoing efforts. Clearly, more studies are needed to determine the best ways to define, diagnose, treat, and perhaps someday even prevent, the range of mood disorders that affect children and adolescents. By supporting a broad range of rigorous research in this area, NIMH seeks to ensure that concerns about under-diagnosis or over-diagnosis can be resolved with valid diagnostic methods and safe, effective treatments.

Press Release: Rates of Bipolar Diagnosis in Youth Rapidly Climbing, Treatment Patterns Similar to Adults

References

1 Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder

McClellan J, Kowatch R, Findling RL.

. J Am Acad Child Adolesc Psychiatry. 2007 Jan;46(1):107-25.

2 Randomized, Placebo-Controlled Trial of Mixed Amphetamine Salts for Symptoms of Comorbid ADHD in Pediatric Bipolar Disorder After Mood Stabilization With Divalproex Sodium

Scheffer RE, Kowatch RA, Carmody T, Rush AJ.

. Am J Psychiatry. 2005 Jan;162(1):58-64.

3

Cognitive flexibility in phenotypes of pediatric bipolar disorder

Dickstein DP, Nelson EE, McClure EB, Grimley ME, Knopf L, Brotman MA, Rich BA, Pine DS, Leibenluft E.

. J Am Acad Child Adolesc Psychiatry. 2007 Mar;46(3):341-55.

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4

Long-Term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD)

Perlis RH, Miyahara S, Marangell LB, Wisniewski SR, Ostacher M, DelBello MP, Bowden CL, Sachs GS, Nierenberg AA; STEP-BD Investigators.

. Biol Psychiatry. 2004 May 1;55(9):875-81.

5

A genome-wide association study implicates diacylglycerol kinase eta (DGKH) and several other genes in the etiology of bipolar disorder

Baum AE, Akula N, Cabanero M, Cardona I, Corona W, Klemens B, Schulze TG, Cichon S, Rietschel M, Nothen MM, Georgi A, Schumacher J, Schwarz M, Abou Jamra R, Hofels S, Propping P, Satagopan J, Detera-Wadleigh SD, Hardy J, McMahon FJ.

. Mol Psychiatry. 2007 May 8; [Epub ahead of print] *Click to see NIMH press release*

6 Genome-wide association study of 14,000 cases of seven common diseases and 3,000 shared controls Wellcome Trust Case Control Consortium.

. Nature. 2007 Jun 7;447(7145):661-78.

Helping Children and Youth With Bipolar Disorder:

Children’s Mental Health Facts: Bipolar Disorder

This fact sheet provides basic information on bipolar disorder in children and describes an approach to getting services and supports, called “systems of care,” that helps children, youth, and families thrive at home, in school, in the community, and throughout life.

What Is Bipolar Disorder?

Although bipolar disorder affects at least 750,000 children in the United States, it is often difficult to recognize and diagnose in children. If left untreated, the disorder puts a child at risk for school failure, drug abuse, and suicide. That is why it is important that you seek the advice of a qualified professional when trying to find out if your child has bipolar disorder.

Bipolar disorder is a brain disorder that causes persistent, overwhelming, and uncontrollable changes in moods, activities, thoughts, and behaviors. A child has a much greater chance of having bipolar disorder if there is a family history of the disorder or depression. This means that parents cannot choose whether or not their children will have bipolar disorder.

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Symptoms of bipolar disorder can be mistaken for other medical/mental health conditions, and children with bipolar disorder can have other mental health needs at the same time. Other disorders that can occur at the same time as bipolar disorder include, but are not limited to, attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, anxiety disorders, autistic spectrum disorders, and drug abuse disorders. The roles that a family’s culture and language play in how causes and symptoms are perceived and then described to a mental health care provider are important, too. Misperceptions and misunderstandings can lead to delayed diagnoses, misdiagnoses, or no diagnoses—which are serious problems when a child needs help. That is why it is important that supports be in place to bridge differences in language and culture. Once bipolar disorder is properly diagnosed, treatment can begin to help children and adolescents with bipolar disorder live productive and fulfilling lives.

What Are the Signs of Bipolar Disorder?

• Excessively elevated moods alternating with periods of depressed or irritable moods;

Unlike some health problems where different people experience the same symptoms, children experience bipolar disorder differently. Often, children with the illness experience mood swings that alternate, or cycle, between periods of “highs” and “lows,” called “mania” and “depression,” with varying moods in between. These cycles can happen much more rapidly than in adults, sometimes occurring many times within a day. Mental health experts differ in their interpretation of what symptoms children experience. The following are commonly reported signs of bipolar disorder:

• Periods of high, goal-directed activity, and/or physical agitation; • Racing thoughts and speaking very fast; • Unusual/erratic sleep patterns and/or a decreased need for sleep; • Difficulty settling as babies; • Severe temper tantrums, sometimes called “rages”; • Excessive involvement in pleasurable activities, daredevil behavior,

and/or grandiose, “super-confident” thinking and behaviors; • Impulsivity and/or distractibility; • Inappropriate sexual activity, even at very young ages; • Hallucinations and/or delusions; • Suicidal thoughts and/or talks of killing self; and • Inflexible, oppositional/defiant, and extremely irritable behavior.

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What Happens After a Bipolar Disorder Diagnosis? If a qualified mental health provider has diagnosed your child with bipolar disorder, the provider may suggest several different treatment options, including strategies for managing behaviors, medications, and/or talk therapy. Your child’s mental health care provider may also suggest enrolling in a system of care, if one is available.

What Is a System of Care? A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families, children, and youth work in partnership with public and private organizations so services and supports are effective, build on the strengths of individuals, and address each person’s cultural and linguistic needs.

• Tailoring services to the unique needs of your child and family;

Specifically, a system of care can help by:

• Making services and supports available in your language and connecting you with professionals who respect your values and beliefs;

• Encouraging you and your child to play as much of a role in the design of a treatment plan as you want; and

• Providing services from within your community, whenever possible.

