Bipolar Disorders Ebooks Catalog

Understanding And Treating Bipolar Disorders

Understanding And Treating Bipolar Disorders

Are You Extremely Happy One Moment and Extremely Sad The Next? Are You On Top Of The World Today And Suddenly Down In The Doldrums Tomorrow? Is Bipolar Disorder Really Making Your Life Miserable? Do You Want To Live Normally Once Again? Finally! Discover Some Highly Effective Tips To Get Rid Of Bipolar Disorder And Stay Happy And Excited Always! Dont Let Bipolar Disorder Ruin Your Life Anymore!

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Married To Mania

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

Married To Mania Overview


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Symptoms of Depression and Bipolar Disorder

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

Treatment of bipolar disorder

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

Current treatments of bipolar disorder

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

Bipolar Disorder

Although face validity would suggest that stabilizing mania or hypomania in patients with bipolar disorder would improve impulse control and judgment, and therefore lead to decreases in substance use, the literature is thin regarding the efficacy of mood stabilizing medications on bipolar and SUD outcomes. An open pilot trial by Gawin and Kleber (1984) suggested that lithium may be effective in reducing cocaine use in patients with cyclothymia and cocaine abuse. However, an open trial of lithium in patients with bipolar spectrum disorders and cocaine abuse (Nunes, McGrath, Wager, & Quitkin, 1990) demon strated little efficacy in mood or cocaine outcome measures. An open label trial with valproate in patients with bipolar disorder and SUD (Brady, Sonne, Anton, & Ballenger, 1995) resulted in improvement in mood and substance use measures. Additionally, open-label trials of lamotrigine (Brown, Nejtek, Perantie, Orsulak, & Bobadilla, 2003) and quetiapine (Brown, Nejtek, Perantie,...

Affective disorders depression and bipolar disease

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

Disease State Diagnosis

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

Disease Basis 60321 Causes of Depression

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

Specificity of Cognitive Vulnerability Factors

There is an important distinction for cognitive models between specific and nonspecific causal factors in emotional disorders. Specific causal factors are relatively unique or focal factors in that they influence and predict the development of a particular disorder, but they do not apply equally to all psychopathology in general. For example, some cognitive vulnerability factors may apply to just a single form of anxiety disorder (e.g., just to OCD). In contrast, others may extend to the whole spectrum of anxiety disorders, but not apply to depression or other psychopathology (e.g., chap. 7, this vol. N. L. Williams, Shahar, Riskind, & Joiner, 2004). Alternatively, nonspecific (or common) causal factors potentially cut across a range of different disorders (e.g., depression, anxiety, bipolar disorders, even schizophrenia) and, in this way, have relatively low discriminatory power (Ingram, 1990 see also D. A. Clark, 1997). Two examples appear to include the experience of...

Catechol Omethyltransferase inhibitors

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

Rates Of Psychiatric Disorders Among People Living With Hiv Infection

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

Mary Ann Cohen and David Chao

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

Early Childhood Developmental Social and Family History

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

Clinical Diagnosis Some Concluding Comments

It is readily apparent that any research on diagnostic groups (e.g., schizophrenia or bipolar disorder) can be no better than the validity or mean-ingfulness of the diagnoses obtained and used. This problem has plagued research in this area for many years. On the one hand, systematic and reliable classification of subjects facilitates research and the accumulation of potentially meaningful data about types of psychopathology. On the other hand, if the classification scheme used for such research is beset with problems of clarity, reliability, and validity, the results based on such classification are bound to be limited in their usefulness. An unreliable and loose scheme is bound to produce unreliable and variable results. The most highly quantified data and the most exacting statistical analyses cannot provide worthwhile conclusions if the assumptions or foundation upon which they are based are weak.

Gender Differences in Psychopathology

Eysenck (1995) suggested that the dispositional trait underlying schizophrenia is an important ingredient of creativity and noted that the incidence of schizophrenia is higher in men than women. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) (American Psychiatric Association, 1994) stated, however, that although men tend to be institutionalized at a greater rate, community-based studies have suggested an equal gender ratio between the men and women who have schizophrenia. As I mention in the chapter on neurotransmitters (chapter 8), enhanced creativity appears to be associated with affective disorders. According to the dSm-IV, bipolar disorders are also equally distributed between men and women. Major depressive disorders, however, are reported more frequently with women. Although the higher incidence of depression in women might be related to an ascertainment-reporting bias (e.g., men are less likely to go for professional help), the incidence of mood...

