Abnormal Mood 6 Mania 9 Hypomania 15 The Syndrome of Depression 17 Mixed States 25

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1 Contents Preface Part I SYMPTOMS, SYNDROMES, AND DIAGNOSIS 1 1. Normal and Abnormal Mood 5 Abnormal Mood 6 Mania 9 Hypomania 15 The Syndrome of Depression 17 Mixed States The Diagnosis of Bipolar Disorder 28 Psychiatric Diagnosis 29 Bipolar I 30 Bipolar II 37 Cyclothymic Disorder 41 Bipolar Spectrum Disorders 44 Rapid-Cycling Bipolar Disorder 49 Schizoaffective Disorder Bipolar Disorder and the DSM-5 54 What Is the DSM? 54 Bipolar Categories in the DSM-5 57 xi _Mondimore_Disorder_int.indd vii

2 4. The Mood Disease 58 Before Bipolar 58 Dr. Kraepelin and Manic-Depressive Insanity 60 Dr. Cade and Lithium 63 Part II TREATMENT The Plastic Brain Mood-Stabilizing Medications 77 Lithium 77 Lamotrigine (Lamictal) 86 Valproate (Depakote, Depakene, Epival) 89 Carbamazepine (Tegretol, Equetro, Epitol) 92 Oxcarbazepine (Trileptal) 94 Other Mood Stabilizers 95 On the Horizon: Promising New Approaches Antidepressant Medications 98 Tricyclic Antidepressants 98 Selective Serotonin Reuptake Inhibitors 100 New Antidepressants 101 Monoamine Oxidase Inhibitors 102 Treating Bipolar Depression Antipsychotic Medications 107 Typical Antipsychotic Medications 108 Atypical Antipsychotic Medications More Medications, Hormones, and Dietary Supplements 115 Medications for Anxiety and Sleep Disturbances 115 Thyroid Hormones 117 Herbal Preparations and Nutritional Supplements 119 Omega-3 Fatty Acids and Fish Oil 120 N-Acetyl Cysteine 120 St. John s Wort Brain-Stimulation Treatments 124 Electroconvulsive Therapy 124 Transcranial Magnetic Stimulation 130 Vagal Nerve Stimulation 132 Emerging Technologies 132 viii contents _Mondimore_Disorder_int.indd viii

3 11. Counseling and Psychotherapy 134 Brain and Mind 135 What Can Therapy Do? 137 Group Psychotherapy 138 Individual Therapy for Depression 139 New Psychotherapies for Bipolar Disorder 142 Traditional Individual Psychotherapy 144 Psychotherapy in Bipolar Disorder: Is It Really Necessary? 146 The Psychiatrist-Psychotherapist: An Extinct Species? Treatment Approaches in Bipolar Disorder 148 Therapeutic Results as a Guide to Treatment 148 Some Principles of Treatment 151 Part III VARIATIONS, CAUSES, AND CONNECTIONS Bipolar Disorder in Children and Adolescents 161 Symptoms of Pediatric Bipolar Disorder 163 Bipolar Disorder and Attention-Deficit Hyperactivity Disorder 164 Treatment and Prognosis Women with Bipolar Disorder: Special Considerations 169 Symptom Differences in Women 169 Postpartum Mood Disorders and Family Planning 170 Premenstrual Syndromes Alcoholism and Drug Abuse 174 Bipolar Binges 174 Effect, Cause, or Association? 178 Use or Abuse? 178 A Deadly Combination 179 Treating Substance Abuse and Addiction The Science of Cycles: Chronobiology 184 Circadian Rhythms 186 Seasonal Affective Disorder 188 The Sleep Cycle and Bipolar Disorder The Genetics of Bipolar Disorder 193 Genes, Chromosomes, and DNA 193 Genetic Diseases 195 What We Know 195 The Search Continues 196 contents ix _Mondimore_Disorder_int.indd ix