How Can I Find a System of Care for My Child With Bipolar Disorder? Contact the system of care community in the box on the back of this fact sheet. If none is listed or that system of care community is not in your area, visit mentalhealth.samhsa.gov/cmhs and click “Child, Adolescent & Family” and then “Systems of Care” to locate a system of care close to you. If you prefer to speak to someone in person to locate a system of care, or if there is not a system of care in your area, contact the National Mental Health Information Center by calling toll-free 1.800.789.2647 or visiting mentalhealth.samhsa.gov.

Are Systems of Care Effective? National data collected for more than a decade support what families in systems of care have been saying: Systems of care work. Data from systems of care related to children and youth with bipolar disorder reflect the following:

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• Children and youth demonstrate improvement in emotional and behavioral functioning.

• Caregivers report that children and youth have a reduction in conflicts with others in the family.

• Caregivers experience an increased ability to do their jobs. • Caregivers report fewer missed days and a reduction in tardiness from

work. • Children and youth with bipolar disorder improve in school-related

tasks, such as paying attention in class, taking notes, and completing assignments on time.

• Children and youth with bipolar disorder have fewer contacts with the juvenile justice system after enrolling in a system of care.

The Core Values of Systems of Care Although systems of care may be different for each community, all share three core values. These values play an important role in ensuring that services and supports are effective and responsive to the needs of each child, youth, and family. These core values are:

• Systems of care are family-driven and youth-guided. • Systems of care are culturally and linguistically competent. • Systems of care are community-based.

At age 12, Austin appears to be a typical sixth grader—he likes to play basketball and video games, and is enrolled in an after-school horseback riding program. He is an honor roll student, and his mother describes him as compassionate, loyal, and a champion for the “underdog.” Austin and his family also manage the challenges of bipolar disorder each day.

Austin’s Story

Austin was diagnosed in first grade with attention-deficit/hyperactivity disorder and separation anxiety disorder, but Austin’s mother, Kim, recalls a series of incidents that led her to question whether her son’s mental health needs were being met. At age 9, Austin set two fires within a week. The first time it happened, Kim thought it was an isolated incident that would not be repeated— Austin said he was lighting candles.

The second time Austin set a fire, however, the situation was very different. While bringing groceries into the house, Austin set a small fire in the car. When Kim discovered signs of the fire the next morning, she says, “I

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immediately got on the phone and started calling his physician. Thoughts were flashing through my mind about what could have happened.”

After Kim received a referral from Austin’s physician for diagnostic testing and other mental health services, she learned that her son had been experiencing hallucinations, which were causing him to set the fires. She also learned that his extreme mood swings, as well as his unusual sleep patterns, were signs of bipolar disorder. As a result, Austin was hospitalized for 20 days and diagnosed with bipolar disorder. During this time, Austin was accepted into a system of care through a referral from his school guidance counselor.

Kim says the system of care played an important role in helping Austin make the transition from the hospital to his home—even providing transportation, as Kim’s car was being repaired at the time. System of care staff helped Kim learn more about her son’s disorder. They also helped her locate services and supports tailored to Austin’s needs, including counseling, health care, specialized schooling, after-school programs, transportation, and child care.

The system of care also empowered Kim to be a more effective advocate for Austin’s needs. Before joining the system of care, she says, “I tried to fit the service to the need, rather than fit the need to the service. That was a mistake.”

Kim also assumed that professionals were best able to determine how to meet her child’s needs. After working in partnership with the system of care, Kim now knows that services and supports should be responsive to Austin’s needs and that her and her son’s input into the services and supports is crucial.

Despite the successes her family has had, Kim emphasizes that the journey to wellness is not over. In addition to coping with the symptoms of bipolar disorder, she and Austin also must overcome the stigma associated with mental illnesses. Together, Kim and Austin counter this stigma by educating others that he, and others with mental illnesses, should be known for who they are rather than the disorders they happen to have. Despite the ongoing challenges of stigma and bipolar disorder, Kim believes that the system of care has made a huge difference in terms of helping her family move forward.

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What Steps Are Necessary To Enroll in a System of Care?

Step One: Diagnosis and Referral—To be considered for system of care enrollment, your child must have a diagnosed behavioral, emotional, or mental health disorder that severely affects his or her life. Additionally, most children and youth are referred to a system of care by mental health providers, educators, juvenile justice professionals, child welfare professionals, physicians, and others who might already be serving your child.

Although each community’s system of care is different, most children and youth in a system of care go through the following steps to be enrolled:

Step Two: Assessment and Intake—Once your child has been diagnosed and has been referred to the system of care, the system of care may ask you to answer some questions that will help you determine whether or not your child and family are eligible to receive services and supports. If your child and family are eligible, you may have to answer more questions so the system of care can begin to understand your needs. Throughout these steps, the system of care will work with you to fill out all of the necessary paperwork.

Step Three: Care Planning and Partnership Building—After your child and family are enrolled, the system of care will work with you to determine what services and supports best fit your child’s and family’s needs. Once the care planning is complete, the system of care will develop partnerships among you and all of those who are helping your child and family to ensure that services and supports are as effective as possible.

Federal Government Resources

For More Information

National Mental Health Information Center Substance Abuse and Mental Health Services Administration mentalhealth.samhsa.gov Tel: 1.800.789.2647 (toll-free; English/Spanish) TDD: 1.866.889.2647

National Institute of Mental Health National Institutes of Health www.nimh.nih.gov

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Tel: 1.866.615.6464 (toll-free; English/Spanish) TTY: 301.443.8431

Additional Resources

Following are some other resources that may be helpful. This list is not exhaustive, and inclusion does not imply endorsement by the Substance Abuse and Mental Health Services Administration or the U.S. Department of Health and Human Services.