Antiepileptic Drug Mechanisms

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

Unmet Medical Needs

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

Multivariate Behavior Genetic Studies of Mood and Anxiety Disorder Symptoms

The relationship between unipolar affective disorder and bipolar affective disorder has also been examined using twin data. Kendler, Pedersen, Neale, and Mathe (1995) reported that their data were consistent with a multiple threshold model in which the two forms of affective disorder are alternative manifestations of a single continuum of liability, rather than separate phenomena with distinct causes, and that bipolar disorder represents a more severe point on the continuum. Kar-kowski and Kendler (1997) analyzed data from the Virginia-based female twin sample described ear lier and reported that the data supported the conceptualization of unipolar and bipolar affective disorder as points of differing severity along the same continuum of illness (i.e., the two disorders have common causes). The application of the multiple threshold model to the bipolar-unipolar distinction is also consistent with two other pieces of data (1) epidemiological studies showing that bipolar disorder occurs...

Harold W Goforth Mary Ann Cohen and James Murrough

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

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

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

Major Depressive Disorder

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

Differential Diagnosis

Multiple studies have indicated that 60 -70 of patients with HIV infection have one or more psychiatric disorders prior to contracting HIV illness (Perry et al., 1990 Williams et al., 1991 Lyketsos et al., 1995). Patients with Axis I disorders, including depression, bipolar disorder, schizophrenia, and substance abuse, may present with cognitive complaints or impairment. Substance intoxication and or withdrawal are also common causes of cognitive impairment, particularly delirium. CNS opportunistic illnesses (OIs) and cancers can also present with a wide range of cognitive and neuropsychiatric symptoms, most often in the context of delirium, as a result of both focal and generalized neuropathological processes. Table 10.3 lists the major CNS OIs, their major symptom presentation, and diagnostic workup.

Treatment Of Psychiatric Disorders In The Context Of

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

Severe Mental Illness And Hiv Risk

Bipolar Disorder Bipolar disorder (previously called manic-depressive illness) is an illness that impacts the affective domain of one's mental health and accounts for many patients with severe mental illness. Often presenting with psychosis, this condition may be misdiagnosed as schizophrenia when severe. In the classic descriptions of manic-depressive illness, patients spend extended periods of time depressed, usually weeks to months at a time, followed by shorter periods when they are in an elevated, euphoric, and energized state, referred to as mania. Most often, patients cycle from one type of mood to the other, these cycles often interspersed with periods of normal moods but occasionally with intermediate mixed states that have features of both depressive and elevated mood states simultaneously or in rapid succession. The emotions and emotional changes in patients with bipolar disorder run their lives and can have a strong effect on their attitude toward treatment from minute to...

Cognitive Vulnerability to Bipolar Spectrum Disorders

Until recently, the basis of the research and theories covering bipolar disorder has been almost exclusively biological in nature. Despite the pioneering work of Kraepelin (1921) suggesting that environmental factors play a part in precipitating manic and depressive episodes, conceptions of bipolar disorder as a genetically based biological illness have dominated over the past century and rightfully so. The data from family, twin, and adoption studies suggesting that bipolar disorder carries a strong genetic predisposition (Goodwin & Jamison, 1990 Nurnberger & Gershon, 1992) and from pharmacotherapy trials indicating the effectiveness of lithium and anticonvulsive drugs in controlling the cycling of bipolar disorder (e.g., Keck & McElroy, 1996) are rather convincing (Miklowitz & Alloy, 1999). However, there has been a growing interest in the role of psychosocial processes in the onset, course, and treatment of bipolar spectrum disorders. This resurgence of interest in...

The Cognitive Vulnerabilitystress Models Of Unipolar Depression

Based on the logic behind cognitive theories of unipolar depression, two predictions can be made concerning vulnerability to manic and hypomanic episodes. On the one hand, based on the hopelessness theory, individuals who characteristically exhibit positive inferential styles for positive life events (stable, global attributions for positive events, positive consequences and positive self-implications of positive events) should react to the occurrence of positive events by becoming hopeful and, in turn, developing euphoria and hypomanic manic symptoms. Similarly, Beck (1976) suggested that manic individuals are characterized by a set of positive self-schemata, consisting of unrealistically positive attitudes about the self, world, and future. Beck hypothesized that when these individuals experience positive events, their positive schemata are activated and promote the development of manic symptoms. Alternatively, given that negative life events have been found to trigger manic...