4 18. Bipolar Biology 198 How the Body Handles Stress 198 Bipolar Disorder and Hormonal Systems 202 Picturing Bipolar Disorder in the Brain Bipolar Disorder and Creativity 207 Part IV GETTING BETTER AND STAYING WELL Living with Bipolar Disorder 217 Confront and Accept the Illness 217 Practice Mood Hygiene 220 Build Your Support System 226 Don t Be a Bipolar Victim Planning for Emergencies 231 Know Whom to Call for Help 234 Insurance Issues 235 Safety Issues and Hospitalization The Role of the Family 239 Recognizing Symptoms 239 Involuntary Treatment and Other Legal Issues 244 More on Safety 246 Getting Support Looking Ahead 250 Resources 255 Suggested Reading 255 Support and Advocacy Organizations 256 Internet Resources 257 Notes 261 Index 279 x contents _Mondimore_Disorder_int.indd x

5 Preface About 2 percent of the population suffers from some form of bipolar disorder. Winston Churchill, George Frideric Handel, Lord Byron, Virginia Woolf, Edgar Allan Poe, Napoleon Bonaparte, and Vincent van Gogh are only a few of the politicians, writers, artists, and musicians who, despite having bipolar disorder, left a mark of greatness upon the world.1 Most persons who are affected by this illness, however, are ordinary people who want nothing more than to get back to their everyday lives after they or their family members have been diagnosed with it. This book is written for them. We psychiatrists have at times become a little complacent about this disease. When lithium became widely available in the United States in the mid- 1970s, many psychiatrists thought the battle to control the illness had been won. Indeed, lithium was and still is a miracle drug for many people who suffer from what was then known as manic-depression. More recent studies indicate that a substantial proportion of patients according to some studies, as many as half have a relapse of their illness despite taking lithium.2 But even as we become more aware of the sobering facts about the difficulty of successfully treating bipolar disorder, an explosion of developments in science and medicine holds great promise for those affected by the disease. In this book I shall relate this good news. Clinical research has shown again and again that many relapses of bipolar disorder occur not because of medication failure, but rather because patients stop taking medication and drop out of treatment. Perhaps patients don t understand that relapse and repetition of illness episodes are the hall- xi _Mondimore_Disorder_int.indd xi

6 mark of the illness, that abruptly stopping medication has been shown to be especially risky, that medication side effects can often be treated or controlled, and that new medications are becoming available all the time. I hope this book helps those who face difficult treatment decisions to make wellinformed and intelligent choices. A survey of patients with bipolar disorder and other mood disorders, carried out by the National Depressive and Manic-Depressive Association (now, the Depression and Bipolar Support Alliance) in the early 1990s, found that 36 percent of those who responded to the questionnaire had not sought professional treatment until more than ten years after their symptoms had begun.3 Of the bipolar patients in this study, 73 percent had received at least one incorrect diagnosis before being identified as having bipolar disorder often many years after first seeking help. The average respondent had seen 3.3 physicians before being correctly diagnosed. Why is this illness so difficult to identify correctly? One reason is that full-blown manic-depressive illness is only one of the several forms this chameleon disorder can take and manic-depressive illness may in fact be less common than the milder forms (the so-called soft bipolar disorders), in which symptoms of mild depression and subtle mood swings may be the only manifestations of bipolar disorder. We are realizing that many patients with these milder forms of the disorder benefit from treatment with mood-stabilizing medications, too. But they can do so only if they seek treatment and are correctly diagnosed. We shall see why many patients who have a bipolar disorder are told they have only depression or a personality disorder and shall also see the consequences of these and other diagnostic errors. Like any other serious illness, bipolar disorder affects not only the person who suffers from the disease but family, friends, and colleagues as well. Family support is crucial to the effective management of symptoms. The disrupted relationships and interpersonal conflicts that the symptoms of the illness can cause make bipolar disorder all the more difficult and complicated to treat. Information and understanding are definitely part of the treatment for this disease, and this book was written not only for the patient but for the patient s family and friends as well. Bipolar disorder can be a fatal disease. Although the figures vary among studies, about 15 percent of persons with bipolar disorder commit suicide;4 many more make suicide attempts. These are preventable deaths, because very effective treatments for this illness exist. I hope that the information this book provides about the treatment of bipolar disorder addresses some of the reasons why individuals are reluctant to enter treatment and dissuades some from stopping treatment against medical advice. Yes, it is my hope that this book will save lives. xii preface _Mondimore_Disorder_int.indd xii