Child and Adolescent Bipolar Foundation www.bpkids.org Tel: 847.256.8525

Federation of Families for Children’s Mental Health www.ffcmh.org Tel: 703.684.7710

NAMI (National Alliance on Mental Illness) www.nami.org Tel: 1.800.950.6264 (toll-free) National Mental Health Association www.nmha.org Tel: 1.800.969.6642 (toll-free)

6. Bipolar Disorder, Mental Illness and Substance Abuse

Over the past decade families, clinicians, and mental health administrators have become increasingly aware of the problem of substance abuse in persons with severe mental illness (Lehman & Dixon, 1995; Minkoff & Drake, 1991; Ridgely et al., 1986). Previously, psychiatric patients were rarely asked about their use of alcohol or drugs, nor were the possible effects of substance abuse on the course of the disorder given more than cursory consideration. Moreover, clinicians who did suspect that their patients might have a problem with substance abuse were limited by the lack of validated instruments for assessing substance use disorders in persons with severe mental illnesses and by the lack of effective treatments.

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Fortunately, substantial progress has been made in recent years in understanding the scope of the problem of co-occuring substance use disorders, in the development of reliable and valid measures for evaluating substance abuse in people with severe psychiatric disorders, such as schizophrenia and bipolar disorder, and in providing effective treatment for persons with both disorders. This toolkit provides the information needed to assess the presence of substance use disorders in persons with a psychiatric disorder, the severity of the alcohol and drug abuse, and where on the continuum of recovery from substance abuse patients fall. In our review, we have placed a premium on measurement tools that are psychometrically sound, user friendly, and time efficient to administer. At the same time, we highlight the limitations of existing instruments and discuss possible threats to the validity of assessments.

We begin with a review of the scope of the problem of substance use disorders in persons with severe psychiatric disorders, including prevalence rates and impact on the course of illness and adjustment. Next, we discuss problems inherent in the measurement of substance abuse in psychiatric clients, and consider the difference between assessment and treatment planning. We then review the recovery process for persons with a substance use disorder, as such a process has implications for the measurement of these disorders, and we describe specific rating scales that can be used to monitor the recovery process. Methodological and training aspects of assessing substance use disorders in severely mentally ill persons are also discussed, as well as strategies for the processing and analysis of obtained data. Finally, we consider the public policy and dissemination implications of conducting substance use assessments on this population.

Scope of the Problem Definitions

The diagnostic term "substance use disorder" refers to a habitual pattern of alcohol or illicit drug use that results in significant impairments in areas of adjustment, such as work, social relationships, economic well-being, involvement in the legal system, or physical health. Traditionally, substance use disorders have been divided into two mutually exclusive classifications-substance abuse and substance dependence-with the latter diagnosis representing the more severe disorder. Although there is some evidence that the abuse/dependence distinction may be etiologically important (Noordsy et al., 1994) and prognostically useful in the population of severely ill

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psychiatric patients (Bartels et al., 1995), the same assessment issues pertain to both classifications. For the purposes of this review we will follow nomenclature from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and refer to a person with either substance abuse or substance dependence as having a substance use disorder.

The time-frame for which a substance use disorder is assessed can have important treatment implications. Generally, assessment techniques focus on providing "lifetime" or "current" diagnoses of a substance use disorder. The specific DSM criteria for specifying the course of a substance use disorder change with each new edition. The DSM-IV uses at least one month without abuse or dependence to indicate early remission and at least one year to indicate sustained remission. Although persons with a lifetime substance use diagnosis that is in remission may be seen as not requiring substance use-related treatment services, their high vulnerability to relapses of their substance use indicates that these patients often require ongoing treatment and assessment.

The term "comorbidity" refers to the presence or co-occurence of two different medical conditions. Thus, persons with a psychiatric disorder (such as schizophrenia) and a substance use disorder (such as alcohol abuse) can be described as having comorbid disorders. They are also sometimes referred to as having a dual diagnosis. In the next section, we review the research on the prevalence of comorbid substance use disorders in persons with severe psychiatric illnesses.

Prevalence

Estimates of the prevalence of substance use disorders in persons with severe mental illness vary considerably, from as low as 10% to as high as over 65% (Safer, 1987; Goodwin & Jamison, 1990; Mueser et al., 1990; Mueser, Bennett, & Kushner, 1995). The high variability in prevalence rates appears to be due to differences across studies in factors such as the treatment setting in which patients are sampled (e.g., community mental health center, acute inpatient, chronic inpatient), whether the community is urban or rural, the demographic mix of the study sample (e.g., proportion of males), and the methods for assessing psychiatric and substance use disorders (e.g., structured clinical interview, chart review) (Galanter, Castaneda, & Ferman, 1988). For example, young males are significantly more prone to develop a substance use disorder (Mueser, Yarnold, &

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Bellack, 1992), so that samples comprised of a high proportion of these clients, as is the case with many studies of "young, chronic" mental clients (Pepper, Kirshner, & Ryglewicz, 1981; Safer, 1987), tend to yield high estimates of the prevalence of substance use disorders. Similarly, clients assessed in an emergency room setting are more likely to have a substance use disorder than clients living in state hospitals (Ritzler et al., 1977; Barbee et al, 1989). Thus, the actual rate of substance use disorders in persons with severe psychiatric disorders is determined, in large part, by the mix of clients receiving treatment in that setting.

Although specific estimates vary, there is overwhelming evidence that persons with severe mental disorders are at increased risk for substance use disorders. The most comprehensive study on the comorbidity of psychiatric and substance use disorders was conducted as part of the Epidemiological Catchment Area (ECA) study (Regier et al., 1990), in which over 20,000 persons living in the community or institutional settings were assessed. The ECA study found that all people with a psychiatric disorder were more prone to substance abuse, but persons with severe mental illness were especially vulnerable. For example, clients with schizophrenia were more than four times as likely to have had a substance use disorder during their lifetime, and those with bipolar disorder were more than five times as likely to have such a diagnosis, than persons in the general population.