Methodological Challenges Of Vulnerability Research In Bipolar Spectrum Disorders

Unfortunately, few studies examining the role of life events as proximal triggers or cognitive styles as distal vulnerabilities for bipolar spectrum disorders have used the preferred prospective designs. Thus, the review here makes note of those studies that do. Indeed, as a group, the bipolar spectrum disorders present especially difficult methodological challenges for conducting tests of vulnerability hypotheses. First, they are highly recurrent with significant interepisode symptomatology and functional impairment. As a consequence, it is very difficult to assess proximal life events or distal cognitive styles at a time when the individual is asymptomatic in order to establish independence of these potential vulnerabilities from symptoms of mania hypomania or depression. One has to be concerned with the possibility that residual symptoms may bias the assessment of life events or cognitions. Second, bipolar disorders have their initial onset at an early age (mean onset of 14 years...

Integrating Cbt And Ipt In

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

Life Events And Bipolar Spectrum Disorders

A growing body of evidence suggests that life events may have an impact on the onset and course of bipolar spectrum disorders (Johnson & Kizer, 2002 Johnson & Roberts, 1995). For the most part, these studies have found that bipolar individuals experienced increased stressful events prior to onset or subsequent episodes of their disorder. Moreover, most have found that the manic hypomanic, as well as the depressive, episodes of bipolar individuals were preceded by negative life events (Johnson & Roberts, 1995). However, several methodological limitations make interpretation of many of these studies difficult. First, many studies used retrospective rather than prospective designs. Retrospective designs have the problems that recall of events may decrease over time and become biased by the individuals' attempts to explain the cause of their disorder to themselves (Brown, 1974,1989). Second, many studies do not distinguish between the depressive and manic hypomanic episodes of...

Retrospective Studies

Several retrospective studies relied on review of medical charts to assess life events in patients with bipolar disorder. Based on retrospective chart review, Leff, Fischer, and Bertelson (1976) found that 35 of bipolar inpa-tients reported a stressful event rated as independent of their behavior in the month prior to onset of episode. Clancy, Crowe, Winokur, and Morrison (1973) also used retrospective chart review and found that 39 of unipolar, 27 of bipolar, and 11 of schizophrenic patients had a stressful event in the 3 months prior to onset of their disorder. No significant differences were found for types of precipitating stressful events for bipolar versus unipolar patients. Ambelas (1979, 1987) conducted two retrospective chart review studies. In the 1979 study, 28 of 67 hypomanic or manic inpatients versus 6 of 60 surgical control patients had experienced an independent stressful event during the 4 weeks prior to hospital admission. In almost all the cases reported, the...

Cognitive Styles And Bipolar Spectrum Disorders

Investigators have largely ignored the role of cognitive processes in bipolar spectrum conditions, mainly focusing on the cognitive factors involved in unipolar depression. Consequently, little is known about the cognitive styles characteristic of individuals with bipolar disorders or whether such cognitive styles increase bipolar individuals' vulnerability to depressive and manic hypomanic episodes in combination with life events. However, in the last decade, there has been increasing interest in the role of cognitive styles as vulnerabilities for episodes of bipolar disorder. Thus, this section reviews the extant cross-sectional research on the cognitive patterns associated with bipolar spectrum disorders and the stability of such patterns as well as longitudinal research on the manner in which cognitive styles may contribute vulnerability to bipolar episodes in response to life events.

Sleep Disturbance In

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

Cognitive Styles Associated with Bipolar Spectrum Disorders

Relatively few studies have directly examined the cognitive styles or information processing of individuals with bipolar mood disorders. Based on the grandiosity that is a common symptom of mania and hypomania, one might expect bipolar individuals (who experience manic or hypo-manic episodes) to exhibit cognitive patterns more positive than those of unipolar depressive individuals. On the other hand, based on psycho-dynamic formulations suggesting that the grandiosity of manic or hypo-manic periods is a defense or counterreaction to underlying depressive tendencies (Freeman, 1971), bipolar individuals would be expected to exhibit cognitive styles as negative as those of unipolar depressives. In a more modern version of the psychodynamic hypothesis, Neale (1988) suggested that grandiose ideas have the function of keeping distressing cognitions out of awareness and are precipitated by underlying low self-regard. Similarly, based on an extension of the cognitive theories of unipolar...