The results of the ECA study, combined with numerous other prevalence studies, indicate that persons with severe psychiatric illness are more likely to have problems with alcohol and drug use than less ill clients or people with no psychiatric disorder. Overall, about half of all persons with a severe psychiatric illness have had a substance use disorder at sometime during their lives, and between 25% and 35% have a current substance use disorder. By comparison, less than 20% of people in the general population have a substance use disorder during their lives. The high rate of substance use disorders among psychiatric clients underscores the importance of accurate assessment in these persons. As described in the next section, there is a high cost, both clinically and economically, of the failure to diagnose and treat substance use disorders in this population.

Consequences of Substance Abuse

Substance abuse among persons with severe mental illness can have negative clinical effects, such as precipitating relapses and

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rehospitalizations, and increasing suicidality and violence; it can lead to adverse medical consequences, such as vulnerability to HIV+ infection, and precipitate psychosocial instability, such as financial problems, housing loss, and homelessness; furthermore, substance abuse can result in higher service utilization, treatment costs, and economic burden to the family (Bartels et al., 1992; Bartels et al., 1993; Clark, 1994; Cournos et al., 1991; Drake, Osher, & Wallach, 1989; Yesavage & Zarcone, 1983). The impact of substance abuse on symptoms is often so marked that clinicians are advised to first explore substance use when a psychiatric client presents with an otherwise unexplained symptom exacerbation. Despite the serious consequences of substance abuse, there are reasons to be optimistic. In most cases, the impact of substance abuse appears to be temporary, and dually diagnosed clients who attain stable remission improve clinically and resemble non-abusing clients (Zisook, et al., 1992). Thus, successfully reducing substance abuse may result in positive outcomes in areas such as symptoms, community tenure, and service utilization.

Evaluation Difficulties

A wide range of different problems complicate the assessment of substance use disorders in persons with severe psychiatric disorders (Drake, Alterman, & Rosenberg, 1993). The major problem in most psychiatric settings is that clinicians simply fail to take a careful history of substance use. For example, a study by Ananth et al. (1989) found that 84% of substance disorder diagnoses that were detected on structured interview were missed when clients were evaluated in emergency settings and on entrance to a state hospital. Clients who are in our research studies on dual disorders are identified as having a substance disorder on only a minority of discharge summaries from a variety of hospitals. Taking a careful history of clients' alcohol and drug use behavior does not guarantee detection of a substance use disorder, but it is the most important first step in the evaluation process. Many clients who do not volunteer information about their use of substances freely admit to alcohol or drug abuse when a history is taken, enabling the clinician to establish a diagnosis.

Some clients are willing and able to describe their substance use behavior, while others are not. When evaluated directly, people with severe mental illness are prone to the usual problems that accompany self-report (e.g., recalling the details of past behavior, responding to the demand characteristics of the situation). In addition to these problems of self-report,

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however, they may have difficulty participating in a structured interview during a symptom exacerbation or in crisis (Barbee et al., 1989). Another common difficulty is that cognitive, psychotic, and mood-related distortions characteristic of psychiatric disorders can interfere with accurate recall. Furthermore, it is often difficult or impossible to discern the causal effects of substance use on psychiatric clients, since they often experience multiple stressors during times of crisis; thus, for example, it may not be possible to determine the role(s) played by substance abuse in precipitating any of the elements of a crisis which include medication noncompliance, a symptom exacerbation, an episode of homelessness, and a hospitalization.

In addition to problems understanding the effects of substance use, psychiatric clients are prone to denial when they have experienced severe sanctions, such as having been extruded from a program or a housing setting, because of substance abuse. Denial is more common for marijuana, cocaine, and other illicit drugs than for alcohol (Stone et al., 1993; Galletly, Field, and Prior, 1993), probably because of laws prohibiting possession and use of such substances. Minimization often occurs due to genuine confusion about the effects of substance use. People with severe mental illnesses have typically had a number of terrible experiences in their lives, and substance abuse, although deleterious, may not be easily identified as a causal agent. In part, this is because clients are typically aware of the short-term positive effects of substance use, such as decreases in anxiety and depression, improved sleep, and temporary feelings of well-being, rather than the long-term negative effects which may be more difficult to detect, such as increases in hallucinations, suicidal thoughts, and interference with the ability to manage one's life.

Another critical problem in evaluating substance abuse in psychiatric clients is that the usual standards for assessment are different in these persons compared to people with a primary substance use disorder, but no psychiatric illness. In other words, the dimensions of assessment-pattern of use, consequences, the dependence syndrome, and subjective distress-are all quite different for persons with severe mental illness than for those without a psychiatric disorder. Thus, people with a severe mental illness tend to incur adverse consequences on using relatively small amounts of alcohol or other drugs (Janowsky et al., 1973; Treffert, 1978; Knudsen & Vilmar, 1984; Drake, Osher, and Wallach, 1989; Lieberman, Kinon, & Loebel, 1990). The consequences that they experience, although often typical for persons with severe mental disorder, are not the consequences that are assessed on

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standard instruments for primary substance abusers. For example, psychiatric clients often encounter difficulties managing their illness, complying with prescribed medications, budgeting disability funds, maintaining housing, and participating in rehabilitation. On the other hand, most clients do not encounter problems with jobs, spouses, and revocation of driver's licenses because they are rarely employed, married, or own their own vehicles.

Because of their sensitivity to the effects of alcohol and other drugs, psychiatric clients often do not develop the syndrome of physiological dependence, including tolerance or withdrawal when they stop using the substance (Drake et al., 1990). Finally, due to the salience of other problems in their lives and the difficulty in making accurate causal connections between substance abuse and adjustment, they often have little subjective distress regarding alcohol and other drug use. For these reasons, standard instruments developed for primary substance abusers are usually inadequate to the task of assessing these problems in persons with severe mental illness. For example, instruments like the Addiction Severity Index (McLellan et al., 1990), which rely on pattern of use and subjective distress, often fail to detect the extent of substance abuse problems in this population.

At this point in time, there is a pressing need to develop new instruments for the assessment of substance abuse in patients with severe psychiatric disorders. Until more refined instruments are available, we recommend taking a multimodal approach. Such an assessment recognizes that no single instrument and no one source of information is sufficient to diagnose a substance use disorder accurately in this population. Rather, the most accurate assessment process makes use of several instruments, pays attention to issues of relevance for this population (e.g., effects on symptoms, treatment compliance, housing stability), obtains information from multiple sources (e.g., patient, relatives, case manager, drug screens), and includes a repeated, longitudinal component. In this toolkit we describe some simple scales and strategies for assessing and monitoring substance abuse over time.

Evaluation vs. Treatment Planning

The approach described here addresses the task of monitoring clients who are in treatment. It is not intended to serve the function of a comprehensive assessment for the purpose of treatment planning. We have reviewed the more complex approach suitable for a thorough clinical assessment

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elsewhere (Drake & Mercer-McFadden, 1995). Clinical assessment links the four tasks of detection, classification, detailed assessment, and treatment planning in a process of reciprocal feedback. The goal is to involve the client in an effort to identify and address all of the biological, psychological, social, and environmental factors that sustain the abusing behaviors.

The Recovery Process

An understanding of the process of recovery from a substance use disorder can aid clinicians in monitoring substance abuse and progress in treatment. Longitudinal research on persons with a primary drug or alcohol use disorder indicates that these disorders are usually chronic over the lifetime, associated with increased mortality rates, and receive only limited amounts of treatment (Vaillant, 1983, 1988; Hser, Anglin, & Powers, 1993). Despite the persistence of these disorders, some persons do achieve sustained abstinence, with about 2-5% reaching stable remission per year, and 1-2% returning to substance abuse. Less information is available about the natural course of clients with severe mental illnesses and substance use disorders, but one long-term study (seven years) of dually diagnosed clients indicates a rate of recovery similar to that in primary substance abusers (Bartels et al., 1995). However, there is also encouraging evidence suggesting that integrated substance abuse and mental health treatment can accelerate the rate of remission in dual diagnosis clients (Drake, Mueser, Clark, & Wallach, in press; Mueser, Drake, & Miles, in press).

7. Client Resources

Illness Management and Recovery Workbook:

Handout 2b: Practical Facts About Bipolar Disorder

“I came to hate the manic side of my illness as much as the depression, since the constant racing thoughts were quite uncontrollable and bothersome. My current treatment plan helps me keep things under much better control.”

David Kime, artist, writer, floral designer, in recovery from bipolar disorder

Introduction

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This handout provides information about bipolar disorder. Facts are given about how a diagnosis is made, the symptoms, how common it is, and the possible courses of the disorder. Several examples are included of famous people who have experienced the symptoms of bipolar disorder and have made positive contributions to society.

Bipolar disorder is a major mental illness that affects many people. It is sometimes called “manic depression.” About one person in every one hundred people (1%) develops the disorder at some time in his or her life. It occurs in every country, every culture, every racial group and at every income level.

What is bipolar disorder?

Bipolar disorder causes symptoms that can interfere with many aspects of people’s lives. Some of the symptoms cause severe mood swings, from the highest of highs (mania) to the lowest of the lows (depression.) Some of the other symptoms of bipolar disorder can make it difficult to know what’s real and what’s not real (psychotic symptoms).

It is important to know that there are many reasons to be optimistic about the future:

• There is effective treatment for bipolar disorder. • People with bipolar disorder can learn to manage their illness. • People with bipolar disorder can lead productive lives.

The more you understand about the illness and take an active role in your treatment, the better you will feel and the more you can accomplish toward your life goals.

Bipolar disorder is a major mental illness that affects many aspects of a person’s life. 1 in every 100 people develops bipolar disorder at some point in his or her

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life. People can learn to manage the symptoms of bipolar disorder and lead productive lives.

Question: What did you know about bipolar disorder before you had personal experience with it?

Bipolar disorder is diagnosed based on a clinical interview conducted by a specially trained professional, usually a doctor, but sometimes a nurse, psychologist, social worker or other mental health practitioner. In the interview, there are questions about symptoms you have experienced and how you are functioning in different areas of your life, such as relationships and work.

How is bipolar disorder diagnosed?

There is currently no blood test, X-ray or brain scan that can be used to diagnose bipolar disorder. To make an accurate diagnosis, however, the doctor may also request a physical exam and certain lab tests or blood tests in order to rule out other causes of symptoms, such as a brain tumor or an injury to the brain.

Bipolar disorder is diagnosed by a clinical interview with a mental health professional.

Question: How long did it take for a mental health professional to accurately diagnose the symptoms you experienced?

It is important to keep in mind that the symptoms of bipolar disorder can be found in other mental disorders. Specifying a diagnosis of bipolar disorder is based on a combination of different symptoms, how long they have been present, and their severity. Symptoms that occur only when a person has used alcohol or drugs are not included.

What are the symptoms of bipolar disorder?

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No one has the exact same symptoms or is bothered to the same degree. You may, however, recognize having experienced some of the following symptoms:

People who have had periods of mania have reported the following symptoms:

Extremely high moods are called “mania.”

Feelings of extreme happiness or excitement. “I was so happy with my life; I felt like I was on top of the world. I thought the whole world loved me and worshipped me.”

Feeling irritable. “I thought I had a brilliant plan for making thousands of dollars. I got very irritated when people asked questions that seemed to doubt me.”

Feeling unrealistically self confident. “I sent a hand written script to Steven Speilberg. I was absolutely sure that he would buy it immediately for his next movie.”

Sleeping less. “I felt like I only needed two hours of sleep a night. I was too excited to sleep any more than that.”

Talking a lot. “People told me I was talking all the time; they couldn’t get a word in edgewise. I couldn’t seem to stop myself because I had so much to say.”

Having racing thoughts. “My head was so full of thoughts I couldn’t keep up with them.”