Stability of Cognitive Styles Associated With Bipolar Spectrum Disorders

The handful of studies examining the stability of the cognitive patterns of bipolar individuals have employed one of two research designs cross-sectional studies of bipolar individuals who are currently euthymic and have remitted from a depressive or hypomanic manic episode or longitudinal studies of bipolar individuals across depressed, hypomanic, and euthymic periods. Most studies have used the remitted design and thus are not optimal for examining the stability of cognitive styles across different phases of the bipolar disorder.

Treatment Of Dually Diagnosed Patients A Heterogeneous Population

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

Cognitive Vulnerability Stress Prediction of Bipolar Mood Episodes

Do the negative cognitive styles or self-referent information processing featured as vulnerabilities in the cognitive theories of unipolar depression also act as vulnerability factors for bipolar spectrum disorders in response to life events That is, do negative cognitive styles increase the likelihood that bipolar individuals become depressed or hypomanic manic when confronted with positive or negative life events Five studies have examined the cognitive vulnerability-stress hypothesis for bipolar disorders.

Other Psychiatric Populations

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

Pharmacotherapy Targeting Substance Dependence in Dually Diagnosed Populations

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

Cultural and Religious Influences

Finally, there is one additional reason why there might be a high percentage of Jews who lead creative lives. Earlier I reviewed the evidence that creativity is often associated with affective disorders such as depression and bipolar disorder. Levav, Kohn, Golding, and Weissman (1997) demonstrated that affective disorders are significantly more common in Jews than Catholics or Protestants.

Behaviors and Medical History That May Lead to Kidney Failure

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

Pathological Gambling and Other Behavioral Addictions

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

Basic Tenets Of Cognitive Models Of Emotional Disorder

Most individuals in stressful situations do not develop clinically significant disorders. Moreover, the specific disorder that emerges for different individuals is not determined just by the precipitating stress alone (i.e., precipitating stresses do not just occur in conjunction with any one clinical disorder). For example, stressful events are elevated in depression (Brown & Harris, 1978 Paykel, 1982), bipolar disorder and mania (see chap. 4, this vol. Johnson & Roberts, 1995), anxiety disorders (Last, Barlow, & O'Brien, 1984 Roy-Byrne, Geraci, & Uhde, 1986), and even schizophrenia (Zucker-man, 1999). In light of these findings, cognitive vulnerability-stress models are offered to help account for not only who is vulnerable to developing emotional disorder (e.g., individuals with a particular cognitive style), and when (e.g., after a stress), but to which disorders they are vulnerable (e.g., depression, eating disorder, etc.).

Univariate Studies of Mood and Anxiety Disorder Symptoms

Finally, several studies examined the causes of affective illness defined broadly (including both depressive disorders and bipolar disorders). Mc-Guffin and Katz (1989) reanalyzed twin data previously reported by Bertelsen, Harvald, and Hauge (1977) and obtained a high heritability of .86, with a very modest contribution of environmental influences (c2 .07 e2 .07). Kendler, Pedersen, Neale, and Mathe (1995) assessed genetic and environmental influences on affective illness (defined using DSM-III-R diagnostic criteria as either major depression with or without history of mania or bipolar illness) in a combined hospital-ascertained and population-based (i.e., unselected) Swedish

Figure 63 Chemical structures of carnitine and uric acid

The primary site of action of SSRIs is now well known to be SERT.4118 As cited earlier, because patients with depression and related illnesses respond so variably to SSRIs, a number of studies have been undertaken to determine whether there is a genotypic explanation for the large differences in clinical response. Current information is not conclusive as a diagnostic tool, but SERTPR s s and STtn2 10 12 genotypes in Caucasians and Asians, respectively, may be correlated with less favorable responses.419'420 Meta-analyses of population- and family-based studies of SERT gene polymorphisms and bipolar disorder have concluded that there is a small but detectable effect of the transporter on the odds ratio of the disease.421 Other studies have concluded that variants in the long promoter region of SERT (5-HTTLPR) are associated with transporter efficiency and cytokine and kinase gene expression relevant to treatment outcome, and with lithium treatment outcome in prophylaxis against mood...