Being easily distracted. “I couldn’t concentrate on what my English teacher was saying because I was distracted by every other sound—the ticking of the clock, the air conditioner humming, a car driving by, someone walking by in the hall, a bird singing outside the window. It was overwhelming.”

Being extremely active. “Sometimes I would work 20 hours a day on my inventions. Or I would re-arrange every stick of furniture in my house—then change it again the next day.”

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Having bad judgment. “I thought nothing bad could happen to me, so I spent everything in my bank account, borrowed from everyone I knew, then ran up all my charge cards. I also had a one night stand with someone that I didn’t know at all—I was lucky he didn’t have AIDS or something.”

“Depression” is defined as including:

Extremely low moods are called “depression.”

Sad mood. “I couldn’t see anything positive in my life. Everything seemed dark and negative.”

Eating too little or too much. “When I am depressed, I lost all interest in food. Nothing looks good and I hardly eat anything. I lost ten pounds the last time.”

Sleeping too little or too much. “I had a lot of trouble falling sleep at night. I would lay awake for hours, tossing and turning. Then I would wake up at 4:00 AM and not be able to go back to sleep. Other people I know with depression have the opposite problem. They feel like sleeping all the time—they spend 12 or more hours a day in bed.”

Feeling tired and low energy. “I dragged myself to work each morning, but I could barely answer the phone once I got there. Everything seemed like such an effort.”

Feeling helpless, hopeless, worthless. “I broke up with my boyfriend because I thought I was a loser and he shouldn’t be stuck with me. He deserved better. It seemed like nothing I did turned out right. I saw nothing but heartache in my future.”

Feeling guilty for things that aren’t your fault. “I started feeling responsible for all kinds of things: my brother’s having cerebral palsy, the car accident that happened in front of my house, even the hurricane that blew the roofs off the buildings down in Florida. Somehow I thought it was all my fault.”

Suicidal thoughts or actions. “When I reached the bottom, I felt that the only way out was to leave this world. I thought my wife and kids would be better off without me. Luckily I didn’t do anything to hurt myself, although I considered it.”

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Trouble concentrating and making decisions. “It took me over an hour to read a one page letter from my bank. I couldn’t keep my mind focused. And one day I couldn’t go to work because I couldn’t decide what shirt to wear.”

Some people with bipolar disorder have psychotic symptoms. They have described the following experiences:

Symptoms which make it hard to know what’s real are called “psychotic symptoms.”

Hearing, seeing, feeling or smelling something that is not actually there (“hallucinations”). “I heard different kinds of voices. Sometimes the voices were o.k., just making comments like ‘now you’re eating lunch.’ But sometimes the voices said things like ‘you’re stupid; no one wants to be friends with such a loser.’ Or they might say scary things about other people, ‘he has a knife and wants to kill you.’”

Having very unusual or unrealistic beliefs that are not shared by others in your culture or religion (“delusions”). “I was convinced that I had special mental powers that could stop missiles in their tracks. I thought the FBI was after me because they wanted to control these powers. I even thought the TV was talking about this.”

Confused thinking (“thought disorder.”) “I used to try to tell my sister what I was thinking, but I would jump from topic to topic and she told me she had no idea what I was talking about.”

The major symptoms of bipolar disorder are mania, depression, and psychotic symptoms.

No one has exactly the same symptoms or experiences them to the same

degree.

Question: Which of the symptoms have you experienced? You can use the following checklists to record your answer.

Symptoms of Mania

Symptom of Mania I had this symptom Example

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Feeling extremely happy or excited

Feeling irritable

Feeling unrealistically self confident

Sleeping less

Talking a lot

Having racing thoughts

Being easily distracted

Being extremely active

Having faulty judgment

Symptoms of Depression

Symptom of depression I had this symptom Example

Sad mood

Eating too little or too much

Sleeping too little or too much

Feeling tired and low energy

Feeling helpless, hopeless, worthless

Feeling guilty for things that weren’t my fault

Suicidal thoughts or actions

Trouble concentrating & making decisions

Symptoms of Psychosis

Symptom of psychosis I had this symptom Example

Hearing, seeing, feeling or smelling something that is not actually present

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Confused thinking

Having very unusual or unrealistic beliefs that are not shared by others in my culture

Bipolar disorder is nobody’s fault. This means that you did not cause the disorder and neither did your family members or anyone else. Scientists believe that the symptoms of bipolar disorder are caused by a chemical imbalance in the brain. Chemicals called “neurotransmitters” send messages in the brain. When they are out of balance, they can cause extreme shifts in your mood. This chemical imbalance can also cause the brain to send messages that contain wrong information.

What causes bipolar disorder?

Scientists do not know what causes this chemical imbalance, but they believe that whatever causes it happens before birth. This means that people have a “biological vulnerability” to develop bipolar disorder, which then develops at a later age.

In addition to biological vulnerability, stress is also believed to play a role in the onset and course of bipolar disorder. The theory of how vulnerability and stress interact with each other is called the “stress-vulnerability model” and is covered in more detail in the handout “The Stress-Vulnerability Model and Treatment Strategies.”

Many questions about bipolar disorder remain unanswered. There are many research projects underway to try to learn more about the illness.

Bipolar disorder is nobody’s fault. Scientists believe that bipolar disorder is caused by a chemical imbalance

in the brain.

Question: What other explanations have you heard about what causes bipolar disorder?

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People usually develop bipolar disorders as teenagers or young adults, approximately age 16 to age 30. People can also have their first symptoms when they are in their 40’s or 50’s. People vary in how often they have symptoms, the severity of the symptoms and how much the disorder interferes with their lives.

What is the course of bipolar disorder? What happens after you first develop symptoms?

Bipolar disorder affects people in very different ways. Some people have a milder form of the disorder and only have symptoms a few times in their lives. Other people have a stronger form of the disorder and have several episodes, some of which require hospitalization.

Bipolar tends to be episodic, with symptoms varying in intensity over time. When symptoms reappear or get worse, this is usually referred to as a “symptom exacerbation” or an “acute episode” or a “relapse.” (More information on this subject is provided in the handout, “Reducing Relapses.”) Some relapses can be managed at home, but other relapses may require hospitalization to protect the person or others.

With effective treatment, most people with bipolar disorder can reduce their symptoms and live productive, meaningful lives.

Bipolar disorder tends to be episodic, with symptoms coming and going at varying levels of intensity.

Question: What has been your experience with symptom relapses?

Some famous people have developed bipolar disorder:

Examples of people who have bipolar disorder

Patti Duke is an American actress who had her own television series and has starred in movies, including “The Miracle Worker.” She also had a singing and writing career.

Robert Boorstin was a special assistant to President Clinton. His work was highly valued in the White House.

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Vincent Van Gogh was one of the most famous painters who ever lived.

Kay Redfield Jamison

Other people who have developed bipolar disorder are not famous, but are quietly leading productive, creative, meaningful lives:

is a psychologist, researcher and writer. In 2001 she won a MacArthur Fellowship, sometimes referred to as “ the genius award.”

Ms. X is an attorney in a large law firm and is active in her church.

Mr. Y teaches in an elementary school. He is married and is expecting his first child.

Mr. Z is actively looking for work. He used to need frequent hospitalizations, but has successfully stayed out of the hospital for 3 years.

There are countless positive examples of people with bipolar disorder who have contributed to society.

Questions:

Do you know other people with bipolar disorder?

If so, what are some examples of their personal strengths?

When referring to mental illness, the word “stigma” means the negative opinions and attitudes that some people have about mental illness. Not everyone with mental illness has experienced stigma, although unfortunately, many have.

What is stigma?

It is important to know that there are two major laws that protect against discrimination against people with physical or psychiatric disabilities. The Americans with Disabilities Act (ADA) makes it illegal to discriminate in the areas of employment, transportation, communication or recreation. The Fair Housing Act (FHA) prohibits housing discrimination.

Stigma is a complicated problem, and there are no easy solutions. Research has shown that as the general public gets to know more about mental

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disorders and as they get to know people who have experienced psychiatric symptoms, their negative beliefs go down.

Many organizations, including the National Institute of Mental Health, the Center for Mental Health Services, The National Alliance on Mental Illness, the National Mental Health Association, and the National Empowerment Center, are working on national campaigns to educate the public and create more laws that protect against discrimination. Contact information for these organizations is listed in the Appendix of the “Recovery Strategies” handout.

If you have experienced stigma and/or would like to know more about strategies for responding to stigma, refer to the Appendix at the end of this handout.

Stigma refers to negative opinions and attitudes about mental illness.

Question: Have you ever experienced stigma because of psychiatric symptoms?

By reading this handout you are already taking an important step, which is learning some practical facts about your illness. Other important steps include:

What are some of the steps you can take to manage your illness?

• Learning how to cope with stress • Building social support • Developing a relapse prevention plan • Using medication effectively • Learning how to cope with symptoms • Getting your needs met in the mental health system

These steps will be covered in the other educational handouts in the Illness Management and Recovery Program.

What you do makes a difference in your recovery. There are steps you can take to manage psychiatric symptoms effectively.

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• Bipolar disorder is a major psychiatric disorder that affects many aspects of a person’s life.

Summary of the main points about bipolar disorder

• 1 in every 100 people develops bipolar disorder at some point in his or her life.

• People can learn to manage the symptoms of bipolar disorder and lead productive lives.

• Bipolar disorder is diagnosed by a clinical interview with a mental health professional.

• The major symptoms of bipolar disorder are mania, depression, and psychotic symptoms.

• No one has exactly the same symptoms or experiences them to the same degree.

• Bipolar disorder is nobody’s fault. • Scientists believe that bipolar disorder is caused by a chemical

imbalance in the brain. • Bipolar disorder tends to be episodic, with symptoms coming and

going at varying levels of intensity. • There are countless positive examples of people with bipolar disorder

who have contributed to society. • Stigma refers to negative opinions and attitudes about mental illness. • What you do makes a difference in your recovery. • There are steps you can take to manage psychiatric symptoms

effectively.

Appendix: Strategies and Resources for Responding to Stigma

It may be helpful for you to develop some personal strategies for responding to stigma. There are advantages and disadvantages to each strategy. What you decide to do depends on the specific situation.

What are some strategies for responding to stigma?

Some possible strategies include:

Sometimes people who experience psychiatric symptoms do not know the facts themselves. They may blame themselves for their symptoms or think they cannot take care of themselves or that they can’t be part of the

Educate yourself about mental disorders

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community. You may have had these negative thoughts or feelings. This is called “self-stigma.”

It is important to fight self-stigma, because it can make you feel discouraged and cause you to lose hope in your recovery. One way to fight self-stigma is to educate yourself about psychiatric symptoms and mental disorders, and to be able to separate myths from facts. For example, knowing that no one causes bipolar disorder can help you to stop blaming yourself or others.

Another way to fight self-stigma is to belong to a support group or another group where you get to know different people who have experienced psychiatric symptoms. You can locate support groups through organizations such as the Consumer Organization and Networking Technical Assistance Center (CONTAC) and the National Empowerment Center. Contact information is provided for these and other helpful organizations in the Appendix to the “Recovery Strategies” handout.

The more you know about mental disorders, the more you can combat prejudice, whether it comes from others or from within yourself.

Correct misinformation in others without disclosing anything about your own experience A co-worker might say, “People with mental illness are all dangerous.” You might decide to reply, “Actually, I read a long article in the paper that said that the majority of people with mental illness are not violent. The media just sensationalizes certain cases.”

To fight stigma, you might decide to correct misinformation without disclosing personal experience.

Selectively disclose your experience with psychiatric symptoms Disclosing information about your own experience with psychiatric symptoms is a personal decision. It’s important to think about how the other person might respond. It’s also important to weigh the risks and benefits to yourself, both in the short term and in the long term. Talking this over with someone in your support system might be helpful.