Salt and Water Deficit

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

Psychiatric Comorbidity And Sequelae

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

Specific Treatment Modalities

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

New Research Areas

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


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

Case Studies

In an ideal situation the identification of novel drug targets in a given disease is performed using diseased and control tissue. However, biological samples derived from a precisely defined patient population and matched controls are scarce. An exception to this rule is the field of oncology research, where profiling experiments can be performed on tumor tissue and healthy control tissue derived from the same patient. In contrast, at the other end of the spectrum, are the diseases of the central nervous system for which it is much more complicated to obtain affected tissue. As an alternative, post-mortem samples are mostly used in diseases such as bipolar disorder, major depression, and schizophrenia. This complication might be resolved in the future if reports on the possible correlation between expression patterns observed in the brains and lymphoblastoid cells in patients with bipolar disorder, are confirmed.15 As an alternative to patient samples, scientists have turned to animal...

Disease State

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

Mood Disorders

Bipolar disorder and alcohol use disorders have a strong association. Bipolar I patients have alcohol dependence in approximately 31 of cases, and another 15 meet criteria for alcohol abuse. Patients with bipolar II ill ness have a rate of alcohol dependence at approximately 21 and an alcohol abuse pattern of 18 . Non-substance-abusing patients with bipolar illness have a more favorable course of treatment than do those who are using alcohol or other drugs. For example, the patients with comorbid substance use and bipolar disorders have more frequent hospitalizations for mood symptoms, earlier onset of bipolar disorder, more rapid cycling, and a greater prevalence of mixed mania. It is more common for bipolar disorder to precede alcoholism, although the reverse situation is certainly found. In either case, it is critical that the alcohol use disorder and the mood disorder be treated in a synchronous fashion, because failure to address one is likely to aggravate the occurrence of the...

Secondary Mania

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

Alcohol Intoxication

Alcoholic Dementia

Acute alcohol intoxication (drunkenness, inebriation) may be mild (blood alcohol 0.1-1.5 dysarthria, incoordination, disinhibition, increased self-confidence, uncritical self-assessment), moderate (blood alcohol 1.5-2.5 ataxia, nystagmus, explosive reactions, aggressiveness, euphoria, suggestibility), or severe (blood alcohol > 2.5 loss of judgment, severe ataxia, impairment of consciousness, au-tonomic symptoms such as hypothermia, hypotension, or respiratory arrest). Concomitant intoxication with other substances (sedatives, hypnotics, illicit drugs) is not uncommon. The possibility of a traumatic brain injury (subdural or epidural hematoma, intracerebral hemorrhage) must also be considered. Pathological intoxication after the intake of relatively small quantities of alcohol is a rare disorder characterized by intense outbursts of emotion and destructive behavior, followed by deep sleep. The patient has no memory of these events. Alcohol withdrawal syndrome. Reduction of...

The Bipolar Spectrum

Jamison, 1990 Johnson & Kizer, 2002). Within the bipolar category, a group of disorders appear to form a continuum or spectrum from the milder, subsyndromal form of manic depression, known as Cyclothymia, to full-blown manic depression, known as Bipolar I Disorder. Indeed, the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV American Psychiatric Association, 1994) identified four types of bipolar disorders Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, and Bipolar Disorder Not Otherwise Specified (NOS). However, Kraepelin (1921) believed that Cyclothymia is on a continuum with full-blown Bipolar I Disorder and, indeed, may be a precursor to it. Five lines of evidence support this continuum model and suggest that Cyclothymia is an integral part of the bipolar spectrum (Alloy & Abramson, 2000). First, the behavior of cyclothymics is qualitatively similar to that of individuals with Bipolar I and II Disorders (Akiskal et al., 1977 Akiskal,...

Prospective Studies

Stronger evidence for the role of stressful life events as proximal triggers of affective episodes in individuals with bipolar disorders comes from the more methodologically adequate prospective studies. Hall, Dunner, Zeller, and Fieve (1977) assessed 38 bipolar patients prospectively at monthly intervals for a total of 10 months. Although overall numbers of life events did not differ for patients who relapsed versus those who did not, hypomanic relapsers had greater numbers of employment-related events than did nonrelapsers. In another report from this study, Hall (1984) noted that a higher number of severe loss events, as well as work-related events, also were reported prior to manic relapse in this sample. Limitations of this study included the failure to control for medication or illness duration, as well as the lack of structured diagnostic interviews to determine relapse. Johnson and Miller (1997) examined negative life events as a predictor of time to recovery from an episode...


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

Protective Factors

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

What Is Cg Treatment

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