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People vary widely in whether they choose to disclose information about themselves, and if so, how much. You may decide to disclose personal information only to family members or close friends. Or you may disclose information to people only when it becomes necessary. For example, you might need a specific accommodation in order to perform your job.

You may feel comfortable disclosing information in a wide variety of settings. You may even be willing to speak publicly about mental illness for educational or advocacy purposes.

In certain situations, you might decide to fight stigma by disclosing some of your own experience.

Become aware of your legal rights

The Americans with Disabilities Act makes it illegal to discriminate against people with physical or psychiatric disabilities in employment, transportation, communication, or recreation. The Fair Housing Act prohibits housing discrimination because of race, color, national origin, religion, sex, family status, or disability (physical or psychiatric).

It’s important to educate yourself about the laws against discrimination. Two major laws that protect against unfair treatment are the Americans with Disabilities Act (ADA) and the Fair Housing Act (FHA).

It is worthwhile to take some time to understand the basic principles of these laws and how they might apply to you. If you feel that your legal rights have been violated, there is a range of possible actions you might take, depending on the situation.

Sometimes it is most effective to speak directly to the person involved. For example, it is usually preferable to approach your employer about the need to provide a reasonable accommodation on the job. An example of a reasonable accommodation would be asking to move your desk to a more quiet area in the office to improve your concentration. Sometimes it may be more effective to talk to an expert to get advice, support, advocacy, mediation, and even legal help. For example, if a landlord refused to rent you an apartment because of psychiatric symptoms you may need to contact the Office of Fair Housing and Equal Opportunity

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(FHEO) in the Department of Housing and Urban Development (HUD) for advice and assistance. If an employer was unresponsive to your request for accommodation on the job, you might want to contact the Equal Employment Opportunity Commission (EEOC).

Contact information for the Office of Fair Housing and Equal Opportunity, the Equal Employment Opportunity Commission and other helpful organizations is provided at the end of this Appendix.

To combat stigma, it is important to know your legal rights and where to seek help if your rights have been violated.

Question:

What strategies have you used to combat stigma?

You can use the following checklist to answer this question.

Strategies for Combating Stigma

Strategy I have used this strategy

Educating yourself about psychiatric symptoms and mental disorders

Correcting misinformation without disclosing your own experience with psychiatric symptoms

Selectively disclosing your experience with psychiatric symptoms

Becoming aware of your legal rights

Seeking out assistance if your legal rights are violated

Other Strategies:

Resources

Anti-Stigma organizations and websites:

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Chicago Consortium for Stigma Research 7230 arbor Drive Tinley Park, IL 60477 Phone: 708-614-2490

Otto Wahl’s Homepage and Guide for Stigmabusters Dept. of Psychology George Mason University Fairfax, VA 22030 website: iso.gmu.edu/-owahl.INDEX.HTM

National Stigma Clearinghouse 245 Eighth Avenue Suite 213 New York, NY 10011 Phone: 212-255-4411 website: community2.webtv.net/stigmanet/HOMEPAGE

Resource Center to Address Discrimination and Stigma 1-800-540-0320 website: www.adscenter.org

Federal agencies:

Equal Employment Opportunity Commission (EEOC) 1801 L Street, NW Washington, D.C. 20507 Phone: 202-663-4900 To locate the nearest office: 1-800-669-4000 website: eeoc.gov

Office of Fair Housing and Equal Opportunity (FHEO)

8. References

Department of Housing and Urban Development 451 7th Street SW Washington, D.C. 20410 Phone: 202-708-1112 website: hud.gov

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Akiskal HS, Bourgeois ML, Angst J, Post R, MollerHJ, Hirschfeld RMA: Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord

American Academy of Child and Adolescent Psychiatry (1997) Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder

Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.

Angst, J; Selloro, R (September 15, 2000), "Historical perspectives and natural history of bipolar disorder", Biological Psychiatry.

Goodwin FK, Jamison KR (1990). Manic-Depressive Illness. New York: Oxford University Press.

Goodwin FK, Jamison KR (2007). Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd Edition. New York: Oxford University Press.

Jamison, Kay Redfield (1995). An Unquiet Mind: A Memoir of Moods and Madness. New York: Knopf

Judd, Lewis L.; Hagop S. Akiskal (January 2003). "The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases". Journal of Affective Disorders.

Judd Lewis L.; Aksikal Hagop S.; Schettler Pamela J. ; Endicott Jean; Leon Andrew C.; Solomon David A.; Coryell William; Maser Jack D.; Keller Martin B. (2005) Psychosocial disability in the course of bipolar I and II disorders : A prospective, comparative, longitudinal study Archives of General Psychiatry, vol. 62. Kato, T. (2007). "Molecular genetics of bipolar disorder and depression." Psychiatry Clin Neuroscience. Kessler, RC; McGonagle, KA; Zhao, S; Nelson, CB; Hughes, M; Eshleman, S; Wittchen, HU; Kendler, KS (1994), "Lifetime and 12-month prevalence

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Robinson DJ (2003). Reel Psychiatry:Movie Portrayals of Psychiatric Conditions. Port Huron, Michigan: Rapid Psychler Press

Robinson LJ, Thompson JM, Gallagher P, Goswami U, Young AH, Ferrier IN, Moore PB. (2006) A meta-analysis of cognitive deficits in euthymic patients with bipolar disorder. J Affect Disord. 2006 Santosa et al. Enhanced creativity in bipolar disorder patients: A controlled study. J Affect Disord. 2006 November 23. Segurado R, Detera-Wadleigh SD, Levinson DF, Lewis CM, Gill M, Nurnberger JI Jr, Craddock N, et al. (2003) Genome Scan Meta-Analysis of Schizophrenia and Bipolar Disorder, Part III: Bipolar Disorder. Am J Hum Genet.